View
0
Download
0
Category
Preview:
Citation preview
Table of Contents
Document Page
1 Enc_0_CoG_Agenda_Public_04052016_rev 32 Enc_1-4_Pub_CoG_MM_17032016_Confirmed 53 Enc_1-5_PCoG_Actions_Tracker_04052016 154 Enc_3-1-1a_Draft_Quality_Report 175 Enc_3-1-1b_Draft_3_QA_Working_Doc 196 Enc_3-2-1a_National_Staff_Survey_April_2016_V2 897 Enc_3-2-1b_Appendix 958 Enc_3-3-1_Governor_Elections_2016 979 Enc_3-3-2_Governor_Engagement_and_Involvement 10710 Enc_3-3-3-1_MEC_Key_Discussions_04052016 11311 Enc_3-3-3-2_GSC_Key_Discussions_04052016 11512 Enc_3-3-3-3_PESC_Key_Discussions_19042016_VS 11713 Enc_4-1_CoG_Attendance_Register_04052016 12114 Enc_4-2_Q4_Monitor_Submission 12315 Enc_4-3-1_Confirmed_MCE_Minutes_18022016 12716 Enc_4-3-2_Confirmed_MM_GSC_15022016 13317 Enc_4-3-3_Confirmed_MM_PESC_18022016 139
This page has been left blank
Key: FE: For Endorsement; FA: For Approval; FR: For Report; FI: For Information
AGENDA
Meeting Public Council Of Governors
Time of meeting 14:30-15:30
Date of meeting Wednesday, 04 May 2016
Meeting Room Large Hall, 4th Floor, Bromley Central Library
Site High Street, Bromley, BR1 1EX
Encl. Lead Time
1. STANDING ITEMS Chair 14:30 1.1. Apologies
1.2. Declarations of Interest
1.3. Chair’s Action
1.4. Minutes of Previous Meeting – 17/03/2016 FA Enc. 1.4
1.5. Matters Arising FE Enc. 1.5
2. Reflection Session on Board of Directors Meeting Verbal 14:35 3. FOR REPORT
3.1. Best Quality of Care
3.1.1. Draft Quality Report 15/16 FE Enc. 3.1.1 G Walters
14:45
3.2. Skilled ‘Can Do’ Teams
3.2.1. National Staff Survey FR Enc. 3.2.1 D Brodwick 14:55
3.3. Governor Involvement & Engagement
3.3.1. Governor Elections FI Enc. 3.3.1 J Seddon 15:05
3.3.2. Governor Engagement & Involvement Activities
FI Enc. 3.3.2 C North 15:10
3.3.3. Sub-Committees Summaries/Actions
3.3.3.1. Membership & Community Engagement FR Enc. 3.3.3.1 F Clark
3.3.3.2. Strategy FR Enc. 3.3.3.2 A McCall
3.3.3.3. Patient Experience & Safety FR Enc. 3.3.3.3 T Duffy
4. FOR INFORMATION 15:25
4.1. Register of Governors Attendance FI Enc. 4.1
4.2. Monitor Quarterly Submission – Quarter 4 FI Enc. 4.2
4.3. Sub-Committee – Confirmed Minutes 4.3.1. Membership & Community Engagement 4.3.2. Strategy 4.3.3. Patient Experience & Safety
FI Enc. 4.3.1 Enc. 4.3.2 Enc. 4.3.3
5. ANY OTHER BUSINESS Chair 15:30
6. DATE OF NEXT MEETING Wednesday, 05 October 2016 from 14:30-15:30 at Bromley Central Library
Sue Slipman Vice Chair Elected: Anoushka de Almeida-Carragher Bromley Eniko Benfield Bromley Fiona Clark Lambeth Paul Corben Bromley Penny Dale Bromley Chris North Lambeth Nanda Ratnavel Lambeth Grace Okoli Lambeth Tim Bradley Lewisham Derek St Clair Cattrall Patient Pida Ripley Patient Helen Ahmet Patient Jan Thomas Patient Craig Jacobs Patient Barbara Pattinson Southwark Andrew McCall Southwark Victoria Silvester Southwark Jo Millet Staff – Nurses and Midwives Nicky Hayes Staff – Nurses and Midwives Daniel Beasley Staff - Allied Health Professionals, Scientific & Technical Roger Engwell Staff – Administration, Clerical & Management Nominated/Partnership Organisations: Cllr Robert Evans Bromley Council Phidelma Lisowska Joint Staff Committee Chris Mottershead King’s College London Cllr. Jim Dickson Lambeth Council Dr Sadru Kheraj Lambeth Clinical Commissioning Group Kieron Williams Southwark Council Dr Noel Baxter Southwark Clinical Commissioning Group Diane Summers Guy’s & St. Thomas’ NHS Foundation Trust In attendance: All Executive Directors All Executive Directors All Non-Executive Directors All Non-Executive Directors Tamara Cowan (TC) Board Secretary Silviyana Yankova (SY) Corporate Governance Assistant (Minutes) Apologies: Lord Kerslake Trust Chair Trudi Kemp Director of Strategic Development Pam Cohen Southwark Roger Paffard South London & Maudsley NHS FoundationTtrust Anand Arya Staff – Medical & Dental Tom Duffy Patient Vacancies Vacant Bromley Clinical Commissioning Group Circulation to: Council of Governors and Board of Directors
Enc. 1.4 Subject to Chair’s Approval
1
Council of Governors – Public Session Minutes of the meeting held on Thursday, 17 March 2016, Bill Whimster Suite, Weston Education Centre, King’s College London, Denmark Hill, London, SE5 9RS Lord Kerslake Trust Chair Elected: Anoushka de Almeida-Carragher Bromley (part) Penny Dale Bromley Fiona Clark Lambeth Chris North Lambeth Grace Okoli Lambeth (part) Nanda Ratnavel Lambeth Tim Bradley Lewisham Helen Ahmet Patient Tom Duffy Patient (part) Pida Ripley Patient Craig Jacobs Patient Jan Thomas Patient Andrew McCall Southwark Victoria Silvester Southwark Pam Cohen Southwark Barbara Pattinson Southwark Roger Engwell Staff – Administration and Clerical Jo Millett Staff – Nurses and Midwives Nicky Hayes Staff – Nurses and Midwives Cornelius Lewis Staff – Allied Health Professionals, Scientific and Technical Anand Arya Staff – Medical and Dental Nominated/Partnership Organisations: Diane Summers Guy’s & St Thomas’ NHS Foundation Trust Chris Mothershead King’s College London Phidelma Lisowka Joint Staff Committee Cllr Jim Dickson Lambeth Council Cllr. Kieron Williams Southwark Council Sadru Kheraj Lambeth CCG In attendance: Judith Seddon Acting Director of Corporate Affairs Tamara Cowan Board Secretary (Minutes) Nick Moberly Chief Executive Officer Colin Gentile Chief Financial Officer (part) Jane Badejoko Corporate Governance Officer Silviyana Yankova Corporate Governance Assistant Apologies: Eniko Benfield Bromley Paul Corben Bromley Derek St Clair Cattrall Patient CV Praveen Staff – Medical and Dentistry Roger Paffard South London & Maudsley NHS Foundation Trust Cllr. Robert Evans Bromley Council Dr Noel Baxter Southwark CCG In attendance: Judith Seddon Acting Director of Corporate Affairs Tamara Cowan Board Secretary
Enc. 1.4 Subject to Chair’s Approval
2
Nick Moberly Chief Executive Officer Colin Gentile Chief Financial Officer Jane Badejoko Corporate Governance Officer (Minutes) Silviyana Yankova Corporate Governance Assistant Geraldine Walters Director of Nursing & Midwifery Alan Goldsman Acting Director of Strategic Development
David Dawson Deputy Director of Strategy Jez Tozer Interim Chief Operating Officer Paul Donohoe Deputy Medical Director Item Subject Action
016/01 Welcome & Apologies The apologies for absence were noted. The Council welcomed Dr Sandru Kheraj nominated governor representative for Lambeth Clinical Commissioning Group, Dr Anand Arya, Medical and Dental staff representative and Daniel Beazley, Allied Health Professionals Scientific and Technical staff representative shadowing Governor Cornelius Lewis, to their first Council of Governors meeting.
016/02 Declarations of Interest There were no declarations of interest.
016/03 Chair’s Action There were no Chair’s action to report.
016/04 Minutes of Previous Meeting The minutes of the meeting held on 10 December 2015, were approved as a correct record. Subject to verification of the reasoning for the insertion of the word ‘and’ at the end of page 7.
016/05 Matters Arising/Action Tracking There were no matters arising from the last meeting.
FOR REPORT
Best Quality of Care
016/06 Patient Experience Report The Council received and noted the Patient Experience Report presented by Jessica Bush. The following key points were reported:
Enc. 1.4 Subject to Chair’s Approval
3
Item Subject Action
The Trust is always striving to improve patient experience across all its sites. Patient experience is measured against CQC fundamental performance standards and Friends and Family Test(FFT). Each year the results are reviewed and an action plan to address low performing areas is completed;
Results from last year indicated that the inpatients services had low scores.
The Trust implemented improvement measures which have produced positive outcomes reflected in the current results. Patient satisfaction on both sites is exceeding the overall ‘How are we doing’ score and FFT targets for the year;
The Trust’s outpatient services results are less positive with both sites
performing below target for overall ‘How are we doing’ scores and FFT. The Trust’s FFT scores are also 5% below the national average;
Outpatient services areas will be subject to a targeted improvement campaign focussing on patient appointments, waiting times in clinic and not providing patients with information or reasons for the length of their wait.
The Trust’s complaints performance improved in quarter 3 (Q3), 46% of all
complaints were responded to within 25 working days of their receipt. Current to date performance indicates that the Trust is operating at 42%;
NHS choices website rated the Trust’s Denmark Hill(DH) site, 4.5 stars out of 5 which was the same as last year. The Princess Royal University Hospital (PRUH) was rated 4.5 stars which is an improvement on last year’s rating of 3.5 stars;
The Trust is currently performing in the top quartile for teaching hospitals
despite the unfavourable outpatients scores; The Council raised the following points in discussions: The overall number of complaints for Q3 have reduced compared to the
increased activity and the number of patients treated by the Trust. This is a positive point; The biggest issue with complaints for the Trust is response time. The Trust is attempting to improve this by having clinical and divisional contribution into complaints to better assess and respond to all issues at the appropriate level.
The outpatient services results are not ideal and there is much work to be
done to improve these but the Trust will be focusing on these areas with a number of initiatives which will also form part of the wider transformation programme;
It was noted that complaints are processed differently from those complaints
that involve duty of candour. Duty of candour cases are put through the rigorous serious complaints procedures;
Enc. 1.4 Subject to Chair’s Approval
4
Item Subject Action
There were high levels of complains in July to August 2014 at the PRUH. This was due to the post-merger organisational redevelopment. The Trust was implementing a number of new patient pathways to improve services. In was also noted that in the last 3 months the PRUH has had restricted access to visitors due to a Norovirus contamination, there may be some complaints associated with the restricted conditions;
The Trust target of 60% response time to complaints is not the final objective the Trust will be satisfied with, it is milestone and a realistic target given the current resources and organisational pressures. The Trust plans to keep increasing this target until it reached 80%;
It was noted that 25% of all Trust complaints relate to the emergency department. Analysis have indicated that there is a direct correlation between numbers of complaints and breaches of the 4 hours emergency department (ED) performance target; and
The Trust plans a number of improvements intermediate schemes aimed at short term relief solutions to the ED problems. But there are wider plans for major changes in services delivery which will be covered under the transformation agenda and should provide a permanent solution to ED issues.
016/07 Quality Priorities & Indicators The Council received the Trust’s proposed quality priority indications for 2016/17. The following key points were reported: The Trust has begun work on proposals for the 2016/17 quality priorities.
They will form the key areas of focus for the Trust in relation to quality of patient care. The Trust will draft these followed by a wider stakeholder consultation programme;
The Trust plans to concentrate on three domains for the year, patient:
safety, outcomes and experience;
Last year the Trust focused on reducing smoking, increased alcohol awareness and exercise promoting to tackle obesity. The results were good with notable success in the increased referrals to stop smoking clinics and alcohol awareness but exercise promotion did not perform as well;
In the patient outcomes domain the Trust achieved success in the improved outcome for patients with hip fractures. In the patient safety domain the Trust concentrated on: surgical safety culture around never events in surgery and medication administration safety;
Performance on most indicators has been successful with some performing
better than others and valuables lessons have been learned by the Trust;
Enc. 1.4 Subject to Chair’s Approval
5
Item Subject Action
For next year the Trust plans to continue with the medication safety theme by focusing on patient use of antibiotics and medication omissions;
The Trust will also be complying with Monitor guidance in the following areas: Referral to treatment within 18 weeks for patients on incomplete pathway:
o A&E four hour wait; o 62 day cancer treatment wait; and o 28 day readmissions.
The list is in order of Monitor’s preference, accordingly the Trust is required
to conduct data testing on the following: o A&E four hour wait; and o Referral to treatment within 18 weeks for patients on incomplete
pathway. The Trust requests that the Council of Governors chose one local indicator
from the following options: • Medication Safety Errors • Venous Thromboembolism (VTE) • 62 day cancer waits; and • 28-day readmission.
The following key points were raised and discussed: The surgical safety priority facilitates the used of surgical safety checklist to
ensure everyone present will contribute to the patient care and all instruments are accounted for at the start and end of every procedure;
The Council was informed that the medical safety priority is recommended for further work in the current year not because it was unsuccessful last year, but because more could be gained by expanding the initiative.
The Council decide by a show of hands that they select the Medication Safety Errors as one of the local indicator for 2016/17. The Council decided that the final quality priority indicators will be presented to the Patient Experience and Safety Governor sub-committee.
PESC
016/08 Report from the Board The Council received the Chief Executive’s Board Report. The following key points were reported: With the end of the financial year fast approaching the Trust will be focusing
on three key objectives: o Maintaining financial and operational grip; o Achieve the targets for the year and setting up the start of the new
2016/17 year; and o Pushing ahead with strategic initiatives.
Enc. 1.4 Subject to Chair’s Approval
6
Item Subject Action
The Trust must continue to maintain a firm grip on its spending and financial controls. There is also important work underway to formulate the longer term future objectives. There are work streams relating to major services reconfiguration, improved infrastructures and capital developments;
The Trust is working closely with the health and social care partners in both Lambeth and Southwark, and Bromley, on how they can work together more effectively to deliver joined up care for local people with sustainable options;
Through OHSEL work the Trust will de undertaking to develop joint sustainability and transformation plans which will drive equality, efficacy and productivity with such things in the agenda as an Orthopaedics sector centre at Orpington;
The Trust will also be looking to move forward on the King’s Health Partners
(KHP) portfolio of services. Work is focused on developing plans to build a Haematology Institute on the DH site and Cardiovascular Services at Guy’s and St Thomas’ NHS Trust(GSTT) site. The partnership is also looking at opportunities for collaboration in Child Health and Neuroscience;
The Trust is looking to drive efficiencies and savings by working on clinical
support services via such forums as Viapath, a pathology service which it jointly owns with GSTT and Serco, which as one of the largest pathology providers nationally is driving sector changes and influencing provision of services;
Teaching and research are key initiatives that will help the Trust become a
word class institution and will also improve the care it provides by being a pioneer in medical innovation;
The Trust is also looking at its internal structures and carrying out reviews
and audits of various services to ensure all are fit for purpose and also to ascertain if some areas are lacking in resource and require support;
The following key points were raised and discussed: The Trust’s largest resource is its staff, the last staff survey results indicated
that there is low staff morale. The Trust has noted the results. A business case has been submitted to Monitor for funding of the transformation programme which will offer staff learning support;
The Trust is planning to complete majority of the CQC ‘must do’ items in 2016 with the exception of those relating to the distance between critical care beds. This item will be completed once the Trust opens its new 60 bed critical care unit; and
A new patient electronic system has been rolled out across the Trust as part
of the transformation plans and joined up working. The new system will permit clinicians access to patient records instantly across all sites. It is expected that there will be learning period for staff.
The Trust will present its capital development vision for the Trust at the Governor workshop in November.
NM/AT
Enc. 1.4 Subject to Chair’s Approval
7
Item Subject Action
016/09 Trust Performance Report The Council received and discussed the month 10 performance report. The following key points were reported and noted: The Trust is showing strong performance in cancer targets for a quarter 3
(Q3), non-validated figures indicate that the Trust is on trend to also achieve cancer target in quarter 4 (Q4) ahead of all other south east London providers;
However, the Trust is an outlier for patients transferred within 100 days from start of their treatment, these are patients who are transferred during their treatment to other providers;
The Trust has not been reporting on the backlog of its referral to treatment
patients. A full scale validation programme has been in effect over the past 12 months to ensure the Trust data is accurate and complete;
The Trust target on return to reporting is 92%, but it will likely average around
85%. The Trust plans to resume reporting of its March 2016 figures;
On its return to reporting the Trust will be publishing large numbers of patients waiting over 18 weeks. The Trust is working closely with its commissioning partner to ensure it can safely clear its back of patients;
The PRUH was behind on its emergency department (ED) trajectory,
performance declined from 89.9% in November to 86.1% in December against target of 95%. However, this is still a 10% improvement on the same period last year;
The introduction of the Transfer of Care Bureau (TCB) at the PRUH has not produced the increase in discharges and bed capacity anticipated. Bromley CCG have set aside a budget to review the performance of the TCB;
The ED at DH and the PRUH have different calibre of patients and local
community pressures;
The DH site ED performance is affected by capacity issues and trauma surgery patient. There has also been sudden increase in the number of patients seeking treatment with 485 patients attending the accident and emergency department in a single week. The growth factor for past year has been over 3.5% and rising.
The following key points were noted in discussions: The specialities with the largest number of backlog patients are
Orthopaedics, Ophthalmology and Neurosurgery. While the Trust is preparing plans that will clear the backlog which is subject to commissioner funding for Orthopaedics and Ophthalmology;
Enc. 1.4 Subject to Chair’s Approval
8
Item Subject Action
Neurosurgery services have a larger national system wide problem, which cannot be solved by the Trust working alone; and
One of the many factors identified that leads to an increase in the number of
patient attendance to ED is no access to General Practitioner (GP). Other factors include an elderly local population with complex medical conditions. There is need for further analysis to better understand the reason for the increase in patient numbers to ED.
016/10 Trust Finance Report The Council received and discussed the month 10 finance report. The following key points were reported and noted: At the end of month 10 the Trust is £73.75m overspend against a target
year-end deficit of £65m. This is after the application of £6.9m of new mitigation measures which are non-recurrent;
The Trust has also received one off support from its Clinical Commissioning Group(CCG) partners;
The Trust debt levels are being managed but they are worse off. NHS England (NHSE) remains the Trust’s largest debtor, negotiations for outstanding payments have been at deadlock and the Trust will going into arbitration;
Cashflow remains stable but very tight;
Initial non-validated figures for month 11 indicate that the Trust may end the
month with a £3m non recurrent surplus; The following key points were noted in discussions: The Trust is not delivering on it’s CIP programme as anticipated. To
minimise slippage in months 11 and 12 the Trust has carried out granular reviews of all CIPs scheme;
The Trust must improve its collection process relating to oversees private patients to whom it provides care. This is a income stream with great potential for success; and
The Trust has been give verbal confirmation that it will receive working
capital facility for next year.
The Council will receive an update on private patient’s income at the October meeting.
CG
Enc. 1.4 Subject to Chair’s Approval
9
Item Subject Action
Governor Involvement & Engagement
016/11 Governor Elections The Trust will be holding Governor election for eight positions in September 2016 A full report will be presented to the Council on 4 May.
016/12 Governor Engagement & Involvement Chris North (CN) updated the Council on the following: Governors started attending Board of Director’s Sub-Committee meetings
form January 2016. This is a positive step which will provide greater interaction between Governor and the Board;
A number of Governors attended the Joint KHP Governor event on 15 January hosted by GSTT. The event was well attended, but feedback from all Governors was that they would prefer a more interactive session for future meetings;
The Governor workshop on 31 January focused on discharge procedures in
the Trust, the presentations were well received; The Trust will be holding a formal review session of the Trust’s
Non-Executive Directors on 9 March all Governors are invited to attend this session; and
Governors are urged to get more involved in the Council of Governor’s
Sub-Committees and workshops. These are an excellent platform to gain further understanding into the Trust and a forum to drill down on specific issues.
016/13 Sub-Committees Summaries/Actions Membership & Community Engagement The Committee received a presentation from Nicola Kingston and Valerie
Dinsmore from Southwark and Lambeth Integrated Care (SLIC). The organisation is an open forum for discussion on all things integrated care; and
The Committee were also informed that SLIC as function will be transforming into a different organisation in April 2016.
Strategy Committee The Committee received and discussed the emerging Trust strategy which
lists the strategic objectives that the Trust will adhere to. These objective will form a key part of the Trust’s transform into a financially sustainable and operationally efficient health provider; and
Enc. 1.4 Subject to Chair’s Approval
10
Item Subject Action
The Committee also received presentations Cllr Jim Dixon and Aland
Goldsman Interim Director of Strategy. Patient Experience & Safety Committee The Committee received a video patient story from Maxine Spencer, Director
of Midwifery. The Committee had trouble hearing the video and understanding the content. It was noted that there was need for further editorial of the video before it was presented as any educational value was lost due to the poor quality.
FOR INFORMATION
016/14 Register of Governors Attendance The Council noted the register of Governors attendance.
016/15 Monitor Quarterly Submission – Quarter 3 The Council noted the Trust’s quarter 3 Monitor submission.
016/16 Sub-Committee – Confirmed Minutes The Council noted the following sub-committee minutes: Membership & Community Engagement Committee –09/07/2015 Strategy Committee – 09/07/2015 Patient Experience and Safety Committee – 09/07/2015
016/17 ANY OTHER BUSINESS
It was noted that Tooba Ahmadi will be leaving the Trust in April, the Council thanked Tooba for all her hard work; and
The Council was informed that Trust will not be moving the Chartwell Inpatient Unit as published in the News Shopper local newspaper, pending the results of a formal consultation.
DATE OF NEXT MEETING Joint Board of Directors and Council of Governors Meeting on Wednesday, 4 May 2016 from 14:30-15:30 at Bromley Library
Enc. 1.5
Action Status as at: 27 April 2016 1
COUNCIL OF GOVERNORS (PUBLIC MEETING) ACTION TRACKER
Date Item Action Who Due Update COMPLETED
17/03/2016 16/07 Quality Priorities & Indicators - The Council decided that the final quality priority indicators will be presented to the Patient Experience and Safety Governor sub-committee.
The action item has been transferred to Patient Experience & Safety Committee. The Committee Chair will feedback to the Council of Governors in due course.
NOT DUE
17/03/2016 16/08 Report from the Board- The Trust will present its capital development vision for the Trust at the Governor workshop in November.
NM/AT 03/11/2016
This page has been left blank
Rep
Dat
Pre
Sub
Act
| Int Eacperfqua Statstan(ARpubPar Thewha Whesect In itlatestak In thupdlocacom | Ac TheQua
DR
port to:
te of meet
esenter:
bject:
tion Requ
troduction
ch year the Tformance ag
ality metrics
tutory guidandalone doc
RA) which isblished on thliament.
e guidance oat should be
en the qualtions which
ts current fost data and
keholders a
he interim, mated inform
al stakeholdmmunication
ction Requ
e Council oality and G
RAFT QU
C
ting: 04
G
D
ired: F
Trust is reqgainst its chand indicat
ance requirecument ands submitted he Trust’s w
on the prode included a
ity report is will suppor
orm, the docd other key ind governo
more work wmation includders have bens team the
ired
of Governoovernance
ALITY RE
Council of
4 May 201
Geraldine W
Draft Quali
OR INFOR
uired to comhosen qualitors.
es that the Td incorporateto Monitor a
website and
uction of thand in some
published wrt the Trust’s
cument is stnformation
ors for initial
will be doneded. Once ceen garneren sent to th
ors is askee Committe
EPORT 20
Governor
16
Walters, D
ty Report
RMATION
mplete a quty priorities
Trust publise it in the Tat the end oNHS Choic
e quality ree cases prov
within the As quality ag
till in the drato be includ
l comments
e to ensure comments fed, the doc
he Board for
ed to note ee for revie
015/16
rs
Director of
& Accoun
uality report and its per
shes the quaTrust’s Annuof May. Theces after it h
port is veryviding the fo
ARA it will crgenda.
aft stage wided. An ear
s.
the documefrom commiument will br final appro
that the dw and com
f Nursing &
nts
which detarformance a
ality report aual Report &e Quality Rehas been la
prescriptiveorm of word
ross referen
th final proorlier draft wa
ent is correcissioners, gbe reviewedoval.
document wmment
Enc. 3
& Midwife
ails its against othe
as a & Accounts eport is aid before
ve, detailing ds.
nce relevan
of reading, aas sent to lo
ct and the governors ad by the
will be sen
3.1.1
1
ery
er
nt
and ocal
nd
nt to
This page has been left blank
1
Enc.3.1.1
2
Draft Document key
1. Red text – updated to be reviewed and finalised in final draft
2. Red text/yellow highlight – old information to be updated
3. Blue text – standard required form of words cannot be revised
4. Blue text/yellow highlight – required working additional information to be included
Enc.3.1.1
Enc.3.1.1
Nur
rsing – e
In comfew yeand Bothe ChJohn’stook ovschoolas Sistactive designHill. Hereredoin 191William
Katherinof KCH
early dev
mmon withears of KCowman, whurch of Es House, lver the nl in Englater Matromember
n the 3rd Ker influen
os in the S7. This w
m Powell,
ne Monk. Fir
velopmen
h most hoCH were with the hEngland Nled by theursing at
and. Kathon in 1885
of the KCKCH whicnce was eSt. Luke c
work of art a firm of
rst Matron
nts
ospitals nalmost no
help of theNursing Se superinKCH anderine Hen5 and retiCH buildich would enormouschapel wat was desf stained
The mosahospital c
nursing ston-existee Bishop Sisterhoontendent d foundednrietta Mired in 19ing commbe built in
s and theas dedicasigned byglass and
aic reredos chapel
tandards ent. In 184
of Londod of St. JSister Mad the firstonk was
906. She mittee helpn 1913 a beautifuated to hey William d mosaic
in the
in the firs48 Todd on, foundJohn. St ary Jonest nursing appointewas an ping to t Denmar
ul mosaic er memoAikan for
c makers.
st
ded
s,
ed
rk
ry r
Enc.3.1.1
5
King’s College Hospital NHS Foundation Trust Quality Report & Accounts 2015/16
Presented to Parliament pursuant to Schedule 7, paragraph 25(4) (a) of the National Health service Act 2006
Enc.3.1.1
6
Enc.3.1.1
7
CONTENTS
PART 1: CHIEF EXECUTIVE’S STATEMENT OF QUALITY 5
PART 2: PRIORITIES FOR IMPROVEMENT AND ASSURANCE STATEMENTS 17
SELECTING OUR IMPROVEMENT PRIORITIES 19
PERFORMANCE AGAINST 2015/16 QUALITY PRIORITIES 21
2016/17 IMPROVEMENT QUALITY PRIORITIES 28
STATEMENTS OF ASSURANCE FROM THE BOARD 32
STATEMENT OF ASSURANCE EVIDENCE 37
TRUST PARTICIPATION IN NCEPOD STUDIES 41
CLINICAL AUDIT PROJECTS REVIEWED BY THE TRUST 41
LOCAL AUDITS – CP TO PROVIDE 49
REPORTING AGAINST CORE INDICATORS 50
PERFORMANCE MEASURES 50
RESPONSIVENESS TO PATIENTS PERSONAL NEEDS 53
FRIENDS & FAMILY TESTS 55
PART 3: OTHER INFORMATION 60
OTHER UNDERLYING QUALITY OF CARE INDICATORS 60
OTHER UNDERLYING QUALITY OF CARE INDICATORS 62
TRUST ACTIONS ON DUTY OF CANDOUR (INCIDENTS/ACTIONS) 65
ANNEX 1: STATEMENTS FROM COMMISSIONERS, LOCAL HEALTHWATCH ORGANISATIONS AND
OVERVIEW AND SCRUTINY COMMITTEES 67
ANNEX 2: STATEMENT OF DIRECTORS’ RESPONSIBILITES FOR THE QUALITY REPORT 68
Enc.3.1.1
8
Enc.3.1.1
9
GLOSSARY ACRONYM/WORD MEANING – To be updated
A&E Accident & Emergency
ACC Accredited Clinical Coder
AHP Allied Health Professionals i.e. Physiotherapists, Occupational Therapists, Speech & Language Therapists etc.
AHSC Academic Health Science Centre
ANS Association of Neurophysiological Scientists Standards
BCIS Bone Cement Implantation Syndrome
BHRS British Heart Rhythm Society
BME Black and Minority Ethnic
BREEAM Building Research Establishment Environmental Assessment Method
BSCN British Society for Clinical Neurophysiology
BSI The British Standards Institution
BSS Breathlessness Support Service
CCG Clinical Commissioning Groups (previously Primary Care Trusts)
CCS Crown Commercial Service
CCTD Critical Care and Trauma Department
CCUTB Critical Care Unit over Theatre Block
C-difficile Clostridium Difficile
CDU Clinical Decisions Unit
CEM Royal College of Emergency Medicine
CHD Congenital Heart Disease
CHR – UK Child Health Clinical Outcome Review Programme (UK)
CLAHRC Collaboration for Leadership in Applied Research and Care
CLINIWEB The Trust's internal web-based information resource for sharing clinical guidelines and statements.
CLL Chronic Lymphocytic Leukaemia
CLRN Comprehensive Local Research Network
CNS Clinical Nurse Specialist
COPD Chronic Obstructive Pulmonary Disease
COPD Chronic Obstructive Pulmonary Disease
COSD Cancer Outcomes and Services Dataset
COSHH Control of Substances Hazardous to Health
CPPD Continuing Professional and Personal Development
CQC Care Quality Commission
CQRG Clinical Quality Review Group (organised by local commissioners)
CQUIN Commissioning for Quality and Innovation
CRF Clinical Research Facility
CRISP Community for Research Involvement and Support for People with Parkinson’s
CT Computerised Tomography
Enc.3.1.1
10
DAHNO National Head & Neck Cancer Audit
DH/KCH DH Denmark Hill. The Trust acute hospital based at Denmark Hill
DNAR Do Not Attempt Cardiopulmonary Resuscitation
DoH Department of Health
DTOC Delayed Transfer of Care
ED Emergency Department
EDS Equality Delivery System
EMS Environmental Management System
EPC Energy Performance Contract
EPMA Electron Probe Micro-Analysis
EPR Electronic Patient Record
ERR Enhanced Rapid Response
ESCO Energy Service Company
EUROPAR European Network for Parkinson’s Disease Research Organization
EWS Early Warning Score
FFT Staff Friends & Family Test
FY Financial Year
GCS Glasgow Coma Scale
GP General Practitioner
GSTS Pathology Venture between King’s, Guy’s and St Thomas’ and Serco plc
GSTT Guy's St Thomas' NHS Foundation Trust
H&S Health & Safety
HASU Hyper Acute Stroke Unit
HAT Hospital Acquired Thrombosis
HAU Health and Aging Units
HCAI Healthcare Acquired Infections
HCAs Health Care Assistants
HESL Health Education South London
HF Heart Failure
HIV Human Immunodeficiency Virus
HNA Holistic Needs Assessment
HQIP Healthcare Quality Improvement Partnership
HRWD ‘How are we doing?’ King’s Patient/User Survey
HSCIC Health and Social Care Information Centre
HSE Health and Safety Executive
HTA Human Tissue Authority
IAPT Improving Access to Psychological Therapies
IBD Inflammatory Bowel Disease
ICAEW Institute of Chartered Accountants in England and Wales Code of Ethics
ICNARC Intensive Care National Audit & Research Centre
ICO Information Commissioner’s Office
ICT Information and Communications Technology
ICU Intensive Care Unit
IG Toolkit Information Governance Toolkit
Enc.3.1.1
11
IGSG Information Governance Steering Group
IGT Information Governance Toolkit
IHDT Integrated Hospital Discharge Team
iMOBILE Specialist critical care outreach team
IPC Integrated Personal Commissioning
ISO International Organization for Standardization
ISS Injury Severity Score
JCC Joint Consultation Committee
KAD King’s Appraisal & Development System
KCH, KING's, TRUST King's College Hospital NHS Foundation Trust
KCL King’s College London – King’s University Partner
KHP King's Health Partners
KHP Online King’s Health Partners Online
KPIs Key Performance Indicators
KPMG LLP King’s Internal Auditor
KPP King’s Performance and Potential
KWIKI The Trust's internal web-based information resource. Used for sharing trust-wide polices, guidance and information. Accessible by all staff and authorised users.
LCA London Cancer Alliance
LCN Local Care Networks
LIPs Local Incentive Premiums
LITU Liver Intensive Therapy Unit
LUCR Local Unified Care Record
MACCE Major Adverse Cardiac and Cerebrovascular Event
MBRRACE-UK Maternal, Newborn and Infant Clinical Outcome Review Programme
MDMs Multidisciplinary Meeting
MDS Myelodysplastic Syndromes
MDTs Multidisciplinary Team
MEOWS Modified Early Obstetric Warning Score
MHRA Medicine Health Regulatory Authority
MINAP The Myocardial Ischaemia National Audit Project
MRI Magnetic Resonance Imaging
MRSA Methicillin-resistant staphylococcus aureus
MTC Major Trauma Services
NAC N-acetylcysteine
NADIA National Diabetes Inpatient Audit
NAOGC National Audit of Oesophageal & Gastric Cancers
NASH National Audit of Seizure Management
NBOCAP National Bowel Cancer Audit Programme
NCEPOD National Confidential Enquiry into Patient Outcome & Death Studies
NCISH National Confidential Inquiry into Suicide & Homicide for People with Mental Illness
NCPES National Cancer Patient Experience Survey
NDA National Diabetes Audit
Enc.3.1.1
12
NEDs Non-Executive Directors
NEST National Employment Savings Trust
NEWS National Early Warning System
NHFD National Hip Fracture Database
NHS National Health Service
NHS Safety Thermometer
A NHS local system for measuring, monitoring, & analysing patient harms and ‘harm-free’ care
NHSBT NHS Blood and Transplant
NICE National Institute for Health & Excellence
NICU Neonatal Intensive Care Unit
NIHR National Institute for Health Research
NJR National Joint Registry
NNAP National Neonatal Audit Programme
NPDA National Paediatric Diabetes Audit
NPID Pregnancy Care in Women with Diabetes
NPSA National Patient Safety Agency
NRAD National Review of Asthma Deaths
NRLS National Reporting and Learning Service
NSCLC Non-Small Lung Cancer
OH/ORPINGTON HOSPITAL
The Trust acquired services at this hospital site on 01 October 2013
OSC King’s Organizational Safety Committee
PALS Patient Advocacy & Liaison Service
PbR Payment by Results
PICANet Paediatric Intensive Care Audit Network
PiMS Patient Administration System
PLACE Patient Led Assessments of the Care Environment
POMH Prescribing Observatory for Mental Health
POTTS Physiological Observation Track & Trigger System
PROMS Patient Reported Outcome Measures
PRUH/KCH PRUH Princess Royal University Hospital. The Trust acquired this acute hospital site on 01 October 2013
PUCAI Paediatric Ulcerative Colitis Activity Index
PwC PricewaterhouseCoopers
QMH Queen Mary’s Hospital
RCPCH Royal College of Paediatric and Child Health
RIDDOR Reporting of Injuries, Dangerous Diseases and Dangerous Occurrences Regulations
ROP Retinopathy of Prematurity
RRT Renal Replacement Therapy
RTT Referral to Treatment
SBAR Situation, Background, Assessment & Recognition factors for prompt & effective communication amongst staff
SCG Specialist Commissioning Group (NHS England)
SEL South East London
Enc.3.1.1
13
SEQOHS Safe Effective Quality Occupational Health Service
SHMI Standardised Hospital Mortality Index. This measure all deaths of patients admitted to hospital and those that occur up to 30 days after discharge from hospital.
SIRO Senior Information Risk Owner
SLAM South London & Maudsley NHS Foundation Trust
SLHT South London Health Care Trust. SLHT dissolved on 01 October 2013 having being entered into the administration process in July 2012.
SLIC Southwark & Lambeth Integrated Care Programme
SSC Surgical Safety Checklist
SSIG Surgical safety Improvement Group
SSNAP Sentinel Stroke National Audit Programme
SUS Secondary Uses Service
SW Social Worker
TARN Trauma Audit & Research Network
TTAs Tablets to take away
TUPE Transfer of Undertakings (Protection of Employment) Regulations
UAE United Arab Emirates
UNE Ulnar Neuropathy at Elbow
VTE Venous-Thromboembolism
WHO World Health Organisation
WTE Whole Time Equivalent
Enc.3.1.1
14
Enc.3.1.1
ChstaKing’s hthe forThis yeeven fuCare’ aWe havStrategStrategembeddfoundatenter aand opp
Our stathe devthey hawe neea posdeliveryand ope We recTeams
1: King's St
hiefatemhas always refront of eear we havrther by lau
as one of ove also devy and a newy. Our ded in ourtion of our
a new year portunities.
aff have bevelopment ave helped d to make t
sitive figury in the NHSerational en
cognise thaare key to
trategy Triang
f Exmen
put quality everything ve increaseunching ‘Beour four ke
veloped a row Nursing a
values r culture ar key strate
forged wit
een activelyof our straus identify
to ensure Krehead ofS in the cur
nvironment.
at our Skilthe quality
gle
xecunt o
and safety that we d
ed our efforest Quality ey strategieobust Qualand Midwifeare deep
and form thegies as wth challenge
y engaged ategies anthe change
ing’s remaif healthcarrent financ
led, Can Dof service w
utiveof qu
at do. rts of
es. ity
ery ply he we es
in nd es ns
are cial
Do we
primsostopanco Oincasu Wstarem WC20atWtodoanHmanHsise QEstLapr Inqu
e’s ualirovide. We
mpact the oo and intetrategy wpportunitiesnd progompassiona
Our developnnovative tatapult Kingustainability
We are tructures tore systematmbedded in
We were insCommission
015). This ittaining a ‘re
Whilst this wo have beenomain acron overall ratospital site
maternity annd young aill and Princite. The Denervices also
Quality Prioach year takeholdersambeth anriorities for
n 2014/15,uality prior
ity e do not ongoing preegral part ill be m
s, robust cagression ate leadersh
ing pioneertransformatg’s into longy.
improving ensure outic and goodn the care w
pected by tduring the nspection reequires impas disappo
n rated gooss all our siting for gooand good rd gynaecolodult servicecess Royal nmark Hill uo received a
orities in consulta
s and govend Southwaimproveme
we chosrities. Outs
underestimessure on o
of our wmore engaareer deve
systems hip.
ring, ambitition prograg term stab
our opeur patient pad clinical st
we provide.
he Care Quperiod (Apr
resulted in tprovement’ inting we ar
od in the carites. We rec
od our Orpinratings for ogy and ch
es at the DeUniversity
urgent care a good ratin
ation with ernors in Bark, chose
ent.
se six chastanding p
15
mate the our staff orkforce agement lopment
and
ous and am will
bility and
erational athways andards
uality ril he Trust rating. re proud ring ceived ngton
ildren enmark Hospital
ng.
our key Bromley, quality
allenging progress
Enc.3.1.1
16
has been made in the outcomes for patients following hip fracture and interventions to reduce preventable ill health. Good progress has also been made in some areas to improve the experience of cancer patients but we recognised more needs to be done and will form part of our transformation programme. Unfortunately, we did not make the level of progress wanted to improve the safer surgery culture and in particular reduce the number of never events to zero. This initiative will be carried forward for another year. Our 2016/17 quality improvement priorities include: 1. Enhanced recovery after surgery
(ERAS).
2. Improved outcomes after emergency abdominal surgery.
3. Improve implementation of sepsis bundles for patients with positive blood cultures and diagnosis of sepsis.
4. Improve the quality of the surgical safety.
5. Improve access to information for patients, service users, carers and parents, where those needs relate to a disability, impairment or sensory loss.
6. Improving outpatient experience.
Data Quality There are a number of inherent limitations in the preparation of Quality Accounts which may affect the reliability or accuracy of the data reported. These include: Data is derived from a large number of
different systems and processes. Only some of these are subject to external assurance, or included in internal audits programme of work each year.
Data is collected by a large number of
teams across the trust alongside their main responsibilities, which may lead to differences in how policies are applied or interpreted. In many cases, data reported reflects clinical judgement about individual cases, where another clinician might have reasonably have classified a case differently.
National data definitions do not
necessarily cover all circumstances, and local interpretations may differ.
Data collection practices and data
definitions are evolving, which may lead to differences over time, both within and between years. The volume of data means that, where changes are made, it is usually not practical to reanalyse historic data.
During the period, we took a reporting holiday for referral to treatment (RTT) data with the endorsement of Monitor and commissioners. During the reporting holiday, we have worked hard on the robustness of our data to ensure we have best information and can treat our patients effectively. We return to reporting in March 2016 with renewed confidence in our systems and accuracy of our RTT data. The Trust and its Board have sought to take all reasonable steps and exercise appropriate due diligence to ensure the accuracy of the data reported, but recognises that it is nonetheless subject to the inherent limitations noted above. Having had due regard for the contents of this statement to the best of my knowledge, the information contained in the following Quality Account is accurate.
Enc.3.1.1
17
Signature
Nick Moberly, Chief Executive Officer
Date
Enc.3.1.1
18
Enc.3.1.1
19
Part 2: Priorities for improvement and assurance statements
Selecting our improvement priorities This quality report provides a summary of our performance against our chosen quality improvement priorities for 2015/16 and outline what we aim to achieve in 2016/17. In choosing the quality improvement priorities, we consult with local commissioners, healthwatch, staff, governors, senior executives and the Board of Directors. We are committed to driving our patient focus strategy which informs our decision making processes. Embedded in the fabric of the Trust’s culture is the ethos of providing of the best quality of care to patients always. We are a busy acute hospital and as such are always making improvements to our services and practices. In addition to our regular programme of improvement works, we chose six priorities within the patient outcomes, patient experience and patient safety domains to give additional focus each year. Periodically we may decide give more focus to some improvement priorities hence they span more than one year. The table overleaf details our past and present priorities.
In accordance with the NHS Quality Accounts Amendment Regulations 2013 and the guidelines set out by Monitor and the Department of health, we have included the following in this report: standardised statements of
assurances from the Board and the required evidence;
performance against key quality indicators;
other information including data key
performance indicators and quality information;
statements from commissioners local
healthwatch organisations and overview and scrutiny committees; and
published statement of the directors’
responsibilities for the quality report.
Enc.3.1.1
20
Past and Present – Our Quality Improvement Priorities
2012/2013 2013/2014 2014/2015 2015/2016 2016/2017
Pat
ien
t O
utc
om
es
Improve
responsivenes to inpatients personal
needs
Dementia
Reducing mortality
associated with alcohol and
smoking
Maximising King’s contribution towards
preventing disease e.g. smoking and alcohol
Improve surgery outcomes – enhanced recovery after surgery
(ERAS)
Chronic obstructive pulmonary
disease
Improve outcomes of patients with hip
fracture
Improve care of patients with hip fracture
Improve emergency abdominal surgery
outcomes
Pat
ien
t E
xper
ien
ce
Improve end of life care
Improve
outpatient experience
Improve experience of
cancer patients
Improve experience of cancer patients
Improve outpatient experience
Improve diabetes
care
Improve patient experience of
discharge
Improve experience of discharge for
patients
Improve experience and co-ordination of
discharge
Improve access to information for patients, service users, carers and
patients
Pat
ien
t S
afet
y
Improve identification and escalation of acutely ill patients
Management of acutely unwell
patient Reduction in falls Medication safety
Improve implementation of sepsis bundles
Minimise harm acquired in the
hospital
Surgical Safety
Checklist
Surgical safety
Safer surgery
Improve quality of the surgical safety checks
Enc.3.1.1
21
Performance against 2015/16 Quality Priorities
PRIORITY 1. Working to reduce preventable ill health
We said we would: Develop our acute sites as ‘health
promoting hospitals’, continuing the culture change started in 2014/15 to make health promotion mainstream.
Increase the number of staff trained to
support patients in reducing smoking and harmful alcohol use.
Increase provision of advice and brief
interventions relating to smoking and harmful alcohol use.
Increase referrals into smoking
cessation and alcohol services. Work with the providers of hospital
food, both on the wards and in our cafes, to promote and deliver healthier food.
Review ways in which we can increase
promotion of exercise to improve health.
Continue work to implement NICE
public health guidance. We were successful in: Rolling out screening programmes for
alcohol and smoking in 31 wards across both acute sites.
Providing brief intervention to all patients that smoke, and those who scored higher than three on the Fast Alcohol Screening Test (FAST) audit tool for alcohol.
Making both acute sites smoke free
and offering patients nicotine replacement therapy whilst in the hospitals.
Launching Carbon Monoxide
monitoring on two wards.
Increasing the numbers of referrals for smoking.
Reviewed the food provided and launched initiatives for promoting healthier eating for patients and staff.
We are also working: Completing training for staff, including
clinical and nurse leads, so they can support and provide screening and brief intervention for alcohol and smoking.
With the Department of Health’s
Prevention, Obesity and Diabetes team take forward obesity screening and related health promotion.
Expanding the screening programme
into paediatric asthma clinics and maternity services.
Developing plans for advice around physical activity for patients and staff.
Developing more initiatives around
balanced diet and healthier food choices.
INSERT IMAGE/QUOTE
Enc.3.1.1
22
PRIORITY 2. Improving outcomes following hip fracture
We said we would: Increase the proportion of patients
getting the surgery they need to repair their hips in less than 36 hours.
Ensure that all patients receive the physiotherapy they need.
Ensure effective shared care between orthopaedics and geriatrics.
Increase the proportion of patients who have a geriatric assessment within 72 hours.
Ensure all patients are tested for delirium before and after surgery.
Ensure all patients have a falls assessment and a bone health review.
Increase the proportion of our patients who have an admission anaesthetic review prior to surgery, to ensure that our patients are in the best health for surgery.
Focus on the care pathway for hip fracture patients on both of our acute hospital sites of, Denmark Hill and the PRUH.
We were successful in: Achieving all these criteria for all our
patients above the national target level since August 2015 (see Figures 1 and 2). When we began this work three years ago, we met the criteria for all patients in just 4% of cases on our Denmark Hill site. We now meet all the criteria for 70% of patients, exceeding the national target of 60%, and meaning that King’s is now one of the best performing Trusts in the country.
Reducing the length of stay for our hip fracture patients cared for in our new hip fracture care areas – by an average of 10 days at Denmark Hill and 9 days at the PRUH.
2: Achievement of all best practice criteria (Denmark Hill)
3: Achievement of all best practice criteria (PRUH)
We are also working: Developing an early mobilisation
protocol for patients.
Development of post-operative care protocol, across both of our sites, and embed this in our Electronic Patient Record system.
Continuing to ensure effective support for these vulnerable patients from our care-of-the-elderly teams.
To streamline our discharge processes and ensure patient and family involvement.
To ensure that our new care pathways are embedded and continue to work well to improve patient care on both of our main acute sites.
Enc.3.1.1
23
PRIORITY 3. Improving experience and coordination of discharge
We said we would: Southwark and Lambeth Integrated
Care (SLIC): Achieve integrated working in the hospital environment building better communications between all parties (internal & external) to facilitate safer patient discharge.
SLIC: Increase and embed Care Home interface meetings - group including hospital and care home managers to enable effective admission and discharge communications.
Continue to increase usage and profile of Homeless team.
Increased usage of the @Home service across all specialties.
Improve timeliness and quality of information around medications for patients and carers.
Ensure all inpatient wards have
individual actions plans to improve discharge, share good practice and innovative ideas.
Ensure all patients who have received care from a therapist has a detailed discharge summary sent to their GPs.
Increase the number of discharges before 11:00 at PRUH.
Ensure a robust referral system to
external agencies such as, Bromley Health and Medihome.
Implement criteria led discharge
throughout medicine and surgery at PRUH.
Commit to Care ward accreditation system discharge indicators to be green across the organisation.
Embed telephone follow-up calls to as routine in all appropriate in patient wards areas (50% in first 6 months up to 85% by year end).
We were successful in: With SLIC, implementing a successful
pilot of an integrated approach to discharge on Donne ward which is now informing how we develop our teams going forward. Time taken for ward based assessments reduced from 22 days to 6 days during the pilot period.
With SLIC, developing and rolling out a Transfer of Care Bundle setting out best practice steps for discharge from hospital to Care Homes. Readmission rates from Care Homes reduced from 22% to 6% during the test period.
Getting @Home established as the
first choice provider for acute out of hospital care for our local Lambeth and Southwark discharges.
Developing our KHP Homeless Team,
linking directly with the new SLaM service to join up support and planning for patients with mental and physical health needs.
Establishing a Transfer of Care
Bureau in autumn 2015 to support discharges and associated communication across the PRUH site.
Finalising a SOP for board rounds at the PRUH with clear roles and responsibilities for discharging patients before lunch.
Introducing registered nurses to the discharge lounge of the PRUH to facilitate patients moving from ward areas.
Introducing use of electronic integrated assessment form now on EMIS system which is used by Bromley GP and community providers.
Enc.3.1.1
24
Rolling out electronic notifications of assessment and discharge now.
Commencing criteria led discharge on
surgical wards at weekends at the PRUH site.
Adopting C2C ward accreditation system for discharge indicators to reflect the changes above.
We are also working: Developing our Integrated Care and
Partnership structure as SLIC comes to an end (March 2016) ensuring effective ongoing links with community, social care and voluntary sector providers.
Developing a more integrated approach to hospital discharge, responding to both local CCG and NHS England CQUINs.
Completing baseline ward audits
which use the safer care bundle to assess ward discharge processes.
Identifying an exemplar ward to and
then developing appropriate actions plans.
INSERT IMAGE/QUOTE
PRIORITY 4. Improving the experience of cancer patients
We said we would: Ensure that all the core MDT members
(doctors and CNSs) are trained in national advanced communication skills training.
Ensure that all patients are seen by the CNS/support worker at diagnosis.
Increase the number of holistic needs assessments undertaken within 31 days of diagnosis and within 6 weeks of completion of treatment.
Ensure all patients receive a FU call from the CNS teams within 48 hours of diagnosis, and within 24 hours of discharge from hospital following treatment.
Ensure that the CNS teams review inpatients at least once during their in-patient stay in order to provide further information and support.
Ensure patients and GPs are provided with an end of treatment summary or care plan.
Establish health and well-being events for patients (for example HOPE courses).
Undertake specialist training for nurses and HCAs on the in-patient wards.
Work with Macmillan to develop the band 4 support worker role in each MDT – an innovative role aimed at helping patients to navigate through their pathways and to provide ‘one to one support’.
Introduce designated nurse led pre-assessment clinics for patients commencing chemotherapy treatment.
Continue with the rolling annual internal peer review of each MDT – holding teams to account for progress
Enc.3.1.1
25
being made against their patient experience action plans.
Develop a designated cancer
information hub in the PRUH Chartwell unit and work with Macmillan to ensure that information pods are available in key areas throughout the PRUH.
Establish a Trust cancer patient experience steering group.
Develop KPIs for the CNS teams, which aid to hold the teams to account for quality improvements.
We were successful in: Securing funding to run four advanced
communication courses for 40 MDT members.
Getting 88% of patients seen by the CNS at diagnosis. The LCA data showed that the Trust was ranked 7th for compliance out of 157 trusts.
Offering patients a HNA at diagnosis in all services and approximately 20% receive one at completion of treatment and this is on an upward trajectory.
Getting more clinical specialties to provide end-of-treatment summaries. This is on an upward trend.
Having a higher presence of CNS’s visiting the wards providing some teaching.
Holding Health and Well Being (HWB) sessions. Two breast specific sessions took place in 2015 with approximately 30 patients in attendance. One generic HWB session focusing on mainly colorectal, haematology and hepatobiliary was also held with 14 patient’s attending.
Inviting all patients to a nurse led pre-
assessment clinic prior to commencing chemotherapy.
Rolling programme of peer review continues for all Cancer MDT’s with
patient experience being the core element for discussion
3 information stands have been funded for the PRUH by Macmillan.
We are also working on: KPI’s for the CNS’s have been written
and will be implemented by April 2016.
Plans to hold six HWB events in 2016 (2 breast and 4 generic).
Continuing to engage patients’ help to design services to meet their needs.
4: Macmillan Information Pods
Enc.3.1.1
26
PRIORITY 5. Medication Safety We said we would: Reduce incidents involving
administration of drugs to patients with known allergies.
Increase in the percentage of nursing staff passing the drug calculation competency assessment at 100%.
Reduce the number of medication
errors involving the wrong patient. Reduce incidents involving 10-fold
errors. We were successful in: Achieving a modest reduction in the
number of incidents involving administration drugs to patient with known allergies reported. This moved from 59 in 2014/15 to 48 (as at February 2016) in 2015/16. The majority of clinical areas are recording 0-1 per month – these are very low compared to the total number of medications administered and further benchmarking is required to assess the scale of this as an issue.
Increasing the percentage of nursing staff passing the drug calculation competency to 52% (excluding new starters). This is a good result given it was a new initiative starting from a baseline of zero in 2015 (calculation based on existing workforce).
Reducing the total number of medication errors to 65 in 2015/16 (79 in 2014/15). The small reduction is very positive but has now plateaued at 7-8 per month.
In year, quarter on quarter there has
been a reduction in 10-fold errors data (10 in Q1; 7 in Q2; 9 in Q3; and 4 in the first 2 months of Q4). Because the data for 2014/15 was incomplete, it is not possible to carry out a year on year analysis but it is encouraging to note the reduction in each quarter.
We are also working on: Developing dose verification chart in
paediatrics to further reduce incidence of tenfold errors.
Amending Denmark Hill discharge letters to include allergy status as part of new EPR upgrade – this will improve the communication of allergy statuses between secondary and primary care.
Rolling out patient wristband printers for Minors and Urgent Care Centre in the Emergency Department to help reduce medication errors from patient misidentification.
An emerging theme from medication incidents in the last year is the number of delayed or omitted medications. Work has been targeted to reduce the number of medicines omitted, including specific training sessions for PDNs and focus groups to identify the underlying reasons for omissions.
INSERT IMAGE/QUOTE
Enc.3.1.1
27
PRIORITY 6. Safer Surgery We said we would: Develop and implement a strategy to
ensure the surgical safety checklist (SSC) is integrated into the working practices of all theatre and/or interventional teams. Improvement was to be assessed against the following objectives: Zero Surgical Never Events.
100% compliance with completion of safer surgical checklist.
>75% compliance with quality of checks performed.
20% improvement in Surgical Safety Culture rating.
We were successful in: Improving the quality of the surgical
safety checks that are performed from 41% in 2014/15 to 61% in 2015/16 (as measured by the annual observational audit). As one of the Trust’s Sign-Up to Safety priorities the Trust has committed to improving the quality of checks by 10% year-on-year
In 2015/16, there was 97% compliance with completion of the checklist (in only 1 endoscopy list at PRUH was there no evidence it was completed).
In 2015/16, 8 surgical Never Events have been reported (as at 14/3/16) which is the same number as were reported in 2014-15. A number of the actions being taken to drive out Never Events are listed below
We are also working on: Revising doctor’s induction and e-
learning to reference surgical safety.
Making routine checklist completion data (broken down by speciality, theatre and surgeon) available on a regular basis to enable remedial
action (such as simulation training) to be focussed on high risk areas.
An externally facilitated training session, run annually on the combined surgical safety consultant development morning. Providing in-house simulation training to areas where particular concerns have been raised through audit or incident data.
Adding ‘Team Brief’ and ‘Debrief’ as a specific time slot on the Trust’s electronic theatre system (Galaxy) to ensure that time is available to perform team briefings and debriefings before and after each theatre list & that performance can be monitored.
Developing local surgical safety interventional procedure standards (LOCSSIPs) in accordance with recently published national standards for all specialties that undertake invasive procedures. Specialties will be asked to present these at the Surgical Safety Improvement Group by September 2016. Higher risk specialties (based on Never Event occurrence) will be prioritised.
A review of junior doctor competency sign-off to ensure that adequate training and support is available to junior staff undertaking invasive procedures using seldinger technique
Continued rollout of the seldinger invasive device insertion sticker and process (2 person contemporaneous check) across all areas (including non-ICU areas) where seldinger technique used
Enc.3.1.1
28
2016/17 Improvement Quality Priorities 2016/17 IMPROVEMENT PRIORITY 1. Enhanced recovery after surgery (ERAS) Aim is to improve outcomes following surgery by ensuring that all interventions clinically proven to have a positive impact are provided, and working well, in our hospitals. We will: Take actions to ensure that all the
relevant steps in the pathways are undertaken on all the Trust’s sites.
Review the pre-assessment, admission and discharge information provided to patients.
Initially work to build and develop from
areas already undertaking ERAS (colorectal, orthopaedic, cardiac and hepatobiliary).
Measures of success: Reduced length of stay.
No increase in emergency
readmission rate.
Increased day-of-surgery admission. 2016/17 IMPROVEMENT PRIORITY 2. Emergency abdominal surgery Aim is to improve outcomes following emergency abdominal surgery by ensuring a well-coordinated, standardised care pathway is in place at Denmark Hill and PRUH. We will: Improve data entry to the National
Emergency Laparotomy (abdominal surgery) Audit project and take local action to improve against the key audit criteria.
Develop internal outcomes monitoring management including sepsis management and decrease AKI progression.
Co-ordinate care of emergency surgery pathways and patient management.
iMobile review of post operative emergency laparotomy and or admission to critical care.
Measures of success: Improvement against key National
Emergency Laparotomy Audit (NELA) criteria, including: o Consultant surgeon review within
12 hours of admission.
o CT scan reported before surgery by a Consultant Radiologist or post FRCR SpR.
o Documentation of risk
preoperatively.
o Preoperative review by consultant surgeon and consultant anaesthetists.
o Consultant surgeon and
consultant anaesthetist present in theatre.
o Postoperative assessment by
care of the elderly specialist in patients aged over 70.
o Daily consultant review and clear
management pathway
o Reduced length of stay.
o Reduced mortality.
2016/17 IMPROVEMENT PRIORITY 3. Sepsis Aim is to improve implementation of sepsis bundles for patients with positive blood cultures and diagnosis of sepsis as defined by EPR order set. We will: Undertake an audit of all positive blood
cultures in early 2016/17 and review
Enc.3.1.1
29
adherence to sepsis bundles in order to achieve baseline data.
Patients with positive blood cultures to be reviewed at least once per day (7 days per week) by a consultant with a clear management plan and microbiology input into drug Rx and duration.
Develop an EPR order set for sepsis
(culture set) this will then allow assessment of this identified cohort against sepsis bundles , consultant and microbiology review
Measures of success: 50% improvement in sepsis bundle
implementation will be expected at the end of 2018-19.
Aim to decrease length of stay for patients with a diagnosis of sepsis.
2016/17 IMPROVEMENT PRIORITY 4. Surgical Safety Aim is to improve the quality of the surgical safety checks by 10% year-on-year, as measured by the annual surgical safety checklist observational audit and quality assessment. Specific focus on sign out. We will:
Training: Provide Annual simulation training on
one of the combined audit mornings.
Deliver in-house scenario training in hotspot areas.
Specific slot on new doctor’s induction
and e-learning.
Procedure and policy: Add ‘Team Brief’ and ‘Debrief’ as a
specific time slot on Galaxy to ensure that time is available to perform it and performance can be tracked.
Implementation of Local surgical safety invasive procedure standards (LocSSIPs) in all interventional areas by September 2016, focussing on
high risk areas first (as identified by previous Never Event and audit data).
Audit compliance of all areas as per Safer Surgery Improvement Group (SSIG) and ensure feedback to SSIG committee.
Feedback and audit
Twice-yearly observational audits in hotspot areas.
Continuation of annual observational audit of invasive procedures across all areas and sites.
Audit specific areas e.g. handover of
plan and procedures to Recovery, ward and CC areas. Define baseline mid-2016.
Measures of success: Audit of overall quality checks needs
to be increased to 92% form 62% by March 2019. Several associated performance indicators will also be measured: o Improvement in the
documentation of surgical handover to recovery and the ward. 50% improvement against baseline expected by March 2019.
o Audit of seldinger technique device insertion checklists. A baseline audit will be undertaken in early 2016/17 and a 50% improvement against baseline expected by March 2019.
o Audit of junior doctor competency
documents (to include competency in central line insertion, chest drain insertion, NGT placement confirmation through aspirate and x-ray interpretation).
o Improvement in the overall % of
procedures that have sign-in, time-out and sign-out recorded on Galaxy (to at least 95% by March 2019).
Enc.3.1.1
30
2016/17 IMPROVEMENT PRIORITY 5. Accessible information Aim is to improve access to information for patients, service users, carers and parents, where those needs relate to a disability, impairment or sensory loss. We will: Put systems in place to ensure that
invite letters for appointments and admission provide opportunity for patients and carers to highlight any adjustments that need to be made for their visits.
Put systems in place to ensure that inpatients assessment includes identification of any impairment or sensory loss and subsequent actions and adjustments.
Develop, pilot and implement
feedback tools for patients with communication difficulties / learning disability.
Training and support King's
Foundation Trust Members / Volunteers to support gathering of feedback in targeted areas of need
Ensure admission, pre assessment
and discharge information is appropriate.
Measures of success: Associated audits demonstrate good
rates of responsiveness, action and patient feedback.
2016/17 IMPROVEMENT PRIORITY 6. Improving outpatient experience Aim improve one key metric where our performance is particularly disappointing – communication in clinic about delays We will Identify specific divisions and
specialties where the most improvement is required for the question “If you had to wait for your appointment, were you told how long you would have to wait?”
Roll-out the Trust’s ‘Experience’
patient feedback reporting system within target areas to provide staff with timely and accessible patient feedback.
Increase survey response rates in our
focus areas to ensure that improvement plans are based on robust data.
Improve information and
communication about waiting. Measures of success Based on the ‘how are we doing?’
survey and Friends and Family Test data, identify clinics in two of our clinical divisions at both the PRUH and Denmark Hill which are most in need of improvement.
Identify areas where performance is good as a means to share good practice and learning.
Gather a better understanding of what
makes for poor experience and, importantly, how patients think we can improve by conducting interviews with patients and relatives.
Establish baseline data and agree
improvement targets. Key staff will have access to and
training on ‘Experience’ system Regular discussion of patient
feedback at clinical and operational team meetings.
‘You Said We Did’ posters to be
displayed in clinic areas. Develop plan to increase survey
responses.
Implement a range of accessible options for patients to provide feedback about their experience, e.g. the use of electronic surveys and
Enc.3.1.1
31
SMS and supported completion with the help of King’s volunteers.
Develop action plan for improvement.
Implement agreed improvement
interventions. Increase scores for “If you had to wait
for your appointment, were you told how long you would have to wait?”
Decrease in the number of negative
comments relating to information on waiting.
INSERT IMAGE/QUOTE
Enc.3.1.1
32
Statements of assurance from the board Relevant health services During 2015/16 the Trust provided and/or sub-contracted [9] relevant health services The Trust has reviewed all data avalaible to them on the quality of care in [all] these relevant health services. The income generated by the relevant health servives reviewed 2015/16 represents [100]% of the total income generated fromt heprovision of relevant health services by the Trust for 2015/16.
Clinical Audits and National Confidential Enquiries During the 2015/16, [50] national clinical audits and [2] national confidential enquires covered relevant health services that the Trust provides. During that period the Trust participated in [100]% national clinical audits and [100]% national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in. The national clinical audits and national confidential enquiries that the Trust was eligible to participate in during 2015/16 are listed on pages 142-146. The national clinical audits and national confidential enquires that the Trust participated (with data collection completed) during 2015/16 can be found on pages 142-146. The national clinical audits and national confidential enquires that the Trust participated in and for which data collection was completed during 2015/16 are listed on pages 142-146 alongside the
number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry. The NCEPOD studies the Trust participated in are detailed on page 146. The reports of [50] national clinical audit were reviewed by the provider in 2015/16 and the Trust intends to take the actions detailed on pages [147-165] to improve the quality of healthcare provided. The reports of [??] local clinical audits were reviewed by the provider in 2015/16 and The Trust intends to take the actions described on pages [166-168]. Information on participation in clinical research The number of patients receiving relevant health services provided or sub-contracted by the Trust in 2015/16 that were recruited during that period to participate in research approved by a research ethics committee was [13,384 – current figure needs to be updated with end-March data]. Clinical coding error rate Payment by Results (PbR)
King’s was not identified as necessary for a Payment by Results (PbR) clinical coding audit in 2015/16, however for Trusts that were subjected to PbR audit in 2014/15, the national average coding error rate identified in the Data Assurance Framework was 8.0% for inpatients.
From the above statements, assurance can be offered to the public that the Trust has in 2015/16:
Enc.3.1.1
33
Performed to essential standards (e.g. meeting CQC registration), as well as excelling beyond these to provide high quality care;
Measured clinical processes and performance to inform and monitor continuous quality improvement;
Participated in national cross-cutting project and initiatives for quality improvement e.g. strong and growing recruitment to clinical trials.
Payment by Results (PbR) The Trust was not identified as necessary for a Payment by Results (PbR) clinical coding audit in 2015/16, however for Trusts that were subjected to PbR audit in 2015/16, the national average coding error rate identified in the Data Assurance Framework was [8]% for inpatients. The percentage of records in the published data:
Patient’s valid NHS Number:
98% for admitted patient care; 99% for outpatient (non-admitted)
patient care; and 92.5% for accident and emergency
care.
Patient’s valid General Medical Practice code: 100% for admitted patient care; 99.8% for outpatient (non-
admitted) patient care; and 99.8% for accident and emergency
care. Information Governance Assessment The Trust’s Information Governance Assessment Report overall score 2015/16 was [74]% and was graded green (satisfactory)
Commissioning for Quality and Innovation (CQUIN) framework
The Trust income in 2015/16 was not conditional on achieving quality improvement and innovation goals through the Commissioning for Quality and Innovation payment framework because the Trust was operating on the default rollover tariff (DTR) and was therefore not entitled to access CQUIN funding. Therefore, King’s has agreed with its Commissioners the implementation of four Local Incentive Premium initiatives for the 2015/16 (£6.4m) in place of local CQUIN schemes and are listed below:
Local Incentive Premium Scheme 1 - Medicines Optimisation (DH)
Local Incentive Premium Scheme 2 - Care Planning (DH)
Local Incentive Premium Scheme 3 –
Prevention - Every Contact Counts (DH and PRUH)
Local Incentive Premium Scheme 4 –
Emergency Care (PRUH).
The value of the CQUIN for 14/15 was £17.5m.
Care Quality Commission+ The Trust is required to register with the Care Quality Commission (CQC) and its current registration status is requires improvement with no conditions. The Trust has not participated in any special reviews or investigations by the CQC during the reporting period. The CQC inspected all three hospital sites in April 2015. The Trust received a rating of requires improvement for the Denmark Hill and PRUH sites. Orrington Hospital received an overall rating of good. The trust continues to work on delivering actions against each of the ‘must do’ and ‘should do’ actions. These actions are
Enc.3.1.1
34
being reviewed through the CQC Steering Group and at executive meetings, with up-dates to the Board of Directors. Inadequate ratings at core services level at the PRUH related to below. Patient flow in PRUH urgent and emergency services The Trust commissioned and delivered an Emergency Pathway Whole System review. We engaged with over 100 stakeholders to understand the root causes of poor performance in Emergency Care across the entire South East health care economy and what needs to be put in place for the end to end emergency care pathway to achieve the desired quality, safety and patient experience. The resulting PRUH Emergency Care Recovery Plan has been put in place comprising: Improvement to patient flow for
supported and simple discharge through creation of a supported Transfer of Care Bureau with the mandate and authority to manage the interface between in-hospital and out-of-hospital services.
Improvement to the management of patient flow through the Emergency Department and enhancement of Emergency Department’s controllable processes.
Improvement of time from referral to
be seen by specialists through agreement of new Standard Operating Procedures for timely patient handover and its implementation between Emergency Department and specialty teams.
Creation and implementation of a
sustainable performance management
system (in-hospital and between PRUH and out of hospital services)
Creation of a separate emergency pathway for frail elderly patients and provision of alternative treatment options beyond inpatient care.
All key milestones on the Emergency Department Recovery Plan have been met, but the Trust still continues to face challenges related to activity levels. Waiting times and patient flow in PRUH outpatient department are being addressed through: A review of booking and scheduling of
existing capacity to support demand and capacity analysis of key specialties, which was completed.
Ongoing review of utilisation of Outpatient Department capacity across the Trust by Outpatient Steering Group and review of how QUIPP Programme can be utilised to reduce new and follow-up attendances. This will feed into the scoping of the outpatient transformation programme (see below).
Scoping of outpatient transformation work stream currently undertaken to achieve step change in outpatient patient flow. Work to cover all areas from booking to in-clinic processes.
Actions to address key issues underlying the rating of requires improvement
Referral to treatment times at Denmark Hill and PRUH: To enable the Trust to improve its performance against the national referral to treatment targets a programme of work
Enc.3.1.1
35
was completed. This Referral to Treatment Recovery Plan included development and implementation of policies, procedures, training and education, standard operating procedures, action cards, standardisation of documentation, launch of RTT systems and reporting, including trust-wide Patient Tracker List, nationally compliant reporting rules and validation timelines. This has provided a clear understanding of the number of patients waiting. Patients are now prioritised and seen as appropriate to reduce the backlog. Documentation of care, including incomplete records, DNACPR documentation and safer surgery checklist These actions all include improvement of process, staff skills and knowledge as well as improvement in monitoring and ensuring that processes are being followed. This work is still ongoing and we expect to achieve significant milestones in Quarter 4 2015/16 and in autumn 2016. We are also introducing e-DNACPR forms by the end of 2016 at DH and in December 2017 at the PRUH. CQC also commented on availability of paper records at the PRUH. Availability of paper notes in clinic at PRUH improved to 94% in November 2015. Work is ongoing with next milestones to be achieved in March 2016 and introduction of EPR at the PRUH towards beginning of 2017. Environment and Capacity Denmark Hill’s environments for Liver and Renal outpatients, Maternity and Critical Care wards and PRUH’s Surgical Admission Lounge were found to require improvement. Where possible, changes to the environment have been, or are currently being made. Alternatively services have been moved to locations that better meet patients’ needs.
Regular reviews of capacity are in place for areas with capacity constraints ensuring that patient safety is maintained. Where required practice has been reviewed and changes communicated to staff to ensure that capacity is managed as efficiently as possible. All capacity issues have been resolved within the limitations of the existing estate of DH. We are in the process of building a new Critical Care Unit with a planned completion date of early 2018. A consultation for the move of the surgical admission lounge at the PRUH is currently being undertaken and the move will take place as soon as issues have been resolved. Improving skills, knowledge and processes to improve patient safety The trust is improving the up-take of training on Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards for staff working in the Emergency Department, Medical Care, Surgery and Children’s. We also appointed MCA leads for both sites and are reviewing all policies and guidance to support staff in meeting their responsibilities. This work is progressing at pace and completion is planned for December 2016. At the DH site a clear pathway for the admission and discharge of end of life care patients with T34 pumps in situ has been developed, published and communicated to relevant staff. Relevant staff have been trained to switch pumps on admission. 24/7 access to trained staff is available to ensure patients receive appropriate care at the right time. Assurances have been received that risks are managed appropriately. An internal audit report on the effectiveness of the CQC action plan is currently awaited and will inform any
Enc.3.1.1
36
further actions that need to be taken to ensure robustness of our actions on our journey to an outstanding CQC rating. The Trust will be taking the following actions to improve data quality: Training programmes have been
established in 2015/16 to deliver education on waiting list and RTT and the impact of poor data quality on these items.
Uncashed appointments have been highlighted trust-wide as an area of focus. These have a significant financial impact along with impact on waiting lists, operational planning and finances.
In conjunction with the RTT training a review was undertaken of outpatient procedures undertaken at Denmark Hill and recording commenced in September 2015.
GP practice closures have now had a systematic approach applied to them and all patients at these practices are traced to minimise clinical risk.
A significant amount of work has been invested across BIU to improve the data quality of our SUS and contract monitoring data which has suffered significantly since the acquisition of SLHT services. The work has also uncovered many data quality issues relating to commissioning data – this work has informed the 2016/17 planning round and has enabled a more robust understanding of our data both internally and externally.
Work has been continuing on aligning
all centrally reported data which has allowed many operational reports to be rolled out across all sites, allowing greater transparency across the trust.
Actions planned for 2016/17:
Continuing the existing trust-wide training programme for all outpatient staff to ensure all outcome fields and referral information is complete to assist with waiting list monitoring, therefore improving quality of care and also to ensure all appointments are charged for.
The recording of outpatient procedures at Denmark Hill will continue to be monitored and will become a key income stream for 2017/18 – this has historically been an area of very poor data quality for the trust and some services running at a loss due to under-recovery of income.
Continue progress on aligning all data
systems trust-wide to allow for easier operational reporting and minimising duplication of work.
These statements are included in accordance with both Monitor’s NHS Foundation Trust Annual Reporting Manual (December 2013) for the quality report, as well as the Department of Health’s Quality Accounts Regulations (2013, 2012, 2011, 2010).
INSERT IMAGE/QUOTE
Enc.3.1.1
37
Statement of assurance evidence
The following list is based on that produced by the Department of Health and Healthcare Quality Improvement Partnership (HQIP). Audit Title Reporting period Participation Number (%) of cases submitt
National Diabetes Adult 01/01/13 - 31/03/15 Yes 5323 cases (100%).
National Diabetes Footcare Audit
14/07/15 - 31/03/16 Yes Data collection in progress until Jul-16.
National Inpatient Audit 21/09/15 - 25/09/15 Yes Due to be published Jul-16.
Pregnancy Care in Women with Diabetes
01/01/15 - 31/12/15 Yes Due to be published in 2016.
Adult Cataract Surgery 21/09/15 - 25/09/15 Yes Due to be published Dec-16.
Rheumatoid and Early Inflammatory Arthritis
Organisational audit: 01/07/15 - 31/07/15
Clinical Audit:
01/07/15 - 30/09/15
Yes Due to be published Jan-17.
Intensive Care National Audit and Research Centre (ICNARC) Case Mix Programme
- General Intensive Care Unit
01/04/15 – 30/06/15 Yes 100%.
National Emergency Laparotomy Audit
01/12/14 - 30/11/15 Yes Due to be published Jun-16.
NHS Blood and Transplant – Audit of Patient Blood Management in Scheduled Surgery
01/02/15 – 30/04/15 Yes 55 cases (100%).
NHS Blood and Transplant – Audit of the Use of Blood in Haematology
01/01/16- 26/02/16 Yes Due to be published Jul-16.
NHS Blood and Transplant – Audit of the Use of Blood in Lower Gastrointestinal Bleeding
01/09/15 – 31/10/15 Yes Due to be published Mar-16.
Inflammatory Bowel Disease – Biologics Audit
11/09/11 – 29/02/16 Yes Data collection in progress until Mar-16.
Enc.3.1.1
38
Audit Title Reporting period Participation Number (%) of cases submitt
Oesophago-gastric Cancer 01/04/14 – 31/03/15 Yes Data collection in progress until Mar-16.
ICNARC Case Mix Programme
- Liver Intensive Therapy Unit (LITU)
01/07/15 – 30/09/15 Yes 100%
Liver Transplant 01/04/06 – 31/03/16 Yes Due to be published Sep-16.
Renal Registry 01/01/15 – 31/12/15 Yes Due to be published Dec-16.
Bowel Cancer 01/04/14 – 31/03/15 Yes Due to be published Dec-16.
Falls and Fragility Fractures Programme - National Hip Fracture Database
01/01/15 – 31/12/15 Yes Due to be published Sep-16.
Falls and Fragility Fractures Programme - Fracture Liaison Service Database
01/01/16 – (end date TBC)
Yes Data submission cut-off date and publication date not yet confirmed by audit supplier.
Falls and Fragility Fractures Programme - National Audit of Inpatient Falls
12/05/15 – 13/05/15 Yes 60 cases (100%)
National Complicated Acute Diverticulitis
01/07/15 – 30/09/15 Yes Due to be published Feb-16.
National Joint Registry 01/01/15 – 31/12/15
Yes Due to be published Sep-16.
Prostate Cancer 01/08/14 – (end date TBC)
Yes Data submission cut-off date and publication date not yet confirmed by audit supplier.
National Patient Reported Outcome Measures (PROMs) Programme
01/04/14 – 31/03/15 Yes Groin hernia surgery: 16%
Varicose vein surgery: 69%
Hip replacement surgery: 88%
Knee replacement surgery: 98%
National Adult Cardiac Surgery Audit
01/04/14 – 31/03/15 Yes Due to be published Sep-16.
Acute Coronary Syndrome or Acute Myocardial Infarction
01/04/14 – 31/03/15 Yes Due to be published Apr-16.
Enc.3.1.1
39
Audit Title Reporting period Participation Number (%) of cases submitt(MINAP)
Cardiac Rhythm Management 01/04/14 – 31/03/15 Yes Due to be published Apr-16.
Congenital Heart Disease - Adults
01/04/14 – 31/03/15 Yes Due to be published Apr-16.
National Audit of Percutaneous Coronary Interventional Procedures
01/01/2015 -31/12/2015
Yes Publication date not yet confirmed by audit supplier.
National Heart Failure Audit 01/04/14 – 31/03/15 Yes Due to be published Apr-16.
Sentinel Stroke National Audit Programme (SSNAP) - Clinical Audit
01/04/14 – 31/03/15 Yes DH HASU = 80-89%; PRUH HASU = 90%; DH and
PRUH stroke units = 90%+
National Vascular Registry – Abdominal Aortic Aneurysm Repairs
01/10/14 – 31/09/15 Yes Publication date not yet confirmed by audit supplier.
National Vascular Registry – Carotid Endarterectomy
01/10/14 – 31/09/15 Yes Publication date not yet confirmed by audit supplier.
UK Parkinson’s Audit: Occupational Therapy Speech and Language
Therapy Physiotherapy Patient Management
Elderly Care and Neurology
30/04/15 - 30/09/15 Yes Due to be published Mar-16.
College of Emergency Medicine - Procedural Sedation in Adults
01/08/15 – 31/01/16 Yes Due to be published May-16.
College of Emergency Medicine - VTE Risk in Lower Limb Immobilisation
01/08/15 – 31/01/16 Yes Due to be published May-16.
Emergency Oxygen 15/08/15 – 01/11/15 Yes 186 cases
Lung Cancer 01/01/15 – 31/12/15 Yes Due to be published Dec-16.
National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme – Pulmonary Rehabilitation Service Clinical Audit
12/01/15 – 10/04/15 Yes Due to be published Feb-16.
National COPD Audit Programme – Pulmonary
12/01/15 – 24/04/15 Yes 100%
Enc.3.1.1
40
Audit Title Reporting period Participation Number (%) of cases submittRehabilitation Service Organisational Audit
Trauma Audit and Research Network (TARN)
01/01/15 – 31/12/15 Yes 715 cases
UK Cystic Fibrosis 01/01/15 – 31/12/15 Yes Due to be published Aug-16.
ICNARC National Cardiac Arrest Audit
01/04/15 – 31/03/16 Yes Due to be published Jun-16.
Maternal, Newborn and Infant Clinical Outcome Review Programme
01/04/13 – 31/12/15 Yes 100%.
Medical and Surgical Clinical Outcome Review Programme
See information below on NCEPOD
participation
Yes See information below on NCEPOD participation.
National Neonatal Audit Programme
01/01/15 – 31/12/15 Yes Due to be published Nov-16.
National Paediatric Diabetes Audit
01/04/15– 31/03/16 Yes Due to be published Nov-16.
Paediatric Asthma 01/11/15 - 30/11/15 Yes Data collection in progress.
Paediatric Intensive Care Audit Network
01/01/12 – 31/12/14 Yes Data collection in progress.
College of Emergency Medicine - Vital Signs in Children
01/08/15 – 31/01/16 Yes Due to be published May-16.
Adult Asthma N/A N/A Did not collect data 2015/16.
Child Health Clinical Outcomes Programme
N/A N/A Did not collect data 2015/16.
Chronic Kidney Disease in Primary Care
N/A N/A Not applicable to secondary care providers.
Congenital Heart Disease - Paediatric
N/A N/A Service not provided at KCH.
Head and Neck Oncology N/A N/A Service not provided at KCH.
National Audit of Dementia N/A N/A Did not collect data 2015/16.
National Audit of Intermediate Care
N/A N/A Service not provided at KCH.
Mental Health Clinical Outcome Review Programme:
N/A N/A Service not provided at KCH.
Enc.3.1.1
41
Audit Title Reporting period Participation Number (%) of cases submittNational Confidential Inquiry into Suicide and Homicide for people with Mental Illness
Non-Invasive Ventilation - Adults
N/A N/A Did not collect data 2015/16.
Paediatric Pneumonia N/A N/A Did not collect data 2015/16.
Prescribing Observatory for Mental Health
N/A N/A Service not provided at KCH.
Pulmonary Hypertension Audit
N/A N/A Service not provided at KCH.
Trust participation in NCEPOD Studies
NCEPOD Title Reporting period Participation % of cases submitted
Acute Pancreatitis 01/01/14 – 30/06/14 Yes Clinical Questionnaire returned = 10/10 (100%). Case notes returned = 8/10 (80%); Organisational questionnaire returned =2/2 (100%)
Mental Health in General Hospitals
13/10/14 – 13/11/14 Yes Due to be published Oct-16.
Clinical audit projects reviewed by the Trust Key: King’s National Clinical Audit Rating Symbol Definition
Positive analysis: Outcome measures better than or within expected range, underperformance against <50% process targets with no demonstrable impact on patient outcome.
Neutral analysis: Outcome measure within expected range, underperformance against >50% process targets with no demonstrable impact on patient outcome.
Negative analysis: Outcome measure outside (below) expected range - negative outlier, underperformance against significant key process targets.
Not applicable – service not provided at this location. National Audit Data source Summary of analysis Rating
DH PRUH
National Neonatal Audit Programme
Royal College of Paediatrics and Child Health (RCPCH), Nov-15
KCH performs above average for 3/5 process criteria. Reduced proportion of babies receiving mother’s milk on DH site – action is in progress.
Enc.3.1.1
42
National Audit Data source Summary of analysis Rating DH PRUH
Rheumatoid and Early Inflammatory Arthritis
British Society for Rheumatology, Jan-16
Reduction in Disease Activity Score by at least 1.2 – KCH achieved 71% for this key outcome measure – above national average (62%). 79% of patients were seen within 3 weeks (national average 38%). Similar to national average for referral, treatment initiation, educational support and treatment target achieved. Data quality issues in completing Rheumatoid Arthritis Impact of Disease score (RAID) – action in progress.
(ICNARC) Case Mix Programme
- General Intensive Care Unit
ICNARC, 02/04/15 – 30/06/15
PRUH is within expected range for survival.
(ICNARC) Case Mix Programme
- General Intensive Care Unit
ICNARC, 01/01/15 – 31/03/15
DH is within expected range for survival.
National Emergency Laparotomy Audit (NELA)
Royal College of Anaesthetists, Jun-15
KCH is below national average against many criteria, significantly influenced by data collection issues. Actions are being taken to improve data collection in the current cycle. This is a Trust Quality Priority for 2016/17.
Audit of Patient Blood Management in Adults undergoing Elective, Scheduled Surgery
NHS Blood and Transplant, Oct-15
KCH performed in line with or above the national average for 8/11 key indicators.
UK Inflammatory Bowel Disease (IBD) Audit:
National Clinical Audit of Biological Therapies
- Adult
Royal College of Physicians, Sep-15
Numbers too small to make quality of care conclusions from results (small numbers nationally). Actions taken at DH and PRUH demonstrate improved data capture across sites.
IBD Audit: National Clinical Audit of Biological Therapies – Paediatric
Royal College of Physicians, Sep-15
DH demonstrated compliance with NICE Technology Appraisal 187.
Enc.3.1.1
43
National Audit Data source Summary of analysis Rating DH PRUH
National Oesophago-Gastric Cancer Audit
Health and Social Care Information Centre (HSCIC), published Nov-15
DH and PRUH patients receive treatment at GSTT. The complication rate achieved by GSTT, at 5.2%, is the lowest achieved by a London Trust. The adjusted 30-day and 90-day mortality rates achieved by GSTT are within expected range at 1.4% and 2.9% respectively.
King’s adjusted emergency re-admission rate of 23% has been incorrectly assigned a green rating in the audit report - it should have received a red rating and is currently under investigation.
(ICNARC) Case Mix Programme - Liver Intensive Care Unit (LITU)
ICNARC, 01/07/15 – 31/09/15
DH is within expected range for survival.
Liver Transplantation Audit – Adults and Paediatrics
NHS Blood & Transplant, Apr-15
KCH has the highest 90-day survival rate nationally for elective liver transplants in adults. KCH within expected range for all indicators.
Annual Report on Liver Transplantation – Adult
NHS Blood and Transplant, Sep-15
DH has the highest 1-year risk-adjusted survival rate nationally for super-urgent transplants. DH within expected range for survival.
Annual Report on Liver Transplantation – Paediatric
NHS Blood and Transplant, Sep-15
DH is within expected range for survival.
Renal Registry Renal Registry, Dec-16
KCH one-year-after-90-day incident survival (adjusted to age 60) from the start of renal replacement therapy is similar to the national average (KCH 90.0%, national average 91.8%), even though King’s has the 2nd highest rate in England of patients starting on renal replacement therapy who have diabetes, and the highest in London, at 39.2%.
National Bowel Cancer Audit
Health and Social Care Information Centre, Dec-15
KCH (and network) adjusted 90-day and 2 year mortality rates are within expected range, 90-day unplanned readmission and 18-month stoma rate within expected range.
National Bowel Health and Social The Trust achieved a lower risk adjusted
Enc.3.1.1
44
National Audit Data source Summary of analysis Rating DH PRUH
Cancer Audit – Consultant-level Outcomes
Care Information Centre, Dec-15
90-day mortality than the national average.
Falls and Fragility Fractures Programme: National Hip Fracture Database (NHFD) Annual Report 2015 – published report (based on Jan – Dec 2014 data).
National Hip Fracture Database, Sep-15
The published report, based on 2014 data, shows both sites below national average against many criteria. At the PRUH the rates for patients sustaining a hip fracture as an in-patient and the 30 day mortality rate are reported as being above the NHFD average.
NHFD online, however (based on data to Dec-15), shows that both sites have performed above the national average from August 2015. Hip Fracture was a Trust Quality Priority 2015/16, focusing on improving the achievement of all 9 best practice criteria – significant improvements have been achieved at both Trust sites (see Quality Priorities section).
Falls and Fragility Fractures Programme: National Audit of Inpatient Falls
National Hip Fracture Database, Oct-15
KCH has the lowest rate of falls per 1,000 occupied bed days (OBDs) in London and the 3rd lowest rate nationally. KCH has the 3rd lowest rate of falls leading to moderate/ severe harm or death per 1,000 OBDs in London.
KCH is below national average against a number of process measures. Actions already planned across sites to improve practice.
National Joint Registry – Enhanced Surgeon and Hospital Information
National Joint Registry, May-15
KCH is within expected range for patient-reported outcomes for hip and knee replacement surgery.
Orpington
National Joint Registry
National Joint Registry Centre, Sep-15
KCH is within expected range for 90-day mortality following hip and knee replacement and for hip and knee revision rate.
Orpington
National Joint Registry – Enhanced Surgeon and Hospital Information
National Joint Registry – online, Nov-15
Patient-Reported Improvement Measures, 90-day mortality and revision rates are within expected range for hip and knee replacement. Consent rate is
Orpington
Enc.3.1.1
45
National Audit Data source Summary of analysis Rating DH PRUH
better than expected at Denmark Hill and Orpington.
National Prostate Cancer Audit – a) Organisational
Audit, and b) Clinical Audit
National Prostate Cancer Audit, Feb-15
Treatment is provided by an integrated Guy’s and St Thomas’ (GSTT) & King’s College Hospital (KCH) team – KCH provides all recommended diagnostic and support service facilities.
Results are reported by GSTT.
Adherence to British Society for Clinical Neurophysiology (BSCN) and Association of Neurophysiological Scientists (ANS) Standards for Ulnar Neuropathy at Elbow (UNE) testing
British Society for Clinical Neuro-physiology (BSCN) and Association of Neurophysiological Scientists (ANS), Nov-15
DH achieved 100% for 10/11 criteria.
The recording of hand temperature requires improvement, which is consistent with the national picture.
Adult Cardiac Surgery
Society for Cardiothoracic Surgery in Great Britain & Ireland (SCTS), Sep-15
Mortality rates are within expected range.
National Audit of Cardiac Rhythm Management Ablation Audit
National Institute Cardiac Outcomes & Research, Mar-15
DH undertakes in excess of the minimum number of procedures and is therefore not identified as an outlier.
Congenital Heart Disease Audit
British Congenital Cardiac Assoc, Jun-15
Mortality rates are within expected range.
Percutaneous Coronary Intervention (PCI) Audit
British Cardiovascular Intervention Society (BCIS), Oct-15
DH performed better than expected for freedom from in-hospital major adverse cardiac and cerebrovascular events. DH is within expected range for 30-day post-PCI survival.
National Heart Failure Audit
National Institute Cardiac Outcomes & Research, Sep-15
Mortality rates are within expected range.
Neurosurgical National Audit
Society of British Neurological
KCH is within expected range for 30-day standardised mortality rate.
Enc.3.1.1
46
National Audit Data source Summary of analysis Rating DH PRUH
Programme Surgeons, Dec-15
Sentinel Stroke National Audit Programme – Hyper Acute Stroke Unit (HASU)
Royal College of Physicians, Jun-15
DH HASU 3rd highest score compared to national peers; PRUH HASU 2nd highest.
Sentinel Stroke National Audit Programme - Hyper Acute Stroke Unit (HASU) data
Royal College of Physicians, Sep-15
PRUH HASU achieved the 2nd highest score compared to national peers; DH HASU 3rd highest.
Vascular Outcomes – Abdominal Aortic Aneurysm Repair and Carotid Endarterectomy Outcomes
NHS England Consultant Outcomes Publication, Sep-15
Mortality rates are within expected range.
College of Emergency Medicine Audit - Assessing for Cognitive Impairment in Older People in the Emergency Department
Royal College of Emergency Medicine, Jun-15
DH performed better or similar to national average for 3/6 standards, and PRUH for 5/6. Cognitive assessment at DH was recorded in 5% of cases (PRUH 60%, national average 11%).
College of Emergency Medicine Audit - Initial Management of the Fitting Child in the Emergency Department
Royal College of Emergency Medicine, Jun-15
Both sites performed at 98-100% against 4/5 standards. The provision of written safety information provided at discharge requires improvement, which is consistent with national picture.
College of Emergency Medicine Audit - Mental Health in the Emergency Department
Royal College of Emergency Medicine, Jun-15
DH performed better than national average for 7/8 standards, and PRUH for 6/8. Assessment by mental health practitioner within 1 hour: DH = 39%, PRUH = 0%, national average = 0%.
Documentation requires improvement.
Emergency Oxygen Audit
British Thoracic Society, Nov-15
61% of DH patients and 41% of PRUH patient did not have a prescription or bedside order in place. An action plan is in place.
National Adult Community Acquired
British Thoracic Society, Jun-15
Fewer in-patient deaths were reported compared to national average (but small
Enc.3.1.1
47
National Audit Data source Summary of analysis Rating DH PRUH
Pneumonia Audit numbers). Median length of stay at KCH was similar to national average (DH = 6 days, PRUH = 4 days, national average = 5 days).
National Lung Cancer Audit (NCLA)
The Royal College of Physicians, Dec-15
King’s performance equals or exceeds the level suggested in the NLCA report 2014, and is statistically better than the national average for: Anticancer treatment Non-small-cell lung cancer (NSCLC)
stage IIIB/IV and PS 0–1 having chemotherapy
3 out of 4 process, imaging and nursing measures equal or exceed the level suggested in the NLCA report. King’s performance is statistically similar to the national average for: NSCLC having surgery Small-cell lung cancer (SCLC)
patients having chemotherapy.
King’s is below the level suggested for ‘Patient seen by nurse specialist’, achieving 51.1% for this measure, compared to 80% recommended by the NLCA.
National Chronic Obstructive Pulmonary Disease Audit Programme - Clinical Audit
Royal College of Physicians, Feb-15
DH performed in line with or above the national average for 26/30 measures linked to national standards. PRUH performed in line with or above the national average for 18/30 measures. (4.3%).
National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme: Resources and Organisation of Pulmonary Rehabilitation Services in England and Wales
Royal College of Physicians and British Thoracic Society, Nov-15
Both DH and PRUH met all 10 organisational Quality Standards specified by the British Thoracic Society.
National Chronic Obstructive Pulmonary Disease (COPD) Audit
Royal College of Physicians, Feb-16
KCH performance was above national average for all key functional outcomes measures.
Enc.3.1.1
48
National Audit Data source Summary of analysis Rating DH PRUH
Programme: Pulmonary Rehabilitation Services in England and Wales Clinical Audit
Trauma Audit & Research Network (TARN) - Clinical Report Core Measures for All Patients: Thoracic and Abdominal Injuries/ Patients in Shock
TARN, Mar-15 South East London, Kent and Medway Trauma Network is the best performing network in comparison to all other Trauma Networks nationally.
DH survival is within expected range.
TARN - Major Trauma Dashboard
TARN, Jun-15 DH performance is better than or similar to national average for 7/8 criteria. The underperforming criteria relate to admission delays, mainly for stable spinal injury cases, due to in-patient capacity, flow and rehab capacity, which is on the Trust Risk Register.
TARN - Online Survival Data
TARN, Jul-15 More trauma patients admitted to KCH are surviving compared to the number expected, based on the severity of their injury.
TARN - Clinical Report II Core Measures for all patients: BOAST 4 eligible fractures, Open limb fractures, Severe pelvic fractures
TARN, Aug-15 South East London, Kent and Medway Trauma Network is the best performing network in comparison to all other Trauma Networks nationally. DH survival is within expected range.
TARN - Major Trauma Dashboard
TARN, Aug-15 DH performed better than previous for 5/10 process criteria.
UK Cystic Fibrosis Registry 2014 Annual Data Report: Strength in Numbers a) Adults, and b) Paediatrics
Cystic Fibrosis Trust, Aug-15
The number of patients with chronic pseudomonas aeruginosa at KCH is below the national average; and KCH has the 2nd highest proportion of adult patients using preventative inhaled medication DNase, 8th highest for children.
National Cardiac Arrest Audit (NCAA)
ICNARC, Sep-15
KCH survival is within expected range.
Enc.3.1.1
49
National Audit Data source Summary of analysis Rating DH PRUH
National Paediatric Diabetes Audit Report 2013 - 14: Part One, Care Processes and Outcomes
Royal College of Paediatrics and Child Health (RCPCH), Sep-15
PRUH performed better than national average for 6/7 process criteria. DH and PRUH performed within NICE target range. DH performed better than national average for 3/7 process criteria. No patients received all process criteria.
Paediatric Intensive Care Audit Network (PICANet)
PICANet, Nov-15 The standardised mortality ratio at DH is one of the lowest nationally and the lowest compared to all London peer trusts.
Potential Donor Audit NHS Blood & Transplant
All process targets were exceeded.
The total number of organ donors fell, in line with the national picture.
Surgical Outcomes Audit - Nephrectomy
British Association of Urological Surgeons, Sep-15
DH is below the national average for the risk-adjusted complication, transfusion and mortality rates.
Surgical Outcomes Audit - Radical Prostatectomy
British Association of Urological Surgeons, Sep-15
DH achieved a 0% transfusion and complication rate.
Local Audits – CP to provide
Enc.3.1.1
50
Reporting against core indicators
All trusts are required to report against a core set of indicators, for at least the last two reporting periods, using a standardised statement set out in the NHS (Quality Accounts) Amendment Regulations 2012. Only indicators that are relevant to the services provided at King’s are included in the tables below.
Performance Measures Foundation Trusts Comparable Value
Ind
icat
or
Mea
sure
Cu
rren
t P
erio
d
Val
ue
Pre
vio
us
Per
iod
Val
ue
Hig
hes
t
Lo
wes
t
Nat
ion
al
Ave
rag
e
So
urc
e
Reg
ula
tory
S
tate
men
t
Su
mm
ary
Ho
spit
al
Mo
rtal
ity
Ind
ex
(SH
MI)
%01 July 2014 - 30 June 2015
89 01 July 2013 - 30 June 2014
91 TBC TBC TBC NHS IC
The [name of trust] considers that this data is as described for the following
reasons [insert reasons]. The [name of trust] [intends to take/has taken] the
following actions to improve this [percentage/proportion/score/rate/number], and so the quality of its services,
by [insert description of actions].
Pat
ien
ts d
eath
s w
ith
pal
liati
ve c
are
cod
ed a
t ei
ther
d
iag
no
sis
or
spec
ialit
y le
vel
%
01 October 2014 - 30
September 2015
41.84
01 October 2013 - 30
September 2014
34.3 TBC TBC TBC NHS IC
The [name of trust] considers that this data is as described for the following
reasons [insert reasons]. The [name of trust] [intends to take/has taken] the
following actions to improve this [percentage/proportion/score/rate/number], and so the quality of its services,
by [insert description of actions].
Enc.3.1.1
51
Performance Measures Foundation Trusts Comparable Value
Ind
icat
or
Mea
sure
Cu
rren
t P
erio
d
Val
ue
Pre
vio
us
Per
iod
Val
ue
Hig
hes
t
Lo
wes
t
Nat
ion
al
Ave
rag
e
So
urc
e
Reg
ula
tory
S
tate
men
t
Pat
ien
ts a
ged
0-
15 (
emer
gen
cy)
read
mit
ted
w
ith
in 2
8 d
ays
of
bei
ng
d
isch
arg
ed
%01 April 2015 -
31 January 2016
1.6 01 April - 31 December
2014 3.9 TBC TBC TBC
PiMS (2015/16), CHKS (2014)
The [name of trust] considers that this data is as described for the following
reasons [insert reasons]. The [name of trust] [intends to take/has taken] the
following actions to improve this [percentage/proportion/score/rate/number], and so the quality of its services,
by [insert description of actions].
Pat
ien
ts a
ged
16
+ o
r o
ver
(em
erg
ency
) re
adm
itte
d
wit
hin
28
day
s o
f b
ein
g
dis
char
ged
%01 April 2015 -
31 January 2016
8.7 01 April - 31 December
2014 4.5 TBC TBC TBC
PiMS (2015/16), CHKS (2014)
The [name of trust] considers that this data is as described for the following
reasons [insert reasons]. The [name of trust] [intends to take/has taken] the
following actions to improve this [percentage/proportion/score/rate/number], and so the quality of its services,
by [insert description of actions].
Ad
mit
ted
pat
ien
ts
wh
o w
ere
risk
as
sess
ed f
or
ven
ou
s th
rom
bo
emb
olis
m
%01 April 2015 - 31 December
2015 96.53
01 April 2014 - 31 March
2015
97.28
TBC TBC TBC VTE returns
The [name of trust] considers that this data is as described for the following
reasons [insert reasons]. The [name of trust] [intends to take/has taken] the
following actions to improve this [percentage/proportion/score/rate/number], and so the quality of its services,
by [insert description of actions].
Enc.3.1.1
52
Performance Measures Foundation Trusts Comparable Value
Ind
icat
or
Mea
sure
Cu
rren
t P
erio
d
Val
ue
Pre
vio
us
Per
iod
Val
ue
Hig
hes
t
Lo
wes
t
Nat
ion
al
Ave
rag
e
So
urc
e
Reg
ula
tory
S
tate
men
t
Cas
es o
f C
dif
fici
le
infe
ctio
n r
epo
rted
fo
r p
atie
nts
ag
ed 2
or
ove
r
Rat
e pe
r 10
0K b
ed d
ays
KCH APR15 - FEB16
Reportable cases rate
/100,000 bed days
(80) 18.49%
KCH 2014/15 Reportable cases rate
/100,000 bed days
(75) 15.43%
TBC TBC TBC
C-diff cases/KH03 G&A + Obs per 100,000.
Note: KH03
excludes Well
babies & Critical Care
The [name of trust] considers that this data is as described for the following
reasons [insert reasons]. The [name of trust] [intends to take/has taken] the
following actions to improve this [percentage/proportion/score/rate/number], and so the quality of its services,
by [insert description of actions].
Enc.3.1.1
53
Responsiveness to patients personal needs National 2014 Scores
Ind
icat
or
Mea
sure
Cu
rren
t P
erio
d
Val
ue
Pre
vio
us
Per
iod
Val
ue
Hig
hes
t
Lo
wes
t
Nat
ion
al
Ave
rag
e
Dat
a S
ou
rce
Reg
ula
tory
S
tate
men
t
Wer
e yo
u in
volv
ed
as m
uch
as
you
w
ante
d t
o b
e in
d
ecis
ion
s ab
ou
t yo
ur
care
an
d
trea
tmen
t?
Sco
re o
ut o
f 10
trus
t-w
ide 2014
National Inpatient Survey
7.0
2013 National Inpatient Survey
7.5 9.2 6.1
Not
ava
ilabl
e
CQC
The [name of trust] considers that this data is as described for the following
reasons [insert reasons]. The [name of trust] [intends to take/has taken] the
following actions to improve this [percentage/proportion/score/rate/number], and so the quality of its services, by
[insert description of actions].
Did
yo
u f
ind
so
meo
ne
on
th
e h
osp
ital
sta
ff t
o
talk
to
ab
ou
t yo
ur
wo
rrie
s an
d
fear
s?
Sco
re o
ut o
f 10
trus
t-w
ide 2014
National Inpatient Survey
5.2
2013 National Inpatient Survey
5.5 8.2 4.3 CQC
The [name of trust] considers that this data is as described for the following
reasons [insert reasons]. The [name of trust] [intends to take/has taken] the
following actions to improve this [percentage/proportion/score/rate/number], and so the quality of its services, by
[insert description of actions].
Wer
e yo
u g
iven
en
ou
gh
pri
vacy
w
hen
dis
cuss
ing
yo
ur
con
dit
ion
o
r tr
eatm
ent?
Sco
re o
ut o
f 10
trus
t-w
ide 2014
National Inpatient Survey
8.0
2013 National Inpatient Survey
8.7 9.4 7.5 CQC
The [name of trust] considers that this data is as described for the following
reasons [insert reasons]. The [name of trust] [intends to take/has taken] the
following actions to improve this [percentage/proportion/score/rate/number], and so the quality of its services, by
[insert description of actions].
Enc.3.1.1
54
Responsiveness to patients personal needs National 2014 Scores
Ind
icat
or
Mea
sure
Cu
rren
t P
erio
d
Val
ue
Pre
vio
us
Per
iod
Val
ue
Hig
hes
t
Lo
wes
t
Nat
ion
al
Ave
rag
e
Dat
a S
ou
rce
Reg
ula
tory
S
tate
men
t
Did
a m
emb
er o
f st
aff
tell
you
ab
ou
t m
edic
atio
n s
ide
effe
cts
to w
atch
fo
r w
hen
yo
u w
ent
ho
me?
Sco
re o
ut o
f 10
trus
t-w
ide
2014 National Inpatient Survey
4.3
2013 National Inpatient Survey
4.7 7.6 3.7 CQC
The [name of trust] considers that this data is as described for the following reasons [insert reasons]. The [name of trust] [intends to take/has taken] the following actions to improve this [percentage/proportion/score/rate/number], and so the quality of its services, by [insert description of actions].
Did
ho
spit
al t
ell y
ou
w
ho
to
co
nta
ct if
yo
u
wer
e w
orr
ied
ab
ou
t yo
ur
con
dit
ion
or
trea
tmen
t af
ter
you
left
h
osp
ital
?
Sco
re o
ut o
f 10
trus
t-w
ide
2014 National Inpatient Survey
7.3
2013 National Inpatient Survey
7.8 9.7 6.5 CQC
The [name of trust] considers that this data is as described for the following reasons [insert reasons]. The [name of trust] [intends to take/has taken] the following actions to improve this [percentage/proportion/score/rate/number], and so the quality of its services, by [insert description of actions].
Enc.3.1.1
55
Patient Friends & Family Tests Comparable
Foundation Trust Value
Ind
icat
or
Mea
sure
Cu
rren
t P
eri
od
Val
ue
Pre
vio
us
Per
iod
Val
ue
Hig
hes
t
Lo
wes
t
Nat
ion
al
Ave
rag
e A
pri
l 15
- J
an 1
6
Dat
a S
ou
rce
Reg
ula
tory
S
tate
men
t
Pat
ien
ts d
isch
arg
ed f
rom
A
ccid
ent
& E
mer
gen
cy
(typ
es 1
/2)
wh
o w
ou
ld
reco
mm
end
th
e T
rust
as
a p
rovi
der
of
care
to
th
eir
fam
ily o
r fr
ien
ds.
%
April 2015 - Jan 2016
(latest available data)
82
Oct 2014 March 15 (scoring
changed Oct 14)
80 100 52 86 NHS
England
The [name of trust] considers that this data is as described for the following reasons [insert reasons]. The [name of trust] [intends to take/has taken] the following actions to improve this [percentage/proportion/score/rate/nu
mber], and so the quality of its services, by [insert description of
actions].
Inp
atie
nts
th
e T
rust
as
a p
rovi
der
of
care
to
th
eir
fam
ily o
r fr
ien
ds?
%
April 2015 - Jan 2016
(latest available data)
94
Oct 2014 March 15 (scoring
changed Oct 14)
94 100 73 96 NHS
England
The [name of trust] considers that this data is as described for the following reasons [insert reasons]. The [name of trust] [intends to take/has taken] the following actions to improve this [percentage/proportion/score/rate/nu
mber], and so the quality of its services, by [insert description of
actions].
Enc.3.1.1
56
Staff – Friends & Family Test and National Staff Surveys
Comparable Foundation Trust
Value
Ind
icat
or
Mea
sure
Cu
rren
t P
eri
od
Val
ue
Pre
vio
us
Per
iod
Val
ue
Hig
hes
t
Lo
wes
t
Nat
ion
al
Ave
rag
e
Dat
a S
ou
rce
Reg
ula
tory
S
tate
men
t
Sta
ff e
mp
loye
d b
y, o
r u
nd
er c
on
trac
t w
ho
w
ou
ld r
eco
mm
end
th
e T
rust
as
a p
rovi
der
of
care
to
th
eir
fam
ily o
r fr
ien
ds.
%*
2015 National Staff Survey (Quarter 3)
3.7
2014 National Staff
Survey (Quarter 3)
3.88 4.10 3.3 3.76
NHS Annual Staff
Survey Results
The Trust considers that this data is as described as it has been taken from the nationally published staff survey results: http://www.nhsstaffsurveys.com/Caches/Files/NHS_staff_survey_2015_RJZ_full.pdf
Sta
ff e
xper
ien
cin
g
har
assm
ent,
bu
llyin
g o
r ab
use
fro
m s
taff
in t
he
last
12
mo
nth
s.
%*
2015 National Staff Survey (Quarter 3)
29
2014 National Staff
Survey (Quarter 3)
25 16 42 26
NHS Annual Staff
Survey Results
The Trust considers that this data is as described as it has been taken from the nationally published staff survey results: http://www.nhsstaffsurveys.com/Caches/Files/NHS_staff_survey_2015_RJZ_full.pdf
Enc.3.1.1
57
Staff – Friends & Family Test and National Staff Surveys
Comparable Foundation Trust
Value
Ind
icat
or
Mea
sure
Cu
rren
t P
eri
od
Val
ue
Pre
vio
us
Per
iod
Val
ue
Hig
hes
t
Lo
wes
t
Nat
ion
al
Ave
rag
e
Dat
a S
ou
rce
Reg
ula
tory
S
tate
men
t
Sta
ff b
elie
vin
g t
he
Tru
st
pro
vid
es e
qu
al
op
po
rtu
nit
ies
for
care
er
pro
gre
ssio
n o
r p
rom
oti
on
%*
2015 National Staff Survey (Quarter 3)
84
2014 National Staff
Survey (Quarter 3)
79 96 76 87
NHS Annual Staff
Survey Results
The Trust considers that this data is as described as it has been taken from the nationally published staff survey results: http://www.nhsstaffsurveys.com/Caches/Files/NHS_staff_survey_2015_RJZ_f
ull.pdf
*30% (255 staff responsed from a sample of 850 staff)
Enc.3.1.1
58
Patient Reported Outcomes Comparable
Foundation Trust Value
Ind
icat
or
Mea
sure
Cu
rren
t P
eri
od
Val
ue
Pre
vio
us
Per
iod
Val
ue
Hig
hes
t
Lo
wes
t
Nat
ion
al
Ave
rag
e
Dat
a S
ou
rce
Reg
ula
tory
S
tate
men
t
Pat
ien
t re
po
rted
o
utc
om
es m
easu
res
gro
in h
ern
ia s
urg
ery
The [name of trust] considers that this data is as described for the following reasons [insert reasons]. The [name of trust] [intends to take/has taken] the following actions to improve this [percentage/proportion/score/rate/number], and so the quality of its services, by [insert description of actions].
Pat
ien
t re
po
rted
o
utc
om
es m
easu
res
vari
cose
vei
n
surg
ery
The [name of trust] considers that this data is as described for the following reasons [insert reasons]. The [name of trust] [intends to take/has taken] the following actions to improve this [percentage/proportion/score/rate/number], and so the quality of its services, by [insert description of actions].
Enc.3.1.1
59
Patient Reported Outcomes Comparable
Foundation Trust Value
Ind
icat
or
Mea
sure
Cu
rren
t P
eri
od
Val
ue
Pre
vio
us
Per
iod
Val
ue
Hig
hes
t
Lo
wes
t
Nat
ion
al
Ave
rag
e
Dat
a S
ou
rce
Reg
ula
tory
S
tate
men
t
Pat
ien
t re
po
rted
o
utc
om
es m
easu
res
hip
rep
lace
men
t su
rger
y
The [name of trust] considers that this data is as described for the following reasons [insert reasons]. The [name of trust] [intends to take/has taken] the following actions to improve this [percentage/proportion/score/rate/number], and so the quality of its services, by [insert description of actions].
Pat
ien
t re
po
rted
o
utc
om
es m
easu
res
knee
rep
lace
men
t su
rger
y
The [name of trust] considers that this data is as described for the following reasons [insert reasons]. The [name of trust] [intends to take/has taken] the following actions to improve this [percentage/proportion/score/rate/number], and so the quality of its services, by [insert description of actions].
Enc.3.1.1
60
Part 3: Other information
Access & Performance - Quality of care indicators Comparable
Foundation Trust values (as at Q3 or
Feb 16)
Ind
icat
or
Mea
sure
Cu
rren
t P
erio
d
Val
ue
Pre
vio
us
Per
iod
Val
ue
Hig
hes
t
Lo
wes
t
Nat
ion
al
Ave
rag
e
Dat
a S
ou
rce
Reg
ula
tory
S
tate
men
t
6-w
eek
dia
gn
ost
ic
wai
ts
% March 2016 5.8 March 2015 5.5 0 9.3 1.3 PiMs/ CRIS
The Trust has a weekly diagnostic waiting list meeting which reviews the breach portfolio and signs off action
plans for the test modality as appropriate.
Max
imu
m w
aiti
ng
ti
me
of
62 d
ays
fro
m
urg
ent
GP
ref
erra
l to
fi
rst
trea
tmen
t fo
r ca
nce
rs
% Jan-March
2016 88.8
Jan-March 2015
84.2 93.5 55.5 83.5 Open Exeter
The Trust discusses all the cancer metrics weekly at the Performance
Improvement Group and monthly at the Patient Access Board where key
actions are reviewed and updated.
Enc.3.1.1
61
Access & Performance - Quality of care indicators Comparable
Foundation Trust values (as at Q3 or
Feb 16)
Ind
icat
or
Mea
sure
Cu
rren
t P
erio
d
Val
ue
Pre
vio
us
Per
iod
Val
ue
Hig
hes
t
Lo
wes
t
Nat
ion
al
Ave
rag
e
Dat
a S
ou
rce
Reg
ula
tory
S
tate
men
t
Per
cen
tag
e o
n in
com
ple
te
pat
hw
ay w
ith
in 1
8 w
eeks
fo
r p
atie
nts
on
inco
mp
lete
p
ath
way
at
the
end
of
the
rep
ort
ing
per
iod
% March 2016 80.4 March 2015 92.2 98 73.8 92.1 PiMs/ Oasis
The Trust took a reporting holiday with the agreement of local commissioners
and Monitor during the period. The Trust returned to reporting in March
2016. Auditors will conduct a review of the Trust’s data as part of the external
assurance process for the Quality Report. The Trust has taken robust
action during the period to improve the quality of its data for this indicator and to ensure that longer waiting patients
are cared for in the short-term.
Enc.3.1.1
62
Patient Safety - Quality of care indicators Comparable
Foundation Trust values
Ind
icat
or
Mea
sure
Cu
rren
t P
erio
d
Val
ue
Pre
vio
us
Per
iod
Val
ue
Hig
hes
t
Lo
wes
t
Nat
ion
al
Ave
rag
e
Dat
a S
ou
rce
Reg
ula
tory
S
tate
men
t
Pat
ien
t sa
fety
inci
den
ts r
epo
rted
to
th
e N
RL
S w
her
e d
eg
ree
of
har
m is
rec
ord
ed a
s ‘s
ever
e h
arm
or
dea
th’ a
s a
per
cen
tag
e o
f al
l pat
ien
t sa
fety
inci
den
ts
rep
ort
ed
% Oct 2014 – Mar 2015
0.96 Apr-Sept
2014 0.6 5.19 0.5 0.6 NRLS
The data for Oct 2014 to Mar 2015 shows that King’s College Hospital is a slight outlier in terms of the proportion of incidents with severe harm or death. King’s considers that the data overestimates the proportion of severe harm/death incidents because a significant proportion of incidents graded in this way will be downgraded post-investigation. This is not always reflected in the NRLS data as it is taken at a point in time.
Rat
e p
atie
nt
safe
ty
inci
den
ts
Num
ber/
1000
be
d da
ys
Oct 2014-Mar 2015
36.06 Apr-Sept
2014 40.7 82.21 3.57 37 NRLS
Kings College Hospital’s rate of reporting compares favourably with most of its peer hospitals
Nu
mb
er o
f p
atie
nt
safe
ty
inci
den
ts
Num
ber
Oct 2014-Mar 2015
8350 Apr-Sept
2014 9844 12784 443 4572 NRLS
Data for the period Apr 2015 – Sep 2015 shows that the total number of incidents has risen to around 10,000 which suggest that reporting is improving on an already solid baseline.
Enc.3.1.1
63
Patient Safety - Quality of care indicators Comparable
Foundation Trust values
Ind
icat
or
Mea
sure
Cu
rren
t P
erio
d
Val
ue
Pre
vio
us
Per
iod
Val
ue
Hig
hes
t
Lo
wes
t
Nat
ion
al
Ave
rag
e
Dat
a S
ou
rce
Reg
ula
tory
S
tate
men
t
The Trust considers that the data is as described because it was taken directly from the National Reporting & Learning System database and relates to acute non-specialist trusts.
Enc.3.1.1
64
Scorecard – latest version with text
Enc.3.1.1
65
Trust actions on duty of candour (incidents/actions)
Initial Implementation: Policy ratified and published on 30th
September 2014. Standardised documentation for
recording Duty of Candour conversations
‘Candour Guardian’ role identified - Dr Rob Elias, Consultant Nephrologist
Presentations at Consultant Development Mornings, Audit Days, Divisional Governance meetings, Nursing for and significant Trust committees were facilitated by the Candour Guardian and the Patient Safety Team.
A series (~10) of Candour drop in sessions were organised across all KCH sites to allow staff to find out more information.
KWIKI webpages developed (accessed over 4000 times to date)
Ongoing work to embed best practice in Candour: Candour Working Group: a team of
interested senior clinicians meet 2-3 monthly to review complicated/difficult cases and assess ways of improving the pathway in future and supporting the clinicians involved
Development of standardised Duty of Candour Letters
Changes to the Duty of Candour form in line with feedback from staff
Roll out of EPR duty of candour form for DH & Orpington and access through the Clinical Portal for PRUH and QMS (‘How to Guides’ developed)
Development of standardised letters to feedback the outcome of investigations into falls, pressure ulcers and hospital acquired thrombosis.
Education, focussed mainly on process, continued. As of February 2015, it was estimated that >800 staff had received face to face training.
Collaborative presentation on with KHP colleagues at National Safety Connections event
Plans for 2016 Duty of Candour Lead is in discussion
with a Human Factors training group to develop a ½ day and 1 day training course for KCH staff
KCH is now involved in the HIN Communities of Practice about Duty of Candour ( first meeting in November 2015, next meeting Jan 2016)
Development of FAQ based on comments from the Survey
Update of the KWIKI page to include some case studies from complex cases
Publication of the Audit Results Develop a methodology in conjunction
with PPI to get feedback from patients involved in Duty of Candour conversations to evaluate their experience.
March 2015 audit - This included a review of 50 cases showed: In 83% of confirmed candour cases
there was documented evidence that a candour discussion had occurred
The requirement to have a candour discussion within 10 working days was not always met (75%) – this was often due to the fact that the level of harm was not clear and was being discussed within clinical teams
In 91% of cases senior staff held the candour conversation
Enc.3.1.1
66
Trust action plan for Sign-Up to Safety Campaign
Campaign Pledges Trust Patient Improvement Plans
1. Putting safety first. Committing to reduce avoidable harm in the NHS by half through taking a systematic approach to safety and making public your locally developed goals, plans and progress. Instil a preoccupation with failure so that systems are designed to prevent error and avoidable harm
To follow
2. Continually learn. Reviewing your incident reporting and investigation processes to make sure that you are truly learning from them and using these lessons to make your organisation more resilient to risks. Listen, learn and act on the feedback from patients and staff and by constantly measuring and monitoring how safe your services are
To follow
3. Being honest. Being open and transparent with people about your progress to tackle patient safety issues and support staff to be candid with patients and their families if something goes wrong
To follow
4. Collaborate. Stepping up and actively collaborating with other organisations and teams; share your work, your ideas and your learning to create a truly national approach to safety. Work together with others, join forces and create partnerships that ensure a sustained approach to sharing and learning across the system
To follow
5. Being supportive. Be kind to your staff, help them bring joy and pride to their work. Be thoughtful when things go wrong; help staff cope and create a positive just culture that asks why things go wrong in order to put them right. Give staff the time, resources and support to work safely and to work on improvements. Thank your staff, reward and recognise their efforts and celebrate your progress towards safer care.
To follow
Enc.3.1.1
67
Annex 1: Statements from commissioners, local Healthwatch organisations and Overview and Scrutiny Committees To follow
Enc.3.1.1
68
Annex 2: Statement of directors’ responsibilites for the quality report The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations to prepare Quality Accounts for each financial year. Monitor has issued guidance to NHS foundation trust boards on the form and content of annual quality reports (which incorporate the above legal requirements) and on the arrangements that NHS foundation trust boards should put in place to support the data quality for the preparation of the quality report. In preparing the Quality Report, directors are required to take steps to satisfy themselves that: the content of the Quality Report
meets the requirements set out in the NHS Foundation Trust Annual Reporting Manual 2015/16 and supporting guidance
the content of the Quality Report is not inconsistent with internal and external sources of information including:
board minutes and papers for the period April 2015 to [the date of this statement]
papers relating to Quality reported to the board over the period April 2015 to [the date of this statement]
feedback from commissioners dated XX/XX/20XX
feedback from governors dated XX/XX/20XX
feedback from local Healthwatch organisations dated XX/XX/20XX
feedback from Overview and Scrutiny Committee dated XX/XX/20XX
the trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated XX/XX/20XX
the [latest] national patient survey XX/XX/20XX
the [latest] national staff survey XX/XX/20XX
the Head of Internal Audit’s annual opinion over the trust’s control environment dated XX/XX/20XX
CQC Intelligent Monitoring Report dated XX/XX/20XX
the Quality Report presents a balanced picture of the NHS foundation trust’s performance over the period covered
the performance information reported in the Quality Report is reliable and accurate
there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Report, and these controls are subject to review to confirm that they are working effectively in practice
the data underpinning the measures of performance reported in the Quality Report is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review and
the Quality Report has been prepared in accordance with Monitor’s annual reporting manual and supporting guidance (which incorporates the Quality Accounts regulations) as well as the standards to support data quality for the preparation of the Quality Report.
Enc.3.1.1
69
The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Report. By order of the board
NB: sign and date in any colour ink except black
Lord Kerslake, Chair
Nick Moberly, Chief Executive Officer
Date
Enc.3.1.1
This page has been left blank
2015 NHS Staff Survey
Results
04 May 2016Council of Governors
Enc. 3.2.1
1
Report to: Council of Governors
Date of meeting: 04 May 2016
Subject: 2015 Annual Staff Survey Results
Author(s): Rob Eames, Associate Director of HR
Presented by: Dawn Brodrick, Executive Director of Workforce Development
Status: Information and discussion
2
Summary of ReportThe purpose of this report is to update the Council of Governors on the 2015 NHS Staff Survey results for the Trust. This report should be read in conjunction with Appendix 1 attached which, is a two side summary of the results of the staff survey.
The reports provides the results and the next steps following the publication of the national staff survey data.
ActionThe Council is asked to note contents of this report which was discussed by the Board of Directors on 06 April 2016.
Enc. 3.2.1
2
• National staff survey open between October and December 2015• National results for 2015 survey were published on 23rd February
2016• Random sample of 850 staff (sample size set nationally)• 255 staff responded• The survey closed with a 30% response rate (national average for
Acute Trusts is 40.6%)• This is a small representation of the workforce, although the results
have been modified to ensure they are statistically sound• In comparison to the 2014 staff survey results only four key findings
have had a significant statistical change, with two findings improving and two getting worse (please see appendix 1)
Response ratesEnc. 3.2.1
3
Key Finding Kings 2015
Kings 2014
Average National Score ‘15
Best National Score ‘15
KF1 Staff recommendation of the organisation as a place to work or receive treatment 3.69 3.86 3.76 4.10
KF2 Staff satisfaction with the quality of work and patient care they are able to deliver 3.88 / N/A 3.93 4.29
KF3 % agreeing that their role makes a difference to patients/ service users 91% / N/A 90% 95%
KF4 Staff motivation at work 3.97 3.80 3.94 4.14
KF5 Recognition and value of staff by managers and the organisation 3.49 / N/A 3.42 3.73
KF6 % reporting good communication between senior management and staff 34% 28% 32% 51%
KF7 % able to contribute towards improvements at work 74% 69% 69% 79%
KF8 Staff satisfaction with the level of responsibility and involvement 3.92 3.88 3.91 4.08
KF9 Effective team working 3.77 / N/A 3.73 3.96
KF10 Support from immediate managers 3.78 3.67 3.69 3.96
KF11 % appraised in last 12 months 73% 65% 86% 95%
KF12 Quality of appraisals 3.16 / N/A 3.05 3.39
KF13 Quality of non-mandatory training, learning or development 4.01 / N/A 4.03 4.18
KF14 Staff satisfaction with resourcing and support 3.19 / N/A 3.30 3.66
KF15 % staff satisfied with the opportunities for flexible working patterns 40% / N/A 49% 58%
KF16 % working extra hours 79% 74% 72% 61%
KF17 % suffering work related stress 45% 41% 36% 24%
KF18 % feeling under pressure in last 3 mths to attend work when feeling unwell 63% 66% 59% 46%
KF19 Org and mgmt interest in and action on health/ wellbeing 3.48 / N/A 3.57 3.97
KF20 % experiencing discrimination at work in last 12 mths 12% 20% 10% 5%
KF21 % believing the organisation provides equal opportunities for career progression/ promotion 84% 79% 87% 96%
KF22 % experiencing physical violence from patients, relatives or the public in last 12 mths 12% 12% 14% 10%
KF23 % experiencing physical violence from staff in last 12 mths 1% 1% 2% 0%
KF24 % reporting most recent experience of violence 46% 58% 53% 72%
KF25 % of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months 33% 34% 28% 19%
KF26 % of staff experiencing harassment, bullying or abuse from staff in last 12 months 29% 25% 26% 16%
KF27 % staff/ colleagues reporting most recent experience of harassment, bullying or abuse 45% 51% 37% 52%
KF28 % staff witnessing potentially harmful errors, near misses or incidents in last month 36% 41% 31% 21%
KF29 % of staff reporting errors, near misses or incidents witnessed in the last month 89% 98% 90% 97%
KF30 Fairness and effectiveness of procedures for reporting errors, near misses and incidents 3.75 N/A 3.70 3.92
KF31 Staff confidence and security in reporting unsafe clinical practice 3.65 3.70 3.62 3.93
KF32 Effective use of patient/ service user feedback 3.83 3.84 3.70 3.97
Staff Engagement Score 3.81 3.77 3.79 4.03
Overview of all results (Please see Appendix 1)
Top 5 Scores Bottom 5 Scores Key Findings most relevant to Francis Report Largest statistically significant change since 2014
Improved since 2014 (could be through chance) Worsened since 2014 (could be through chance) / No 2014 comparator (New 2015 Key Finding)
Enc. 3.2.1
4
• There have been some positive results around staff motivation and commitment to King’s and the overall level of staff engagement has improved (although further work is still required in this area)
• The results from 255 respondents show that line management, communication and staff involvement is good and team working is effective
• The results have again highlighted some areas for improvement that we are already in the process of developing initiatives for, as part of the King’s BEST strategy and workforce strategy development process (e.g. appraisals, equality, staff engagement/morale, health and wellbeing and line management capability etc)
• We are also using other workforce metrics locally such as turnover rate, stability rate, exit questionnaires and leaver data to triangulate the health of our workforce and we will use and develop these combined metrics further in the future
SummaryEnc. 3.2.1
5
• Due to the low numbers of staff responding we are not proposing to develop specific Divisional or Occupational Group Staff Survey action plans for this year
• A significant increase in staff feedback through the staff survey is required to get a better understanding of staff views. In 2016 the survey will be open for all staff to participate and we also need to increase the overall Trust response rate
• Staff engagement will be key as part of our vision/strategy and organisational design and development (ODD) work
• We will continue to embed the strategic narrative/direction of the Trust in all that we do
• We will use “2-way“ communication and feedback mechanisms to listen and involve staff in the decisions that affect them as part of the strategy and the ODD work
• We will lead staff in a way that drives accountabilities, ways of working and delivers a culture that aligns to the BEST strategy
Next steps Enc. 3.2.1
6
STAFF SURVEY 2015 HEADLINES
OVERVIEW: The survey closed with a 30% (national average is 40.6%) response rate (255 staff) from a random sample of 850 staff. This is a small representation of the workforce; the results have been modified to ensure they’re statistically sound. In comparison to the 2014 staff survey results only four key findings have significantly changed. The overall staff engagement score has positively improved since 2014 however this was brought down by lower than average scores in staff recommending the Trust as a place to work or be treated. This will be monitored in the Q4 FFT. Despite this staff believe that patient and service user feedback is effectively used putting Kings in the best 20%. The results show that 14 of the 32 key findings for King’s are above average with 5 in the top 20% of acute Trusts. Staff are motivated at work which has significantly increased since last year; when appraisals happen they are of good and above average quality; staff are involved in improvements at work with good communication between them and senior management; line managers are supportive which is also reflected in effective team working. Staff also feel confident to report harassment, bullying or abuse and unsafe clinical practice, their view is that the procedures for reporting near misses and incidents are fair and effective, however despite this the results indicate that staff are not reporting incidents as much as they should be. Physical violence between staff is also low. In contrast 17 of the 32 key findings are worse than the average of acute trusts with 9 of these being in the worst 20%. Areas of concern include staff feeling the pressure to work extra hours, reporting stress at work, a lack of flexible working and appraisals not being completed. The quality of non-statutory and mandatory training on offer is considered worse than average. There is an increase in staff witnessing potentially harmful errors, near misses or incidents which are not being reported. Staff are not satisfied with the quality of care they are able to deliver and they have a low view of the organisations and management’s commitment to their health and wellbeing. The view is that discrimination exists alongside a lack of equal opportunity for career progression/promotion.
IN THE BEST 20% OF ACUTE TRUSTS BETTER THAN AVERAGE OF ACUTE TRUSTS
KF7. Staff ability to contribute toward improvements at work (best)
KF10. Support from immediate managers (best) KF27. % reporting most recent experience of
harassment, bullying or abuse (best) KF32. Effective use of patient / service user
feedback (best) KF23. % experiencing physical violence from staff
in last 12 mths (lowest)
KF3. % agreeing that their role makes a difference to patients / service users
KF4. Staff motivation at work (significantly since 2014)
KF5. Recognition and value of staff by managers and the organisation
KF9. Effective team working KF12. Quality of appraisals KF22. % experiencing physical violence from patients,
relatives or the public in last 12 mths KF6. % reporting good communication between senior
management and staff KF30. Fairness and effectiveness of procedures for
reporting errors, near misses and incidents KF31. Staff confidence and security in reporting unsafe
clinical practice
WORST 20% OF ACUTE TRUSTS NATIONALLY WORSE THAN AVERAGE OF ACUTE TRUSTS KF11. Percentage of staff appraised in last 12
months KF14. Staff satisfaction with resourcing and support KF15. Percentage of staff satisfied with the
opportunities for flexible working patterns KF16. Percentage of staff working extra hours KF17. Percentage of staff suffering work related
stress in last 12 months KF19. Org and mgmt. interest in and action on
health/ wellbeing KF24. % reporting most recent incident of violence KF25. % experiencing harassment, bullying or
abuse from patients, relatives or the public in last 12 months
KF28. Percentage of staff witnessing potentially harmful errors, near misses or incidents in last month
KF1. Staff recommendation of the organisation as a place to work or receive treatment (significantly since 2014)
KF2. Staff satisfaction with the quality of work and patient care they are able to deliver
KF13. Quality of non-mandatory training, learning or development
KF18.% feeling pressure in last 3 mths to attend work when feeling unwell
KF26.% experiencing harassment, bullying or abuse from staff in last 12 mths
KF20.% experiencing discrimination at work in last 12 mths (significantly since 2014)
KF21.believing the organisation provides equal opportunities for career progression/promotion
KF29. % reporting errors, near misses or incidents witnessed in last 12 mths (significantly since 2014)
Enc.3.2.1 Appendix 1
TRUST 2015 STAFF SURVEY RESULTS
Key Finding Kings 2015
Kings 2014
Average National score ‘15
Best National Score ‘15
KF1 Staff recommendation of the organisation as a place to work or receive treatment 3.69 3.86 3.76 4.10
KF2 Staff satisfaction with the quality of work and patient care they are able to deliver 3.88 / N/A 3.93 4.29
KF3 % agreeing that their role makes a difference to patients/ service users 91% / N/A 90% 95%
KF4 Staff motivation at work 3.97 3.80 3.94 4.14
KF5 Recognition and value of staff by managers and the organisation 3.49 / N/A 3.42 3.73
KF6 % reporting good communication between senior management and staff 34% 28% 32% 51%
KF7 % able to contribute towards improvements at work 74% 69% 69% 79%
KF8 Staff satisfaction with the level of responsibility and involvement 3.92 3.88 3.91 4.08
KF9 Effective team working 3.77 / N/A 3.73 3.96
KF10 Support from immediate managers 3.78 3.67 3.69 3.96
KF11 % appraised in last 12 months 73% 65% 86% 95%
KF12 Quality of appraisals 3.16 / N/A 3.05 3.39
KF13 Quality of non-mandatory training, learning or development 4.01 / N/A 4.03 4.18
KF14 Staff satisfaction with resourcing and support 3.19 / N/A 3.30 3.66
KF15 % staff satisfied with the opportunities for flexible working patterns 40% / N/A 49% 58%
KF16 % working extra hours 79% 74% 72% 61%
KF17 % suffering work related stress 45% 41% 36% 24%
KF18 % feeling under pressure in last 3 mths to attend work when feeling unwell 63% 66% 59% 46%
KF19 Org and mgmt interest in and action on health/ wellbeing 3.48 / N/A 3.57 3.97
KF20 % experiencing discrimination at work in last 12 mths 12% 20% 10% 5%
KF21 % believing the organisation provides equal opportunities for career progression/ promotion
84% 79% 87% 96%
KF22 % experiencing physical violence from patients, relatives or the public in last 12 mths 12% 12% 14% 10%
KF23 % experiencing physical violence from staff in last 12 mths 1% 1% 2% 0%
KF24 % reporting most recent experience of violence 46% 58% 53% 72%
KF25 % of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months
33% 34% 28% 19%
KF26 % of staff experiencing harassment, bullying or abuse from staff in last 12 months 29% 25% 26% 16%
KF27 % staff/ colleagues reporting most recent experience of harassment, bullying or abuse
45% 51% 37% 52%
KF28 % staff witnessing potentially harmful errors, near misses or incidents in last month 36% 41% 31% 21%
KF29 % of staff reporting errors, near misses or incidents witnessed in the last month 89% 98% 90% 97%
KF30 Fairness and effectiveness of procedures for reporting errors, near misses and incidents
3.75 N/A 3.70 3.92
KF31 Staff confidence and security in reporting unsafe clinical practice 3.65 3.70 3.62 3.93
KF32 Effective use of patient/ service user feedback 3.83 3.84 3.70 3.97
Staff Engagement Score 3.81 3.77 3.79 4.03
Key
Top 5 Scores Bottom 5 Scores Key finding most relevant to the Francis report Statistically significant change since 2014 Improved since ‘14 (could be by chance) Worsened since ‘14 (could be by chance) / No Comparison from 2014 ( A new 2015 KF)
Enc.3.2.1 Appendix 1
Governor Elections2016
Council of Governors04 May 2016
Enc.3.3.1
1
Report to: Council of Governors
Date of meeting: 04 May 2016
Subject: Governor Elections
Author(s): Tamara Cowan, Board Secretary
Presented by: Judith Seddon, Acting Director of Corporate Affairs & Trust Secretary
Sponsor: Judith Seddon, Acting Director of Corporate Affairs & Trust Secretary
History: previously considered KE and verbal update at Council of Governors
Status: For Information/Endorsement
2
Summary of Report
• This reports provide Board od Directors with information about the 2016 Governor elections.
Action required• The Board is ask to note the forthcoming governor elections and note the process to be undertaken.
Enc.3.3.1
2
3
Legal: The Council of Governors are part of the Trust’s governance framework and the Trust is required to hold elections for governors.
Financial: The election will cost the Trust circa £11,000
Assurance: Having an effective governing body in place will provide assurance to the Trust.
Clinical: No direct implications
Equality & Diversity: No direct implications
Performance: No direct implications
Strategy: No direct implications
Workforce: No direct implications
Estates: No direct implications
Reputation: No direct implications
Other:(please specify) No direct implications
Key implicationsEnc.3.3.1
3
• Council is made up of 34 Governors– 13 elected from public constituencies of
Lambeth, Lewisham, Southwark and Bromley;
– 6 elected from the patient constituencies;
– 5 elected from the staff constituencies; and
– 10 appointed from key stakeholders
BackgroundEnc.3.3.1
4
• Public, Patient and Staff Governors are elected by the Members of the Trust
• Public and Patient Members are required to sign-up to membership of the Trust
• Staff are automatically opted-in as Members, they do have option to opt-out
Background cont’d.Enc.3.3.1
5
• The following governor terms will come to an end November 2016:– 2 Patient Governors– 1 Staff (Nursing & Midwifery) Governor
• The following governor terms will come to an end January 2017:– 4 Bromley Governors– 1 Lewisham Governor
2016 ElectionsEnc.3.3.1
6
Current Governor Term Details Eligible for Re-Election
Interested in Re-election?
Anoushka de Almeida-Carragher First, 3 year Yes No
Eniko Benfield First, 3 year Yes Yes
Paul Corben First, 3 year Yes Yes
Penny Dale First, 3 year Yes Yes
Tim Bradley Replaced Alan Hall (01/10/2015)
Yes Yes
Tom Duffy Last, 2 year No N/A
Jan Thomas Last, 2 year No N/A
Nicky Hayes Last, 2 year No N/A
2016 Elections, Current Postholders
Enc.3.3.1
7
• Elections are: – In line with Monitor’s Model Election Rules, enshrined
in Trust’s Constitution (formal timeframe of 40 days between Notice and Close of Poll;
– Run by independent scrutineers, Electoral Reform Services
• NEW this year – Electronic Information & Online Voting which will:– Save the Trust money;– Improve engagement with wider audience– More lead time to publicise this new process
2016 Elections ProcessEnc.3.3.1
8
High Level TimetableEvents When What
Rai
sing
Ele
ctio
n A
war
enes
s &
Pu
blic
ity
Apr
il-S
epte
mbe
r 201
6
Presentation & Flyers at Trust Community Events
Presentations & Flyers by governors at Trust Health Talks & Staff Induction
Notices on Trust external and internal websites
Notices & flyers around Trust sites
Notices, flyers and presentations though stakeholder
Messages in Trust’s Membership bulletin
Governor Awareness Sessions
Form
al E
lect
ion
Proc
ess
May
–S
epte
mbe
r 20
16
Notice of Election (formal)
Nominations & Publication of Statements
Notice of Poll
Voting Period (end-August – end-September)
Gov
erno
r Ind
uctio
ns &
Tr
aini
ngs
Clo
se o
f Pol
l -Te
rm
com
men
cem
ent
Shadow Governor Meetings
Attend Board Meetings
Buddying Current Governors
Attend Governor Development Day
Attend Governor Workshops
Site Tours
Enc.3.3.1
9
This page has been left blank
Rep
Dat
Pre
Act
| Int Govcorp Monfor g
The | Ac Govund
GOVE
port to:
te of meet
esenter:
tion Requ
troduction
vernors havporation as
nitor’s guidagovernors toGovernors or changes
Governors trust, its visboard.
Governors of the trust than just th
e report detaSchedule oUndertakenGovernor E
ction Requ
vernors ardertaken si
ERNOR EN
C
ting: 04
C
ired: F
ve a generaa whole an
ance for goo representshould see
s being disc
should feedsion, perform
should try tthat they reeir own per
ails the folloof Meetings n Governor Engagemen
ired
re asked nce the las
NGAGEME
Council of
4 May 201
Chris North
OR INFOR
al duty to “tnd the intere
vernors sugt the interesk the viewsussed by th
dback to memance and
to make surepresent thersonal views
owing for infInvolving GEngageme
nt & Involvem
to note thst meeting
ENT & INV
Governor
16
h, Lead Go
RMATION
to represenests of the p
ggests the fst of membes of membehe trust.
embers andmaterial str
re when thee interests os.
formation: Governors dent & Involvement Regis
he engageof the Cou
VOLVEME
rs
overnor
t the interepublic”.
following keers and the rs and the p
d the public rategic prop
ey are commof members
during the Pement Initia
ster
ement anduncil.
ENT REPO
sts of the m
ey principlespublic:
public on m
informationposals made
municating ws and the pu
eriod atives
d involvem
ORT
members o
s as the me
aterial issue
n about the e by the tru
with directoublic rather
ment activ
1
f the
eans
es
st
ors
ities
Enc. 3.3.2
2
1. | Engagement & Involvement Opportunity During the Period Governors have attended the following scheduled meetings for the period 10 March 2016 – 27 April 2016: Date Activity 17 March Council of Governors Meeting
31 March Review Session
06 April Board of Directors Meeting (Public)
14 April Membership and Community Engagement Committee Meeting
14 April Governor Strategy Committee Meeting
19 April Patient Experience and Safety Committee Meeting
Governors have also been busy undertaking the initiatives outlined in the Governor Engagement & Involvement Register as follows: Involvement Activity Governor Attendee(s) Governors Attended
During the Period Members Health Talk Penny Dale Yes Breakfast Meeting with Chairman Penny Dale
Chris North Fiona Clark Roger Paffard Jan Thomas Andrew McCall Helen Ahmet Victoria Silvester
Yes
Community Events Andrew McCall Fiona Clark
Yes
Go See Visits Chris North Penny Dale Fiona Clark
Yes
Southwark & Lambeth Citizens Forum Andrew McCall Yes Council of Governors Planning Meeting with Chairman
Chris North Yes
Corporate Induction Roger Engwell Yes Internal Audit Appointment Committee Helen Ahmet Yes Bromley Health & Well Being Board Meeting
Penny Dale Yes
Nutrition in Elderly Patients Meeting Penny Dale Yes PLACE Visits Penny Dale
Fiona Clark Yes
Public Health Committee Fiona Clark Yes End of Life Committee Fiona Clark Yes Nominations Committee Fiona Clark Yes
Enc. 3.3.2
3
Involvement Activity Governor attendee(s)
Trust Lead Meeting Date Meeting Time Meeting Venue Additional Information
Public Health Committee
Tom Duffy Pida Ripley Victoria Silvester Grace Okoli Sue Gallagher Fiona Clark
Chair: John Moxham (Organiser Mika Kuszai)
There is no limit to governor attendance for these meetings. Should any other governors wish to attend, please advise the Foundation Trust Office
21/04/2016 10:00-11:30 TBC 28/07/2016 10:00-11:30 Dulwich Room 27/10/2016 10:00-11:30 Dulwich Room Staff Commendation Panel
Jan Thomas Fiona Clark Penny Dale
Chair: John Karani Contact: Linda Flay
09/05/2016 07/11/2016
11:00 11:00
Dulwich Room
9 May 11:00 Dulwich Room 7 November 11:00 Dulwich Room Improving King’s Patient Food Service – Food Service and Nutrition Group
Victoria Silvester Jan Thomas
Chair/Lead: Jan Flint
TBC TBC TBC Reserve Governor: Roger Engwell Comes under the Nutrition Support Steering Group (NSSG) which is a sub-group of the Patient Safety Committee.
Patient Food Audits (DH)
Victoria Silvester Fiona Clark Jan Thomas
Chair/Lead: Jan Flint
TBC TBC TBC Reserve Governor: Roger Engwell
Organ Donor Committee
Jan Thomas Chair/Lead: Ben Rhodes
The committee meets quarterly, the next date is yet to be agreed
Community Events (DH & PRUH)
No limit to attendance
Lead: Sally Lingard
Detail provided in the monthly stakeholder calendar
Patient Experience Committee
Victoria Silvester Pida Ripley
Lead: Jessica Bush
Reserve Governor: Tom Duffy
23/03/2016 14:30-16:30 Dulwich Room 25/05/2016 14:00-16:00 Board Room, PRUH 27/07/2016 14:00-16:00 Dulwich Room 27/09/2016 11:00-13:00 Board Room, PRUH
Enc. 3.3.2
4
Involvement Activity Governor attendee(s)
Trust Lead Meeting Date Meeting Time Meeting Venue Additional Information
29/11/2016 10:00-12:00 Dulwich Room National Governors’ Forum (FTN Network)
Tom Duffy Jan Thomas
n/a TBC TBC TBC
NHS providers Focus Group
Tim Bradley n/a 20 April 2016 10:00-15:30 28 Great Russell Street
Serious Complaints Committee
Pida Ripley Lead: Judith Seddon
Reserve Governor: Fiona Clark
12/05/2016 10:00-12:00 Dulwich Room 14/07/2016 11:30-13:30 TBA 13/10/2016 13:00-15:00 Dulwich Room End of Life Care Steering Group
Fiona Clark Jan Thomas
Contact: Wendy Prentice, Xan Neethling
Reserve Governor: Penny Dale
1 April 10:00-11:30 Dulwich Room 6 May 10:00-11:30 Dinwoodie 1 & 2 10 June Dulwich Room 22 Jul 10:00-11:30 Dulwich Room 26 Aug 10:00-11:30 Dulwich Room 30 Sep 10:00-11:30 Dulwich Room 4 Nov 10:00-11:30 Dinwoodie 1 & 2 9 Dec 10:00-11:30 Dulwich Room Maternity Services Liaison Group
Anoushka de Almeida-Carragher
Lay Chair: Joanna Brien
29 Jan 12:30-14:30 Jenny Lee House Remaining dates and venues TBC
Go See Visits All Governors Geraldine Walters (Helen Day)
Monthly following Board meetings
Denmark Hill and Princess Royal University Hospital sites
Please advise the Foundation Trust Office should you wish to attend the Go See Visits following the Trust Board of Directors meeting
PLACE Visits All Governors Various Adhoc Dignity Visits All Governors Nicky Hayes TBC King’s In Conversations All Governors Jenny Steele TBC Quality Accounts Engagement
All PESC Members Adhoc See governor sub-committee
Enc. 3.3.2
5
Involvement Activity Governor attendee(s)
Trust Lead Meeting Date Meeting Time Meeting Venue Additional Information
Denmark Hill Phlebotomy Focus Group
1 required Phil Brown/ Althea Haye (Linda Akkad PA)
TBC TBC TBC This group is looking for one governor to attend discussion on the present services at the King’s site and be a source of consultation for improvements.
This page has been left blank
M
M
A
Meeting:
Meeting D
Action:
SUMMARY Transport The Comm Transport fand Castle Initial public However, aKent road abe made af The Trust aSE5 Forumimpact on tstaff and viscause; The resultsareas in Loage. A largtransport linplatforms a The surveyimprove loc Stakeholde The Comm The Trust cThe more nand Social The Trust isgroups.
Su
Date:
Y OF KEY D
Update an
mittee welcom
for London hstation. Tw
c consultati
at the end oas the prefefter the Lon
along with rem have beenthe local aresitors to the
s of the survondon. With ge number onks and poo
at Denmark
y results havcal transpor
er & Trans
mittee receiv
continues tonotable eveCare, Alista
s also activ
mmaries/
Members
4 May 20
For Infor
DISCUSSIO
d Transpo
med Sophy
had previouwo main exte
on indicated
f 2015, TFLerred optiondon Mayora
epresentatin in contact ea the Came Trust and
vey indicatemore than
of patients aor travel expHill rail stat
ve been prert links.
port Updat
ved the Trus
o engage wint over the air Burt who
ely participa
/Actions f
ship and C
016
rmation
ON POINTS
rt Survey R
y Tayler from
usly announension propd that Camb
L announce. No immedal election i
ves from Sowith TFL to
mberwell extSLAM was
that Trust 2 likely to balso travel tperience. Ttion which w
esented to T
tes
st’s Stakeho
ith various slast few mo
o visited the
ating in the
from Gove
Communit
S
Results Pre
m Priority A
nced plans tposals wereberwell was
ed it would bdiate dates n May 2016
outh Londoo help provitension wou
s carried out
patients anbe disabled to the site bhere were a
was branded
TFL and the
older and Tr
stakeholderonths was ae Diabetic F
Our Health
ernor Sub
ty Engage
esentation
ction for Ca
to extend the explored, vs the prefer
be perusingwere annou6;
n and Maudde then wituld provide.t by the Tru
nd visitors hand more t
by car due toalso a few cd as unsafe
e Trust will c
ransport up
rs, membera visit by theFoot Clinic a
hier South E
b-Commit
ement Com
amberwell T
he Bakerloovia Old Kenred extensio
the Bakerlounced and a
dsley NHS Th greater un A joint transt and its p
have a differthan 3 likelyo low confidcomments ae by some; a
continue to
dates:
s of parliame Minister oat Denmark
East London
ttee
Enc
mmittee
Transport (P
o line beyonnt road or Con option;
oo line exteany final de
Trust (SLAMnderstand onsport surveartners in s
rent profile ty to be overdence in locabout the ovand
work with t
ment and NHof State for Hill on 17 M
n (OHSEL)
. 3.3.3.1
1
PACT).
d Elephant amberwell.
ension via Oecision woul
M), PACT aof the positivey of patiensupport of th
to most othr 60 years ocal public vercrowded
hem to
HS agencieCommunity
March; and
project
Old ld
and ve
nt, heir
er of
d
s. y
Communit The Comm The Trust hevent was osecond wasLambeth, a Governor C The Comm The Trust wthe frequen The next iselections. Membersh The Comm The Trust wrecruit more Evaluation The Comm It was noteattended. Tinformation Governor EThe Comm
• The – 2 – 1
• The – 4 – 1
Any Other It was notestarting shoproceeding
ty Event Fe
mittee receiv
held two eveon Thursdas on Wedne
and Lewisha
Contributio
mittee receiv
will only pubncy of the is
sue of @Ki
hip Update
mittee receiv
will end the e members
n of Membe
mittee receiv
d that someThe talks aren from Senio
Election mittee were i
following goPatient GoStaff (Nurs
following goBromley GLewisham
Business
d that the portly. Duringg with more
eedback
ved feedbac
ening eventay 3 March 2esday 9 Maam member
on to @Kin
ved updates
blish 3 issuessues. The 3
ng’s will be
ved an upda
year with ju from the T
er’s Health
ved a presen
e talks are me a key benor Clinicians
nformed tha
overnor termvernors
sing & Midw
overnor termovernors Governor
planning for g last year’stime alloca
ck on the Tr
ts for its me2016 at the
arch 2016 atrs. Both eve
ng’s magaz
s on @King’
es of @King3 issues ma
published
ated on Trus
ust over 11,rusts volunt
Talks
ntation on th
more populanefit to mems and ask q
at the Trust
ms will com
wifery) Gove
ms will com
this year’s s event memtion for the
rust’s Comm
embers at tw Bromley Lit Cambridgeents were w
zine
’s Magazine
g’s Magazinay have inc
in June and
st members
000 membeteer’s and y
he Trust’s a
ar than othembers and a
uestions.
t will be run
me to an end
ernor
me to an end
annual memmbers statequestions a
munity evets
wo locationsibrary for itse House in
well attended
e:
ne per finanreased num
d will focus
ship:
ers. The Truyoung mem
annual eval
ers but all taan informal f
ning Gover
d November
d January 2
mbers meetd they wouand answer
s in March:
s in south es Bromley cCamberwed.
cial year. Wmber of page
on the upco
ust memberbers.
uation of th
alks were alforum where
nor election
r 2016:
017:
ting on 29 Sld prefer a mrs section of
Enc
Enc
east Londonconstituencyell for Southw
While this is es as need
oming Gove
rship will be
e member’s
lways adeqre they can
ns for 8 pos
September,more interaf the event.
. 3.3.3.1
. 3.3.3.1
2
n. The first y and the wark,
a reductioned; and
ernor
e looking to
s health talk
uately receive
sitions:
would be ctive forma
n
ks:
t to
Enc. 3.3.3.2
1
Meeting: Governor Strategy Committee
Meeting Date: 04 May 2016
Action: For Information
SUMMARY OF KEY DISCUSSION POINTS NHS Performance Measurement The Committee received and noted the presentation from Sam Benghiat focusing on possible ways to measure NHS performance. The National Health Service (NHS) is a broad system of numerous healthcare organisations trying to achieve good healthcare for current and future generations. The development of ‘perfect’ data for all clinical services is hard to achieve due to direct impact of external factors on the entire healthcare industry. The current performance measures do not always encourage the outcomes sought by most organisations as these systems assess the overall performance of processes and do not target specific clinical elements.
Strategic Planning Update (Where Are We Now?) The Committee received a brief overview of the current strategic planning goals and related issues. It was highlighted that the Trust aims to move towards a place-based commissioning where healthcare providers would deliver best value patient services through collaborative planning. KHP Update The Committee noted the King’s Health Partners (KHP) update and it was highlighted that work continues on the development of the Strategic Outline Cases (SOC) for both Haematology and Cardiovascular. There are ongoing discussions that the KHP Institutes plans would be woven into the Sustainability and Transformation Plan (STP). Horizon Scan The Committee noted the horizon scan and the relevant strategic issues. The Public Accounts Committee report on acute finances emphasises the need to develop adequate plans to meet the £22bn efficiency challenges. The healthcare providers are aiming to introduce enhanced workforce plans to reduce the agency overspend. The Trust has taken appropriate actions to minimise the impact of junior doctors’ strikes on service delivery and staff morale. 2016/17 Final Operational Plan The Committee received and noted the latest update on the 2016/17 Operational Plan. The Operational Plan has been constructed using a set of assumptions for income, expenditure, capital and financing; and stretch performance targets for improvements to patient waiting times.
Enc. 3.3.3.2
2
The financial ‘bridge’ shows that with support from STP funding, tariff growth and investments from local Clinical Commissioning Groups (CCGs), the Trust expects to improve its revenue deficit position by £57m to a projected £8m deficit in 2016/17. The Trust acknowledges that further access to distressed funding will be required to improve creditor payment performance and to fund the capital schemes required to meet the core facilities maintenance and re-equipping needs.
Commercial Services Performance Update The Committee received and noted an update on commercial services performance. NHS is entering a period of unprecedented change. The combination of aging population, increased levels of complex diseases and greater patient expectations have increased the demand for services and healthcare providers need to find viable ways for funding. The Trust has the potential to raise additional funds to support clinical services and financial stability through a number of commercial opportunities, which would be closely aligned with its core strengths and points of differentiation. Clinical Academic Site Strategy The Committee noted the clinical academic site strategy update. The Trust is currently exploring various options for the implementation of a clinical academic site strategy, which would improve capacity performance and transform current clinical processes. Finance and Performance Reports (M10) The Committee received and noted the month 10 Finance and Performance reports. Committee members have expressed thanks to Executive colleagues for their candour and openness. KEY ACTIONS FROM MEETING Action Who Progress The Committee agreed that the strategy objectives would be discussed at the next meeting.
GSC Completed
The Committee agreed that Governors will have an opportunity to input into the Operational Plan via the NEDs/Governors Review Session or another forum.
Govs Completed
Enc. 3.3.3.3
1
`Meeting: Patient Experience & Safety Committee
Meeting Date: 4 May 2016
Action: For Information
SUMMARY OF KEY DISCUSSION POINTS Patient Story The Committee welcomed Irene Karrouze(IK), Continence Nurse, who presented a patient case on the successful implementation of a passports. IK relayed the story of the patient Mr X who had been catheterised in the Trust and the challenges he faced in getting adequate community care on issues relating to his catheter.
Mr X, aged 77, was catheterised and discharged with a urinary catheter. Mr X lived alone, with no family and had other illnesses. Following his discharge the patient was sent home with a catheter. Over the next few weeks the patient attended the Trust’s emergency departments ten times with catheter related issues;
During his last visit the patient was very distressed about the catheter and refused to leave the ward until the issues were resolved. Following a review with the Continence team and discussions with the consultant a decision was made to start the patient on alfa blockers and also to conduct trial without catheter (TWOC);
On his discharge Mr X was provided with a catheter passport which can help staff easily ascertain his history and also empower district nurses to provide the right care to the patient in his home as opposed to calling an ambulance and bring the patient to the emergency department every time there was an issue;
The patient was much happier and expressed his gratitude to the Trust for the use of the catheter passport in his case; and
The Committee agreed that the catheter passport was an excellent tool and that if possible its use should be extended to other medical conditions.
Safeguarding Adults
The Committee received the annual safeguarding children’s report.
Following significate changes to caselaw legislation relating to deprivation of liberty safeguards (DoLS). The Trust had to quickly understand and apply the new rules to its patients. The implications of the caselaw was that there are now considerably more patients to whom DoLS applications are applicable.
2
The Trust had a learning period in relation to appropriate applications, the safeguarding team is now skillful in preparing applications. The Denmark Hill team holds a weekly meeting with social sector partners and doctors. The meetings at the Princess Royal are held monthly with different partners; and
1.
The Trust is below the 80% target on staff training relating to DoLS. It should however be noted that the nursing staff group are on target on DoLS training. The safeguarding team is working toward improving training levels for all other professional staff groups.
Safeguarding Children
The Committee received the annual safeguarding children’s report.
The safeguarding team was able to recruit to the key position of safeguarding Doctor for the Denmark Hill site in March 2016. Funds were also secured to recruit a fulltime specialist midwife for women with mental-ill health at the Princess Royal University Hospital, this post is currently advertised;
Midwives were also provided with training on female genital mutilation at their annual children’s safeguarding update. The Havens and the young person’s midwifery group attended additional training on child sexual exploitation; and
The Trust will be opening a new Havens facility close to the Denmark Hill site shortly.
CQC Action Plan Update
The Committee received an update on the Trust’s compliance with the Care Quality
Commission actions plan.
The Trust was inspected by the Care Quality Commission(CQC) between 13 to 17 April 2015. The inspection report was published at the end September 2015. The Trust was rated as ‘requires improvement’;
The inspection report identified a number of actions the Trust must correct. An action
plan was drafted with identified timeline to correct the ‘must do’ items in the report.
Progress on the action plan is monitored via the Trust’s CQC Steering Group with
issues escalated to King’s Executive (KE) and Board of Directors where appropriate;
The Trust invited KPMG to undertake a review of action plan development in March
2016. The review identified that progress on the action plan was very good with the
greater proportion of the of the ‘must do’ items completed. However a small number of
new concerns were identified; and
The Trust will continue to work on the action plan and increase accountability and
ownership of actions to ensure that changes in practice embed and the Trust is
compliant with all CQC standards of care.
Enc. 3.3.3.3
3
Governor Involvement Updates
The Quality and Governance Committee indicated that the Trust has a few deep rooted
problems which remain difficult to solve. The Chair noted at the last meeting on 17 March
that "we are always making the same points about complaints but things don’t seem to
improve", similarly with falls in the hospital. The Committee will continue to address these
issues within the Trust.
The Committee of the Commissioners (CQRG) has a long membership list. It is a very
different Committee compared to Trust committees and there is no consistency of attendees.
The last committee meeting focused on Antimicrobial Stewardship and the proposed review
by NHS London relating to the length of time patients had to wait before they were informed
they do not have cancer.
Month 10 Finance and Performance Reports
The Committee noted the reports.
Decisions from the Metting
The Committee decided it would no longer receive copies of the Trust monthly finance and
performance reports as part of its pack of papers, because these are circulated regularly to
all Governors with the monthly Board of Directors papers.
This page has been left blank
REGISTER OF GOVERNOR ATTENDANCE (PUBLIC)
CONSTITUENCY REASON FOR ABSENCE
1 2 3 4 5
Prof Sir George Alberti Chair Retired on 31/03/2015
Lord Robert Kerslake Chair √ √
Ms Anoushka de Almeida-Carragher Bromley √ √
Ms Eniko Benfield Bromley
Mr Paul Corben Bromley
Ms Penny Dale Bromley √
Mr Alan Hall Lewisham Resigned on 10/09/2015
Ms Fiona Clark Lambeth
Mr Christopher North Lambeth
Mr Nandakumar Ratnavel Lambeth
Dr Grace Okoli Lambeth
Ms Barbara Pattinson Southwark
Ms Pam Cohen Southwark
Mr Andrew McCall Southwark
Mrs Victoria Silvester Southwark
Miss Jo Millett Staff - Nurses and Midwives
Ms Nicky Hayes Staff - Nurses and Midwives
Mr CV Praveen Staff - Medical and Dentistry Resigned on 07/03/2016
Dr Cornelius Lewis Staff - Allied Health Professionals Resigned on 01/04/2016
Mr Roger Engwell Staff - Administration and Clerical
Mr Anand Arya Staff - Medical and Dental Staff Group
Mr Daniel BeazleyStaff - Allied Health Professionals, Scientific & Technical
Joined on 02/04/2016
Ms Helen Ahmet Patient
Mr Derek St Clair Cattrall Patient
Mr Thomas Duffy Patient
Mrs Catriona Ogilvy Patient Governor role terminated. Replaced by Craig Jacobs
Mrs Pida Ripley Patient
Ms Jan Thomas Patient
Mr Craig Jacobs Patient Joined on 25/09/2015
Mr Tim Bradley Patient Joined on 25/09/2015
Cllr Robert Evans Bromley Council
Ms Diane Summers Guy's & St Thomas' Hospital NHS Foundation Trust
Mrs Phidelma Lisowska Joint Staff Committee √ √
Mr Chris Mottershead King's College London √
Ms Sue Gallagher Lambeth CCG Resigned on 24/10/2015
Mr Richard Gibbs Southwark CCG Resigned on 22/10/2015
Mr Jim Gunner Bromley CCG Resigned on 29/04/2015
Cllr Jim Dickson Lambeth Council √ √
Cllr Kieron Williams Southwark Council √ √
Mr Roger Pafford South London and Maudsley NHS FT Joined on 02/01/2015
Dr Sadru Kheraj Lambeth CCG √ Joined on 01/01/2016
Mr Noel Baxter Southwark CCG Joined on 01/02/2016
NAME MEETINGS ATTENDED
Meeting Dates Key: (1) 10 December 2015; (2) 17 March 2016;
Enc. 4.1
This page has been left blank
Rep
Dat
Pre
Act
| Int NHSbasin fimee Theincluconadd As dapprequ On Jan(Coand | Ac Theacti
MO
port to:
te of meet
esenter:
tion Requ
troduction
S Foundatiois during 20nances, meeting condit
e submissioudes analystinuity of risition to othe
delegated bproved the quired timefra
26 April theuary – 31 Mnfirmed/No financial p
ction Requ
e Council oivities unde
ONITOR Q
C
ting: 04
N
ired: F
on Trusts ar015/16. Theeeting natiotions enshri
n is made insis of the finsk rating agaer informatio
by the Boardquarterly suame to Mon
e CommitteeMarch 2016t Confirmederformance
ired
of Governoertaken sin
UARTELY
Council of
4 May 201
Nick Mober
OR INFOR
re required e submissional targets ned in the it
n the form onancial posiainst the infon.
d the Financbmissions tnitor.
e considere, and decided) below take.
ors is askence the last
Y SUBMISS
Governor
16
rly, Chief
RMATION
to make in-on is based
and indicatts licence.
of a compreition, perforformation s
ce & Perforto ensure th
ed the Truste how best king accoun
ed to note t meeting o
SION - QU
rs
Executive
-year submon the Trusors and any
ehensive retrmance agaubmitted in
rmance Comhat submiss
t’s performato respond
nt of the late
the engagof the Coun
UARTER 4
e Director
issions on ast’s quarterlyy other area
turn to monainst nationa
the Trust’s
mmittee revsion are mad
ance during to the state
est reports o
gement andncil.
Enc
a quarterly y performanas pertinent
nitor which al targets, s annual pla
viewed and de within th
the quarterements on operatio
d involvem
c. 4.2
1
nce t to
an, in
he
r, 01
nal
ment
Enc. 4.2
Appendix 1: Board Declaration
Board Response
For finance, that: 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. Rationale for signing not confirmed The Trust is still reliant on the working capital facility from Monitor. The Trust Continuity of Service Risk Rating of 1 at the end of Quarter 4.
NOT CONFIRMED
For governance, that: 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. Rationale for signing not confirmed The Trust self-certified that there was a risk it would not meet the following targets in its Annual Plan:
Referral to treatment targets – 18 weeks for admitted/non-admitted/incomplete; and
A&E 4-hour target; and 62-day cancer waits; and C.Diff – Quarters 1-4
In quarter 4 the Trust did not meet the following targets:
18 weeks in aggregate incomplete pathway; and A&E 4-hour target; and The number of cases of c.diff is above trajectory The 2 week Wait breast target is currently an unvalidated position
NOT CONFIRMED
Otherwise: The board confirms that there are no matters arising in the quarter requiring an exception report to Monitor (per the Risk Assessment Framework, Diagram 6) which have not already been reported. Rationale for signing confirmed
The Trust is not aware of any other matters arising that Monitor is not already aware.
CONFIRMED
Consolidated subsidiaries: Number of subsidiaries included in the finances of this return. This template should not include the results of your NHS charitable funds.
1
Click to go to index
Summary of Financial Statements for King’s College Hospital NHS Foundation Trust
units sense
Audited For
PrevYE ending
31-Mar-15
Plan For
Month ending
31-Mar-16
Actual For
Month ending
31-Mar-16
Variance For
Month ending
31-Mar-16
Plan For
YTD ending
31-Mar-16
Actual For
YTD ending
31-Mar-16
Variance For
YTD ending
31-Mar-16
Plan For
Year ending
31-Mar-16
Summary Income and Expenditure Account
Operating income (inc in EBITDA)NHS Clinical income £m (+ve) 880.626 71.363 - (71.363) 860.388 825.345 (35.044) 860.388 Non-NHS Clinical income £m (+ve) 16.345 1.569 - (1.569) 19.783 21.240 1.457 19.783 Non-Clinical income £m (+ve) 186.811 11.819 - (11.819) 141.844 123.200 (18.644) 141.844 Total £m 1,083.782 84.750 0.000 (84.750) 1,022.015 969.785 (52.230) 1,022.015
Operating expenses (inc in EBITDA)Employee expense £m (-ve) (620.182) (49.776) - 49.776 (628.355) (575.133) 53.222 (628.355) Non-Pay expense £m (-ve) (401.385) (27.350) - 27.350 (345.619) (362.770) (17.151) (345.619) PFI / LIFT expense £m (-ve) (51.173) (4.931) - 4.931 (53.891) (50.781) 3.110 (53.891) Total £m (1,072.740) (82.057) 0.000 82.057 (1,027.865) (988.684) 39.181 (1,027.865)
EBITDA £m 11.042 2.693 - (2.693) (5.850) (18.899) (13.049) (5.850) EBITDA Margin % % 1.02% 3.18% 0.00% (3.18%) (0.57%) (1.95%) (1.38%) (0.57%)
Operating income (exc from EBITDA)Donations and Grants for PPE and intangible assets £m (+ve) - 0.134 - (0.134) 0.900 1.103 0.203 0.900
Operating expenses (exc from EBITDA)Depreciation & Amortisation £m (-ve) (22.152) (1.954) - 1.954 (23.446) (18.182) 5.264 (23.446) Impairment (Losses) / Reversals £m (+/-ve) (4.535) (0.459) - 0.459 (5.500) (5.039) 0.461 (5.500) Restructuring costs £m (-ve) - - - - - - - -Total £m (26.687) (2.413) 0.000 2.413 (28.946) (23.221) 5.725 (28.946)
Non-operating incomeFinance income £m (+ve) 0.969 0.228 - (0.228) 2.500 0.092 (2.408) 2.500 Gain / (Losses) on asset disposals £m (+/-ve) (0.285) (0.039) - 0.039 (0.350) (0.111) 0.239 (0.350) Gain on transfers by absorption £m (+ve) - - - - - - - -Other non - operating income £m (+ve) - - - - - - - -Total £m 0.684 0.189 0.000 (0.189) 2.150 (0.019) (2.169) 2.150
Non-operating expensesInterest expense (non-PFI / LIFT) £m (-ve) (1.809) (0.337) - 0.337 (3.670) (3.490) 0.180 (3.670) Interest expense (PFI / LIFT) £m (-ve) (17.279) (1.413) - 1.413 (16.962) (15.553) 1.409 (16.962) PDC expense £m (-ve) (11.272) (0.961) - 0.961 (11.523) (8.961) 2.562 (11.523) Other finance costs £m (-ve) (0.153) (0.012) - 0.012 (0.150) (0.121) 0.029 (0.150) Non-operating PFI costs (e.g. contingent rent) £m (-ve) (6.163) (0.537) - 0.537 (6.452) (6.017) 0.435 (6.452) Losses on transfers by absorption £m (-ve) - - - - - - - -Other non-operating expenses (including tax) £m (-ve) (0.250) - - - - - - -Total £m (36.926) (3.260) 0.000 3.260 (38.757) (34.142) 4.615 (38.757)
Surplus / (Deficit) after tax £m (51.887) (2.657) 0.000 2.657 (70.503) (75.179) (4.676) (70.503)
Profit/(loss) from discontinued Operations, Net of Tax £m (+/-ve) - - - - - - - -
Surplus / (Deficit) after tax from Continuing Operations £m (51.887) (2.657) 0.000 2.657 (70.503) (75.179) (4.676) (70.503)
Memorandum Lines:
Surplus / (Deficit) before impairments and transfers £m (47.352) (2.198) - 2.198 (65.003) (70.140) (5.137) (65.003)
One off income/costs £m (4.820) (0.498) - 0.498 (5.850) (5.150) 0.700 (5.850) Normalised Surplus / (Deficit) £m (47.067) (2.159) - 2.159 (64.653) (70.029) (5.376) (64.653) Normalised Surplus / Deficit Margin % % (4.34%) (2.54%) 0.00% 2.54% (6.31%) (7.21%) (0.91%) (6.31%)
Summary Statement of Financial Position
Non-current AssetsIntangible assets £m (+ve) 3.495 2.704 - (2.704) 2.704 - (2.704) 2.704 Property, Plant & Equipment £m (+ve) 365.304 375.295 - (375.295) 375.295 - (375.295) 375.295 On-balance sheet PFI £m (+ve) 247.392 258.148 - (258.148) 258.148 - (258.148) 258.148 Other £m (+ve) 11.659 13.410 - (13.410) 13.410 - (13.410) 13.410 Total £m 627.850 649.557 0.000 (649.557) 649.557 0.000 (649.557) 649.557
Current AssetsCash and cash equivalents £m (+ve) 43.445 2.000 - (2.000) 2.000 - (2.000) 2.000 Other current assets £m (+ve) 115.307 112.578 - (112.578) 112.578 - (112.578) 112.578 Total £m 158.752 114.578 0.000 (114.578) 114.578 0.000 (114.578) 114.578
Current LiabilitiesOverdrafts and drawdowns in committed facilities £m (-ve) - (26.494) - 26.494 (26.494) - 26.494 (26.494) PFI / LIFT leases £m (-ve) (3.550) (3.898) - 3.898 (3.898) - 3.898 (3.898) Other borrowings £m (-ve) (4.074) (63.774) - 63.774 (63.774) - 63.774 (63.774) Other current liabilities £m (-ve) (175.701) (134.804) - 134.804 (134.804) - 134.804 (134.804) Total £m (183.325) (228.970) 0.000 228.970 (228.970) 0.000 228.970 (228.970)
Non-current LiabilitiesPFI / LIFT leases £m (-ve) (155.109) (151.211) - 151.211 (151.211) - 151.211 (151.211) Other borrowings £m (-ve) (67.462) (63.386) - 63.386 (63.386) - 63.386 (63.386) Other non-current liabilities £m (-ve) (6.295) (4.995) - 4.995 (4.995) - 4.995 (4.995) Total £m (228.866) (219.592) 0.000 219.592 (219.592) 0.000 219.592 (219.592)
Reserves £m (+ve) 374.413 315.394 291.744 (23.650) 315.394 291.744 (23.650) 315.394
Summary Statement of Cash Flows
Surplus (Deficit) from Operations £m (15.645) 0.414 - (0.414) (33.896) (41.018) (7.122) (33.896)
Operating activitiesNon-operating and non-cash items in operating surplus/(deficit) £m (+/-ve) 26.648 1.697 - (1.697) 17.350 14.955 (2.395) 17.350 Operating Cash flows before movements in working capital £m 11.003 2.111 0.000 (2.111) (16.546) (26.063) (9.517) (16.546)
Movements in working capital £m (+/-ve) 48.424 2.246 (7.173) (9.419) (29.445) (35.551) (6.106) (29.445) Increase/(Decrease) in non-current provisions £m (+/-ve) - (0.434) (6.295) (5.861) (1.300) (6.295) (4.995) (1.300) Net cash inflow/(outflow) from operating activities £m 59.427 3.923 (13.468) (17.391) (47.291) (67.909) (20.618) (47.291)
Investing activitiesCapital Expenditure (Accruals basis) £m (-ve) i (49.147) (3.262) - 3.262 (38.903) (23.883) 15.020 (38.903) Increase/(decrease) in Capital Creditors £m (+/-ve) (1.669) 0.100 - (0.100) 1.200 (0.051) (1.251) 1.200 Proceeds on disposal of PPE, intangible assets and investment property £m (+ve) 0.012 0.002 - (0.002) 0.021 0.001 (0.020) 0.021 Other cash flows from investing activities £m (+/-ve) 0.213 0.038 - (0.038) 0.220 (0.247) (0.467) 0.220 Net cash inflow/(outflow) from investing activities £m (50.591) (3.122) 0.000 3.122 (37.462) (24.180) 13.282 (37.462)
Financing activitiesPublic Dividend Capital repaid £m (-ve) - - - - - (9.400) (9.400) -Repayment of borrowings £m (-ve) i (1.285) - - - (3.883) (3.884) (0.001) (3.883) Capital element of finance lease rental payments £m (-ve) i (3.199) (0.296) - 0.296 (3.550) (3.253) 0.297 (3.550) Interest element of finance lease rental payments £m (-ve) i (23.443) (1.952) - 1.952 (23.414) (19.929) 3.485 (23.414) Interest paid on borrowings £m (-ve) (1.452) - - - (2.908) (3.546) (0.638) (2.908) Other cash flows from financing activities £m (+/-ve) 9.462 (1.787) - 1.787 50.561 89.606 39.045 50.561 Net cash inflow/(outflow) from financing activities £m (19.917) (4.035) 0.000 4.035 16.806 49.594 32.788 16.806
Opening cash and cash equivalents less bank overdraft £m (+/-ve) 54.526 (21.269) 14.418 35.687 43.453 43.445 (0.008) 43.453 Net cash increase / (decrease) £m (11.081) (3.234) (13.468) (10.234) (67.947) (42.495) 25.452 (67.947) Changes due to transfers by absorption £m (+/-ve) - - - - - - - -Closing cash and cash equivalents less bank overdraft £m 43.445 (24.502) 0.950 25.452 (24.494) 0.950 25.444 (24.494)
Financial Sustainability Risk Rating
Capital Service CoverRevenue Available for Capital Service £m 11.761 (3.350) (25.007) (21.657) (3.350) Capital Service £m (41.160) (46.190) (41.279) 4.911 (46.190) Capital Service Cover metric 0.0x 0.29 (0.07) (0.61) (0.53) (0.07) Capital Service Cover rating Score 1 1 1 1
LiquidityWorking Capital for FSRR £m (+/-ve) (41.663) (131.482) - 131.482 (131.482) Operating Expenses within EBITDA, Total £m (1,072.740) (1,027.865) (988.684) 39.181 (1,027.865) Liquidity metric Days (13.982) (46.050) - 46.050 (46.050) Liquidity rating Score 2 1 4 1
I&E MarginNormalised Surplus/(Deficit) £m (+/-ve) (47.067) (64.653) (76.229) (11.576) (64.653) Adjusted Total Income for FSRR £m (+ve) 1,084.751 1,025.415 964.779 (60.636) 1,025.415 I&E Margin % (4.34%) (6.31%) (7.90%) (1.60%) (6.31%)I&E Margin rating Score 1 1 1 1
I&E Margin VarianceI&E Margin % (6.31%) (7.90%) (1.60%) (6.31%)I&E Margin Variance From Plan % -4.37% (4.37%) -1.60% (4.37%)I&E Margin Variance From Plan rating Score 1 2 1
Overall Financial Sustainability Risk Rating Score 1 2 1
Continuity of Service Risk Rating Score 2
CIPs
CIPs as a percentage of opex within EBITDA less PFI expenses % 1.94% 12.62% 0.00% (12.62%) 7.43% 4.46% (2.97%) 7.43%CIPs £m (+ve) 20.160 11.141 - (11.141) 78.143 43.749 (34.394) 78.143
Appendix 1
Click to go to index
Targets and indicators as set out in the Risk Assessment Framework (RAF) - definitions per RAF Appendix ANOTE: If a particular indicator does not apply to your FT then please enter "Not relevant" for those lines.
Key:
Threshold or target YTD
Scoring Per Risk
Assessment Framework
Risk declared
Scoring Per Risk
Assessment Framework
Performance Declaration Comments / explanations
Scoring Per Risk
Assessment Framework
Performance Declaration Comments / explanations
Scoring Per Risk
Assessment Framework
Performance Declaration Comments / explanations
Scoring Per Risk
Assessment Framework
Performance Declaration Comments / explanations
Scoring Per Risk
Assessment Framework
must completemay need to complete
Target or Indicator (per Risk Assessment Framework)
Referral to treatment time, 18 weeks in aggregate, incomplete pathways i 92% 1.0 Yes 1 0.0% Not met Data not submitted with agree 1 0.0% Not met Data not submitted with agree 1 0.0% Not met Data not submitted with agree 1 0.0% Not met Data not submitted with agree 1
A&E Clinical Quality - Total Time in A&E under 4 hours i 95% 1.0 Yes 1 89.9% Not met 1 91.8% Not met 1 89.3% Not met 1 83.4% Not met 1
Cancer 62 Day Waits for first treatment (from urgent GP referral) - post local breach re-allocation i 85% 1.0 Yes 84.6% Not met 86.4% Achieved 86.3% Achieved 89.4% Achieved
Cancer 62 Day Waits for first treatment (from NHS Cancer Screening Service referral) - post local breach re-allocation i 90% 1.0 No 95.5% Achieved 92.6% Achieved 97.5% Achieved 92.9% Achieved
Cancer 62 Day Waits for first treatment (from urgent GP referral) - pre local breach re-allocation i 0.0% 0.0% 0.0% 0.0%
Cancer 62 Day Waits for first treatment (from NHS Cancer Screening Service referral) - pre local breach re-allocation i 0.0% 0.0% 0.0% 0.0%
Cancer 31 day wait for second or subsequent treatment - surgery i 94% 1.0 No 98.8% Achieved 95.3% Achieved 98.8% Achieved 98.2% Achieved
Cancer 31 day wait for second or subsequent treatment - drug treatments i 98% 1.0 No 99.5% Achieved 100.0% Achieved 100.0% Achieved 100.0% Achieved
Cancer 31 day wait for second or subsequent treatment - radiotherapy i 94% 1.0 No 100.0% Achieved 100.0% Achieved 99.4% Achieved 99.1% Achieved
Cancer 31 day wait from diagnosis to first treatment i 96% 1.0 No 0 98.4% Achieved 0 99.3% Achieved 0 99.3% Achieved 0 98.1% Achieved 0
Cancer 2 week (all cancers) i 93% 1.0 No 97.0% Achieved 97.5% Achieved 95.1% Achieved 93.1% Achieved
Cancer 2 week (breast symptoms) i 93% 1.0 No 99.1% Achieved 99.2% Achieved 98.7% Achieved 91.6% Not met
Care Programme Approach (CPA) follow up within 7 days of discharge i 95% 1.0 N/A 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant
Care Programme Approach (CPA) formal review within 12 months i 95% 1.0 N/A 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant
Admissions had access to crisis resolution / home treatment teams i 95% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0
Meeting commitment to serve new psychosis cases by early intervention teams OLD measure - use until Q1 2016/17 i 95% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0
Ambulance Category A 8 Minute Response Time - Red 1 Calls i 75% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0
Ambulance Category A 8 Minute Response Time - Red 2 Calls i 75% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0
Ambulance Category A 19 Minute Transportation Time i 95% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0
C.Diff due to lapses in care (YTD) i 72 1.0 Yes 1 28 Not met 1 47 Not met 1 67 Not met 1 82 Not met 1
Total C.Diff YTD (including: cases deemed not to be due to lapse in care and cases under review) i 0 0 0 0
C.Diff cases under review i 0 0 0 0
Minimising MH delayed transfers of care i <=7.5% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0
Meeting commitment to serve new psychosis cases by early intervention teams NEW measure (scored from Q4 2015/16) i 50% 1.0 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant 0
Improving Access to Psychological Therapies - Patients referred within 6 weeks NEW measure (scored from Q3 2015/16) i 75% 1.0 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant 0 0.0% Not relevant 0
Improving Access to Psychological Therapies - Patients referred within 18 weeks NEW measure (scored from Q3 2015/16) i 95% 1.0 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant 0 0.0% Not relevant 0
Data completeness, MH: identifiers i 97% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0
Data completeness, MH: outcomes i 50% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0
Compliance with requirements regarding access to healthcare for people with a learning disability i N/A 1.0 No 0 N/A Achieved 0 N/A Achieved 0 N/A Achieved 0 N/A Achieved 0
Community care - referral to treatment information completeness i 50% 1.0 N/A 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant
Community care - referral information completeness i 50% 1.0 N/A 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant
Community care - activity information completeness i 50% 1.0 N/A 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant
Risk of, or actual, failure to deliver Commissioner Requested Services N/A N/A No No No No
Date of last CQC inspection i N/A N/A 13/04/2015 13/04/2015 13/04/2015 13/04/2015
CQC compliance action outstanding (as at time of submission) N/A N/A No Final CQC Inspection Report pending Yes Yes Yes
CQC enforcement action within last 12 months (as at time of submission) N/A N/A No No No No
CQC enforcement action (including notices) currently in effect (as at time of submission) N/A N/A No Final CQC Inspection Report pending No No No
Moderate CQC concerns or impacts regarding the safety of healthcare provision (as at time of submission) i N/A N/A No Final CQC Inspection Report pending No We have requirement notices in place and must do's which we ar No We have requirement notices in place and must do's which we ar No We have requirement notices in place and must d
Major CQC concerns or impacts regarding the safety of healthcare provision (as at time of submission) i N/A N/A No Final CQC Inspection Report pending No No No
Overall rating from CQC inspection (as at time of submission) i N/A N/A N/A Final CQC Inspection Report pending Requires improvement Requires improvement Requires improvement
CQC recommendation to place trust into Special Measures (as at time of submission) N/A N/A No No No No
Trust unable to declare ongoing compliance with minimum standards of CQC registration N/A N/A No No No No
Trust has not complied with the high secure services Directorate (High Secure MH trusts only) N/A N/A N/A N/A N/A N/A
Results left to complete:0 i 0 0 0 0
Checks Count:0 i
Checks left to clear:0 i OK
Service Performance Scorei 4 4 3 3 4
0
0
0
Report by Exception
0
1
0
0
0
Quarter 2
0
0
0
0
0
0
Quarter 3
0
0
0
Declaration of risks against healthcare targets and indicators for 201516 by King’s College Hospital NHS Foundation Trust
1
0
0
0
0
0
0
Quarter 4
1
Annual Plan Quarter 1
Appendix 2
1
Governors’ Membership & Community Engagement Committee Minutes of the meeting held at 11:30 on 18 February 2016, in the Dulwich Meeting Room, King’s College Hospital, Denmark Hill
Members: Fiona Clark (FC) Public Governor/ Committee Chair Penny Dale (PD) Public Governor Chris North (CN) Public Governor (Lead Governor) Pida Ripley (PR) Patient Governor Tom Duffy (TD) Patient Governor Barbara Pattinson (BP) Public Governor Jan Thomas (JT) Patient Governor In attendance: Tim Bradley Patient Governor Jessica Bush (JB) Head of Engagement and Patient Experience Petula Storey (PS) Head of Volunteering Sally Lingard (SL) Director of Communications Sarah Willoughby (SW) Stakeholder Relations Manager Tamara Cowan (TC) Board Secretary Jane Badejoko (JB1) Corporate Governance Officer (minutes) Nicola Kingston (NK) External Speaker (SLIC)- Item 2.1 only Valerie Dinsmore (VD) Integrated lead for Customer Engagement, Health and Wellbeing
Board - Item 2.1 only Rachel Rundquist PPI & Membership Team Intern Apologies: Andrew McCall (AM) Public Governor Phidelma Lisowska (PL) Joint Staff Governor
Item
Subject
Action
016/01 Welcome and apologies Apologies for absence were noted.
016/02 Minutes of the Previous Meeting The minutes of the previous meeting were approved as a correct record.
016/03 Action Tracker The action tracker was noted.
016/04 MEMBERS IN FOCUS
016/05 External Speakers from the Citizens Forum The Committee welcomed Nicola Kingston and Valerie Dinsmore from Southwark and Lambeth Integrated Care (SLIC) citizens’ forum.
Enc. 4.3.1
2
Item Subject
Action
The following key points were reported: SLIC is a partnership organisation between the local GP Federations, the
three local NHS Foundation Hospital Trusts which include Guy’s and St Thomas’ (GSTT) NHS Foundation Trust, South London & Maudsley NHS Foundation Trust and King’s College Hospital NHS Foundation Trust and Southwark and Lambeth Clinical Commissioning Groups and Southwark and Lambeth local authorities and people in Southwark and Lambeth localities with support and funding from the GSTT Charity;
The organisation was created 3 years ago to form a common discussion
platform between health, social care providers, voluntary sector organisations and local people, with the aim to work together on integrated care and improve the way care is delivered in the community;
SLIC was given start-up funding from the GSTT charity which will end in
March 2016. But there are plans for the organisation to continue under in new format of a Strategic Partnership. The work on integrated care is ongoing and there is need for continued co-operation between local health and social care providers and the public;
SLIC is governed by a citizens Board which is composed of 19 members
who are a mix of volunteer citizens from Southwark and Lambeth, Healthwatch Lambeth and Southwark staff and CCG staff, they meet monthly with Sir Ron Kerr serving as the meeting Chair;
The meetings include discussions on various health issues and detailed
discussions on how to best redesign the whole system to make it fit for purpose;
The following key points were discussed and noted: SLIC as an independent organisation has been providing a unique benefit
to the local community by collecting information on services available locally and passing this onto on to members of the public when required;
South East London as sector must work together to improve healthcare and
provision to local residents that will include cooperation between hospital, General Practitioners (GP), community care providers, the voluntary sector and social housing organisations;
Lessons on joint up working can be learned from the voluntary and faith
sectors which are an excellent source of learning provide all partners are willing to work together; and
It was noted that SLIC citizens Board has no influence over how services
are provided or run but it does feedback public views/experiences to providers via its open meetings.
016/06 Stakeholder Update The Committee received the stakeholder update from Sarah Willoughby.
Enc. 4.3.1
3
Item Subject
Action
The following key points were reported: The stakeholder team attended a number of events at Lambeth, Lewisham and Southwark in November 2015. Also in attendance were local authority staff, Clinical Commissioning Group (CCG) staff and NHS England representatives, the main topic was strategic updates and discussions on the future of healthcare; and
The team also scheduled a number of face to face meetings between Nick
Moberly, Chief Executive Officer and Ministers of Parliaments (MP) and the new the Chief Executive Officer for NHS improvement agency Jim Mackey.
016/07 Update on Transport Matters
The Committee received the Transport update from Sarah Willoughby. The following key points were reported: Transport for London (TFL) published a commissioner report at the end of
2015 indicating their proposed intensions to proceed with the Bakerloo line extension via Old Kent Road and not via Camberwell which was considered as a possible line extension. The announcement did not include a start date for the construction work. However, the report does state that there is need to improve South East London travel links and reduce the congestion on Walworth Road;
The Trust will be liaising with TFL and putting forward an evidence based case to support the Bakerloo line extension via Camberwell, which would be beneficial to local residents and provide easy access to the Denmark Hill site and improved transport links to the whole area;
Southwark Council has announced it will be developing a business case for the proposed re-opening of Camberwell Rail station which was closed in 1916; and
Bromley bus services are running a consultation on proposed bus route
changes to buses R11 and R3. The changes will bring about ease of travel between the Princess Royal University Hospital (PRUH) and the Orpington site.
The following key points were discussed: Previously the Trust’s ran a transport feeder group which reported into this
Committee. The feeder group discussed transport matters but was disbanded in 2014 due to low Governor attendance.
The oversight function for all transport matters then reverted to this Committee. Accordingly, transport matters has been a regular feature on the Membership & Community Engagement Committee (MCEC).
A detailed discussion ensued with options such as reinstating the transport group or amending the name of MCEC to include the word ‘transport’. It was agreed that the word ‘community’ in MCEC embraced transport matters and that the current coverage of transport matters was sufficient and not necessitating re-establishing a separate transport group;
Enc. 4.3.1
4
Item Subject
Action
The Trust is currently running a short survey jointly with SLAM and local interest groups open to all staff, patients and local people who visit the site. The aim of the survey is to form part of the evidence based case that will be presented to TFL in the attempt to lobby for the Bakerloo line extension via Camberwell; To ensure the survey provides a true reflection of patient’s opinions the Trust will be holding an onsite survey day at Denmark Hill on 25 February 2016. Paper based surveys will be available to patients and the Trust volunteers will be available to assist patients and visitors; and The Bromley bus consultation will close at the end of March 2016, further updates will be provided to the Committee in due course.
It was agreed that the Committee would: 1) Receive the results from the transport survey and a written report on
transport matters; and
2) Retain its current name and transport matters would be a feature of each meeting.
SW
016/08 Membership Update The Committee received the Membership Update Report from Jessica Bush. The following key points were reported: The Trust’s membership remains stable and annual targets have largely
been met. The Trust will be looking to increase its membership numbers in Lambeth constituency and young members from all constituencies; and
The Trust will be submitting the annual membership report to Monitor at the
end of March 2016. The report will be accompanied by a narrative summary, this is a new reporting feature.
016/09 Young Person’s Involvement at Bromley College The Committee received the Young person’s report from Jessica Bush. The following key points were reported: The Trust interacted with students at Bromley College in 2015, this was
brought about following the successful collaboration between the Trust and Lambeth College;
The collaboration proved to be successful and provided the Trust with an
insight into young adults’ interest. Students were divided into 5 teams and asked to update the Trust’s young adult members recruitment poster; and
The results were very encouraging and the Trust was delighted that they all
selected the NHS blue as the colour of preference. They also suggested the poster should include social media links and list the benefits of being a member examples, work experience, voluntary possibilities and any discounts available.
Enc. 4.3.1
5
Item Subject
Action
The following key points were discussed: The Trust has taken all the useful information on board and the next stage
would be to produce the poster. There are also discussions taking place on the possibility of advertising the fact that NHS Discounts national scheme is available to Trust members;
It was noted that members of NHS Trusts are able to register and receive the benefits of NHS discounts scheme; and
The Trust will be doing a call out to all members, asking for anyone with design skills who would like to assist with the production of the new posters.
016/10 Update on Volunteers The Committee received an update of Trust Volunteers from Jessica Bush. The following key points were reported: The Trust volunteers are not automatically enrolled as Trust members, they
have to complete a form to requesting to become members. This is different from staff who are automatically enrolled as members;
The Trust’s Volunteer programme is being reviewed as a whole to make
sure all information is stored at a single point and volunteer numbers and placements are easily accessible; and
The volunteer programme review will also look at the possibility of an option
to register as a Trust member on the volunteer application form at the earliest stage of the application process.
016/11 Governor Contribution to @King’s Magazine The Committee received an update on @King’s magazine from Sally Lingard. The following key points were reported: The Trust will publish 3 @King’s magazine per financial year, this means
that the next issues of @King’s magazine will be in the new financial year post April 2016; and
The next issue will focus on the upcoming Governor election. The following key point was discussed: It was noted that in the past Governor contributions to the magazine had
been re-written, it was agreed that while in some circumstances the Trust may need to edit and reduce the governor contribution to ensure it fits in with the permitted wording count but if this is done the contributing Governor will always be consulted prior to publication.
016/12 Governor Engagement & Involvement Report The Committee noted the governor engagement and involvement report.
Enc. 4.3.1
6
Item Subject
Action
016/13 Membership Community Event The Committee received information about the Trust upcoming Community events from Sally Lingard. The following key points were reported:
The Trust will be holding 2 community events in March, with the first taking place on Thursday 3 March from 5pm at Bromley Central Library, High St, Bromley BR1 1EX.
The second event will be held on Wednesday 9 March from 5pm Cambridge House, 1 Addington Square, London SE5 0HF;
The events are an opportunity for the Trust to interact with Trust members
and patients and have discussion sessions on key issues and developments over the past year and Trust plans for the year ahead; and
The Trust requires Governors to attend the event to engage with members
and give a short presentation on the role of a Governor.
016/14 Committee Work Plan 2016 The Committee approved the work plan.
016/15
Month 9 Finance and Performance Reports
The Committee received and noted the finance and performance reports for month 9. The Committee decided to no longer receive the Finance and Performance reports as these reports are presented at the monthly Trust Board of Directors meeting.
016/16 Any Other Business
There were no items of any other business raised for discussion.
016/17
Date of Next Meeting The next meeting will be held on Thursday, 14 April 2016, from 11:30-13:30 in Dulwich Committee Room.
Enc. 4.3.1
1
Governor Strategy Committee Minutes of the meeting of the Governors’ Strategy Committee held at 15:30-17:30 on Monday, 15 February 2016 in the Dulwich Committee Room, King’s College Hospital, Denmark Hill. Members: Andrew McCall (AM) Committee Chair Barbara Pattinson (BP) Public Governor Chris North (CN) Public Governor Fiona Clark (FC) Public Governor Nanda Ratnavel (NR) Public Governor Penny Dale (PD) Public Governor Phidelma Lisowska (PL) Joint Staff Governor Pida Ripley (PR) Patient Governor Tom Duffy (TD) Patient Governor In attendance: Alan Goldsman (AG) Acting Director of Strategy David Dawson (DD) Deputy Director of Strategy Colin Gentile (CG) Chief Financial Officer Joe Farrington-Douglas (JFD) Senior Strategy Advisor Tamara Cowan (TC) Board Secretary Tim Bradley (TB) Public Governor Cllr Jim Dickson (JD) Cabinet Member for Health & Wellbeing, London Borough of
Lambeth (Item 2.1 only) Sarah Willoughby (SW) Stakeholder Relations Manager Silviyana Yankova (SY) Corporate Governance Assistant (Minutes) Apologies: Lord Kerslake (BK) Trust Chair Trudi Kemp (TK) Director of Strategy Judith Seddon (JS) Acting Director of Corporate Affairs Jill Solly (JS1) Head of Primary/Secondary Care Interface Jan Thomas (JT) Patient Governor
Item
Subject Action
16/1 Welcome and Apologies The Committee Chair welcomed members and attendees to the Governor Strategy Committee meeting and the apologies for absence were noted.
16/2 Minutes of the Previous Meeting The minutes of the meeting held on 22 October 2015 were approved as a correct record.
16/3 Action Tracker The Committee noted the action tracker and the following updates: Action Item 15/04, Aims and Forward Plan of the Committee - It was
Enc. 4.3.2
2
Item Subject Action
agreed that this item would be removed from the action tracker as the Committee Chair received feedback from Committee members;
Action Item 15/37, 7-Day Working – It was noted that it would be useful to
have contribution from Prof. Julia Wendon relating to 7-day working at a future Governor Workshop.
JW
16/4 Integration of Health and Social Care Services in Lambeth The Committee received and noted the presentation from Cllr Jim Dickson relating to the integration of health and social care services in Lambeth. The following key points were reported: The integration initiative aims to improve the outcomes for vulnerable adults in
Lambeth and deliver cashable savings best achieved by integrating commissioning and services supported by wider partnerships with health providers;
The purpose of the Southwark and Lambeth Strategic Partnership is to align
key strategies and build a shared vision of integrated care as well as sharing best practices;
The partnership aims to address various matters of people using or working in
health and social care services in Lambeth and Southwark; The Committee in Common has been established with a shared governance
framework looking at how budgets are spent and commissioning for Mental Health and Older People;
The integrated reablement has been commissioned in partnership with Guy’s
and St Thomas’ NHS Foundation Trust (GSTT) ensuring people well-being and independence;
The partnership is creating a unified point of access for health and care
community independent services via locality care networks; Another focus of the initiative is to mainstream successful Southwark and
Lambeth Integrated Care (SLIC) projects and continue to test locality geriatricians and primary care holistic assessments;
Various approaches to support residents have been implemented in particular
improving mental healthcare deals for BME residents; The following key points were discussed: Appropriate actions have been taken to minimise delays in transfer of care by
providing people with the right care as well as offering appropriate health packages; and
Over the past few years facilities for disabled people have been closed or
consolidated into one improved and integrated centre.
16/5 Strategic Planning Update (Where Are We Now?) The Committee received an overview of the current strategic planning aims and related issues.
Enc. 4.3.2
3
Item Subject Action
The following key points were reported: In accordance with Monitor requirements, the Trust has to produce a 2016/17
operational plan which will be submitted on 11 April 2016. The key issue is that the organisation needs to achieve a better alignment across the healthcare sector as a whole;
The NHS is moving towards a place-based system of commissioning where
NHS commissioners and providers come together to deliver best value through collaborative planning;
An affordability gap of £818m has been identified across the healthcare sector
over the next five years. Key emerging strategies to address the affordability gap include three broad
approaches: - There is an expectation that individual organisations will scrutinise costs,
limiting waste and applying good business practices which should help achieve 2% efficiency;
- The productivity at scale approach is looking at using the combined power
of the South East London health sector to improve clinical and non-clinical services; and
- Ensuring organisations are optimising workforce across the sector.
There are significant strategic planning initiatives across the healthcare sector
and the Trust needs to participate actively in the alignment process and ensures that its strategy is in alignment with the external healthcare environment.
16/6 Trust Strategic Vision/Mission (Triangle) The Committee received and discussed the Emerging Trust Strategy. The report provides clear strategic objectives allowing the Trust to transform into an organisation that is financially sustainable, operationally efficient and offering outstanding care for patients across all services. The following key points were reported: The Trust aims to articulate a shared understanding of key principles to set
clear organisational purpose and forward strategy. The overall goals will be translated into annual operational objectives at each level of the organisation, clearly communicating them so they are owned at the frontline;
The Trust is moving very determinately towards the deficit target of £65m by
the end of the financial year and there has been a significant proportion of cost improvement plans (CIPs) delivered to date;
The organisation has improved working across sites and management teams
are developing a new organisational structure;
It is vital to maintain and improve “grip” by gaining control of finances and continue addressing key clinical and operational performance issues;
Enc. 4.3.2
4
Item Subject Action
The Trust needs to continue implementing significant systemic changes by strategic alignment, building skills and transforming services;
It was highlighted that the long-term sustainability across South East London
healthcare system can be achieved by working closely; The Trust will attract and retain outstanding people across clinical and non-
clinical services by offering great development opportunities and talent management;
The introduction of a “clean sheet” approach aims to systematically redesign
clinical services and consistently deliver outstanding quality that is ‘best in class’ and efficient;
The “Triangle” is a tool which will support clarity of the Trust’s mission, forward
objectives and support delivery of the best quality of care. The following key points were discussed: The Committee responded positively to the Trust’s forward initiatives and
noted that the changes will boost staff morale and organisational culture; and The Trust is aiming to embed performance management culture and systems
across the wards and offer staff opportunities for training and continuous development.
It was agreed that the objectives and milestones underpinning the “Triangle” would be discussed further at the Council of Governors meeting.
DD
16/7 Update on Financial Plan, CIPs & Transformation The Committee received and noted the Financial Plan, CIPs and Transformation update. The following key points were reported: The Trust remains focused on delivering its £65m deficit target for 2015/16; The Trust is £71.9m overspent at month 9; The organisation is aiming to implement a mitigation plan to successfully
manage the deficit target. The success of the plan will require particular emphasis on CIPs delivery and managing the risk of penalties from NHS England;
Current mitigation plans will generate between £19m to £22.6m of financial improvement;
It is crucial for the Trust to deliver its £65m deficit target which would unlock
goodwill;
A letter was sent from the system out to large acute Trusts delivering care offering a proportion of £1.6bn sustainability and transformation funding;
The proposed plan does not require funding to be spent on waiting lists and other related issues. The funding would be distributed to the bottom line to improve providers’ position;
Enc. 4.3.2
5
Item Subject Action
The Trust has been offered £30m funding however the underlying condition is that the Trust would be required to deliver £4m surplus and operational improvements are required primarily on waiting times and A&E;
The Trust realises that achieving financial and service delivery as well as good
quality and patient experience is challenging especially with further cost savings;
It was agreed that Governors will have an opportunity to input into the Operational Plan at the Council of Governors meeting.
SY
16/8 KHP Update The Committee received and noted the KHP update. It was highlighted that a session on KHP Institutes would be organised at a later date.
16/9 Horizon Scan The Committee noted the Horizon Scan update and the relevant strategic issues. The following key points were reported: There have been significant changes across the external healthcare
environment mainly focusing on financial, regulatory and planning frameworks. The front-loaded funding has been taken away from the frontline and healthcare providers need to meet certain criteria to obtain the additional funding;
For the first time Commissioners and NHS providers are working on the same
framework and timetables for annual planning and must demonstrate robust plans to meet financial control targets in order to qualify for additional financial support; and
The newly implemented regulatory framework across the healthcare sector is closely aligned with the system for Commissioners and NHS England which is aiming to bring together quality and finance.
16/10 Draft Work Plan for Governors’ Strategy Committee for 2016 The Committee noted the draft work plan for 2016 and the Committee Chair thanked members for their contribution.
16/11 Finance and Performance Reports (M09) The Committed received and noted the Finance and Performance reports for month 9.
16/12 Any Other Business There were no matters of any other business to discuss.
16/13 Date of Next Meeting The Governor Strategy Committee meeting will be held on 14 April 2016 at 14:30 in the Dulwich Committee Room, Denmark Hill.
Enc. 4.3.2
This page has been left blank
1
Governors’ Patient Experience & Safety Committee Minutes of the meeting held at 9.00am on 18 February 2016 in the Dulwich Committee Room, King’s College Hospital Members:
Tom Duffy (TD) Patient Governor, Committee Chair Pida Ripley (PR) Patient Governor Jan Thomas (JT) Patient Governor Penny Dale (PD) Public Governor – Bromley Chris North (CN) Public Governor – Lambeth Tim Bradley (TB) Public Governor – Lewisham Victoria Silvester (VS) Public Governor – Southwark Roger Engwell (RE) Staff Governor – Admin & Clerical Nicky Hayes (NH) Staff Governor – Nursing Midwifery In attendance:
Judith Seddon (JS) Associate Director of Governance Jessica Bush (JB) Head of Public & Patient Involvement Maxine Spencer (MS) Director of Midwifery & Head of Gynae Nursing Geraldine Walters (GW) Executive Director of Nursing & Midwifery Richard Hinckley (RH) Head of Patient Safety & Risk Management Tooba Ahmadi (TA) Corporate Governance Officer (minutes) Apologies:
Derek St Clair Cattrall (DC) Patient Governor Craig Jacobs (CJ) Patient Governor Jo Millett (JM) Staff Governor – Nursing & Midwifery Phidelma Lisowska (PL) Joint Staff Committee Faith Boardman (FB) Non-Executive Director Item Subject Action
016/00 Welcome, introduction and apologies
Apologies for absence were noted.
016/01 Minutes of the previous meeting – 08/10/2015
The minutes of the previous meeting were approved as a correct record subject to amending the constituency for Tim Bradley to Public Governor – Lewisham.
016/02 Action Tracker/Matters Arising
The Committee noted the action tracker.
PATIENT EXPERIENCE
016/03 Patient Experience/ Video Story
The Committee watched a video of a patient relaying her experience following the birth of her two children. The patient’s story highlighted issues with the
Enc.4.3.3
2
Item Subject Action
lack of professionalism, communication and attention from the midwife during her first labour.
The patient also described her positive experience through the ‘caseload midwifery’ care, which provided continued care throughout her pregnancy. The patient felt satisfied of her care following the birth of her second child and suggested that patients should be asked for feedback about their experience during labour and how the midwives performed soon after birth, whilst the experience is still fresh.
Governors raised the following points in discussions:
It is important patient video stories are shared with staff so lessons can be learnt;
There are some powerful themes coming from this patient story and it is important patient stories are shared with staff so lessons can be leant, in particular with those staff directly involved with the care;
It was highlighted that the maternity team works very hard to drive improvements through various initiatives with limited resources. There has been significant improvement in the vacancy rates and the Trust is continuing to ensure the core staff are in post;
Governors commented that the patient video stories should be shorter and snappier. Governors also appreciated the hard work that goes into producing the video from a raw recording with limited resources, time and media expertise;
However, the external review of the Communication’s team, which is
currently being undertaken, should consider providing support to internal patient communication and information such as video stories;
Governors noted the ‘whose shoes’ initiative, which was launched at
the recent Stakeholder Events. The responses from the event were collected and transferred into a poster to bring maternity patient experiences to live; and
The Trust is also in the process to address a number of issues and
pledges that were identified from the ‘whose shoes’ initiative. This is the beginning of a significant strategy to transform care.
016/04 National Maternity Survey Results 2015
Maxine Spencer, Director of Midwifery presented the results of the Care Quality Commission (CQC) 2015 National Maternity Survey and the Trust’s performance. This was the first maternity survey results as an enlarged
Enc.4.3.3
3
Item Subject Action
organisation where all women (excluding under 16s) who had live births at the Trust in February 2015 were surveyed.
The following key points were noted:
The Trust’s response rate was 38% compared to 41% nationally and the overall performance was rated Amber ‘same as expected’;
Out of 24 comparable indicators, the Trust improved on 14, performed same on one indicator and scored less well for eight indicators;
Overall DH performed slightly better than the PRUH. The Oasis
birthing centre at the PRUH is performing well and the Trust is pushing the use of this facility further;
The top performing trust scored an overall rating of 49, lowest
performing trust 43 and King’s overall rating was 46. Therefore, there is a very small margin that the Trust could push to improve and initiatives such as ‘continuity of care’ and ‘whose shoes’ are important to help the Trust drive further improvements;
Governors raised concern on scores relating to ‘care in hospital after birth’ question, which was rated Red. The Trust is working to address a number of issues and streamline various processes, in particular reducing the unproductive admin processes that a very busy team is encumbered with; and
The Trust is also providing five midwives a two day accredited course to improve their skills and help new mothers with their breastfeeding.
The Committee commended and thanked MS for presenting the patient video story and the maternity survey results as well as her transformational work in ‘whose shoes’ initiative.
PATIENT SAFETY & RISK MANAGEMENT
016/05 Patient Safety Update and Safer Surgical Checklist
The Committee received a comprehensive report on patient safety at the Trust, highlighting the safety culture and systems that are embedded within the Trust to ensure patient safety. The following key points were noted:
The Adverse Incident (AI) reporting rate is relatively high and consistent between sites with the proportion of low grade incidents increasing;
Enc.4.3.3
4
Item Subject Action
The proportion of AIs with significant harm is decreasing and the 2014 staff survey results indicated strong performance in AI management with 99% of staff knowing how to report an AI;
Surgical Safety was chosen as a Quality Priority for 2015-16 and
there has been significant improvement following the implementation of a number of initiatives. There are fewer surgical never events occurring in theatre settings now;
However, further improvements can be delivered; therefore surgical
safety will be carried forward as a quality priority for 2016-17;
Improvements will be measured against a number of Key Performance Indicators including zero surgical never events and 100% compliance with completion of safer surgical checklist;
Medication safety was another quality priority in 2015-16. All outcome
measures were achieved with the exception of ‘reducing incidents involving 10-fold errors’;
Medication Safety will be taken forward as a quality priority for 2016-17. A number of improvement initiatives such as the introduction of an escalation pathway when drug is not available timely have been identified to drive further improvement;
Falls and pressure ulcers continue to remain an issue and this is
reflective of increased complexity and acuity of the patients at the Trust;
VTE is another area of concern and further work in relation to VTE
risk assessment in elective orthopaedics is underway; and
There had been a decrease in the number incidents involving deteriorating patients. However, this has increased at the PRUH during the reporting period and a number of actions are being taken to mitigate against the risk. This includes tracking of emergency laparotomy post-operative and the pilot of iMobile referral pathway at DH.
In response to Governors comments the following key points were noted: The feedback from the recent CQC inspection found the Trust to
have robust governance structures to investigate AIs. However, communicating learnings to staff was flagged as an issue;
This has been added as a ‘should do action’ and a number of improvement initiatives have already been put in place to ensure learnings from complaints and AIs are part of the culture;
Enc.4.3.3
5
Item Subject Action
Grip socks are provided to patients at risk of falls and pressure ulcers are assigned to the community, if the patient comes to the Trust with a pre-existing pressure ulcers;
In ophthalmology changes have been made to improve the service.
This includes appointing a Clinical Director for the service who is driving cohesive behaviours and standardisation of IT systems and equipment across sites;
It is difficult to bench mark ‘10-fold errors’ as allergy data are not
coordinated nationally and information is not easily accessible; and
Never Event will form part of the doctors’ appraisal and revalidation process. A list of all surgeons with zero never events are published to encourage peer pressure improvement; and
Staff are informed about never events through speciality, safety and
local ward level meetings to ensure key messages reach all front line staff. There is also staff alert through regular newsletters and bulletins.
016/06 Trust Quality Priorities 2016/17
The Committee received the review of the Trust performance against the 2015-16 quality priorities and the proposed quality priorities for 2016-17.
The following key points were noted: On the whole performance against 2015-16 priorities have been
mixed with most of the objectives in progress;
The Committee noted the detailed performance and Red Amber Green (RAG) rating against each objective in each of the quality priority domains;
Governors noted the proposed long list of priorities in each quality
domain for 2016-17 as outlined below. This has been sent to stakeholders for their input and the Committee was also asked for their comments and suggestions; Outcomes
o Improving outcomes for patients with sepsis o Improving outcomes for patients undergoing emergency
abdominal surgery o Improving outcomes for patients following planned major
surgery Safety
o Never Events –“improve safety in invasive procedures”.
Enc.4.3.3
6
Item Subject Action
o Sepsis – “improvement of its recognition, management and escalation”
o Reduce Medication Omissions Experience
o Improving staff health and wellbeing to improve patient experience
o Improving outpatient experience o Improving accessible information for disabled people
Governors were supportive of all the proposed priorities for 2016-17. The following additional comments and suggestions were noted:
The Trust should avoid lighter life style changes such as smoking and alcohol. There should be more focus on clinical issues;
Issues in relation to front line services were raised at the Annual Members Meeting in September. Therefore, the Trust should consider front line services such as administration and appointment process issues as a quality priority to improve patient experience;
It was commented the front line service issues could possibly tie in with accessible information but there should be greater focus on getting the communication right;
Accessible information should be available for all patients and not just the disabled patients; and
The Trust’s performance in infection control is satisfying and as infection control is given a key focus at the weekly Executive meetings and in balancing with other priorities, it may not be appropriate as a priority this year.
The Committee recommended the proposed priorities to the Council of Governors and it was noted that the Council will be asked to select and ratify the mandated quality priority at its meeting on 17 March 2016.
GOVERNOR INVOLVEMENT UPDATES
016/07 Serious Complaints Committee (SCC)
The Committee received and noted the agenda from the Serious Complaints Committee (SCC), which is attended by a Governor representative on regular basis. The SCC met on 15 October 2015 and discussed the response time to complaints in detail, which is still a significant issue for the Trust. The Committee also received a presentation and case study on Networked Services.
Enc.4.3.3
7
Item Subject Action
016/08 Patient Experience Committee (PEC)
The Governor representatives of the Patient Experience Committee (PEC) reported that the Committee met on 27 January 2016 and it was highlighted that the PRUH performance in the national maternity survey was in par with DH site.
There are a number of unregistered maternity patients that end up at the Trust, in particular at the PRUH. The Trust is aware of the issues in relation to maternity service and a number of actions are being undertaken to address the issue and improve performance.
016/09 Commissioners Quality Review Group (CQRG)
The Governor representative of the Commissioner Quality Review Group (CQRG) reported that the Group met in January and discussed a number of items including an update from the Trust on the CQC action plan. The CQRG is a Committee of the Commissioners with a long membership list, which includes GPs. It is a very different Committee compared to any Trust committees and there is no consistency of attendees.
016/10 Quality and Governance Committee (QGC)
This was the first Board Committee attended and observed by a Governor. It was a very useful meeting and provided the opportunity to observe the Non-Executive Director (NED) in action. There was a significant amount of challenge from the NEDs on various issues including lack of isolation facility at NICU, providing training to non-compliant staff and complaints performance. It was suggested that there should be a nominated clinical lead for each patient complaint and this should form part of their continued professional development (CPD).
FOR INFORMATION
016/11 Governor Involvement Activities
The Committee received and noted the Governor Engagement Report for the period 1 November 2015-11 February 2016.
016/12 Finance & Performance Report
The Committee received and noted the month 9 Finance and Performance Report.
016/13 Monthly Patient Experience Report
The Committee received and noted the monthly Patient Experience Report for December 2015.
Enc.4.3.3
8
Item Subject Action
016/14 Committee Workplan 2016
The Committee received and noted its work plan for 2016.
016/15 ANY OTHER BUSINESS
There were no matters of any other business raised for discussion.
016/16 DATE OF NEXT MEETING
Tuesday, 19 April 2016, 17:30-19:30 in the Dulwich Committee Room
Enc.4.3.3
Recommended