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TRUST BOARD MEETING IN PUBLIC
AGENDA
12 April 2018 at 9.30am – 12.00noon
Terrace Executive Meeting Room, Spice of Life Restaurant, Watford Hospital
Apologies should be conveyed to the Trust Secretary, Jean Hickman on jean.hickman@whht.nhs.uk or call 01923 436 283
Item ref
Title Objective Previously presented
Lead Paper or verbal
01/58 Opening and welcome
To note N/A Chair Verbal
02/58 Maternity Incentive Scheme To receive N/A Divisional Director Women’s
and Children’s services
Presentation
OPENING
03/58 Apologies for absence
To note N/A Chair Verbal
04/58 Declarations of interests To note N/A Chair Paper
05/58 Minutes of the meeting held on 01 March 2018
For approval
N/A Chair Paper
06/58 Board action log from 01 March 2018 and previous meetings and decision log
To note N/A Chair Paper
07/58 Chair’s report
For information
N/A Chair Paper
08/58 Chief Executive’s report For information
N/A Chief Executive
Paper
PERFORMANCE
09/58 Integrated performance report – month 11
For information
and assurance
Trust Executive Committee
Chief Operating Officer
Paper
DELIVER A LONG TERM STRATEGY (BAF RISK 9)
10/58 Strategy update For information
and assurance
Trust Executive Committee
Deputy Chief Executive
Paper
GOVERNANCE
11/58 2018/19 corporate aims and objectives
For approval
Trust Executive Committee
Deputy Chief Executive
Paper
12/58 Board assurance framework update
For information
All Deputy Chief Executive
Paper
AGENDA
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COMMITTEE REPORTS
13/58 Assurance report from Finance and Investment Committee
For information
and assurance
Finance and Investment Committee
Committee Chair/ Chief Financial
Officer
Paper
14/58 Assurance report from Clinical Outcomes and Effectiveness Committee
For information
and assurance
Clinical outcomes and effectiveness
committee
Committee Chair/Chief Nurse
Verbal
15/58 Assurance report from the Patient and Staff Experience Committee
For information
and assurance
Patient and Staff Experience Committee
Committee Chair/Director of
Human Resources
Paper
REPORT TO CORPORATE TRUSTEE
16/58 Assurance report from the Charitable Funds Committee
For information
and assurance
Charitable Funds
Committee
Committee Chair/ Director of
Communications
Paper
ANY OTHER BUSINESS
17/58 Any other business previously notified to the chair
N/A N/A Chair Verbal
QUESTION TIME
18/58 Questions from Hertfordshire Healthwatch
To receive
N/A
Chair Verbal
19/58 Questions from our patients and members of the public
To receive N/A Chair Verbal
ADMINISTRATION
20/58 Draft agenda for next meeting
To approve N/A Chair Paper
21/58 Date of the next board meeting in public: 03 May 2018 Lecture Room, Postgraduate Centre, St Albans Hospital
To note N/A Chair Verbal
AGENDA
2 of 114 Trust Board Meeting in Public-12/04/18
the very best care for every patient, every day
Trust Board
Meeting 12th
April 2018
2
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aternity Incentive Schem
e presentation
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the very best care for every patient, every day
Maternity Safety Strategy actions and Clinical
Negligence Scheme for Trusts (CNST) incentive
Scheme
Marcellina Coker
CD Obstetrics WACs Division
2
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aternity Incentive Schem
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What are the aims of the CNST incentive scheme and
why maternity?
• DoH ambition to reward actions to improve maternity safety
• Trial of the CNST incentive scheme for 2018/19.
• Discretionary
• Aligned to Intervention objective of Five year strategy: Delivering fair
resolution and learning from harm.
• Obstetric claims represent biggest area of spend (cost £500m in
2016/17) of the clinical negligence claims
• Obstetric claims represented 10% of the volume and 50% of the value
2016/17.
2
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aternity Incentive Schem
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the very best care for every patient, every day
What are the 10 maternity safety actions?
• 1. Use of National Perinatal Mortality Review Tool to review perinatal
deaths?
• 2. Submit data to the Maternity Services Data Set (MSDS) to the
required standard?
• 3. Transitional care facilities that are in place and operational to
support the implementation of the ATAIN Programme?
• 4. An effective system of medical workforce planning?
• 5. An effective system of midwifery workforce planning?
• 6.Compliance with the Saving Babies' Lives care bundle?
2
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aternity Incentive Schem
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What are the 10 maternity safety actions?
• 7. A patient feedback mechanism , such as the Maternity Voices
Partnership Forum, and that regularly act on feedback?
• 8. Evidence that 90% of each maternity unit staff group have attended
an 'inhouse’ multi-professional maternity emergencies training
session within the last training year?
• 9. Demonstrate that the trust safety champions (obstetrician and
midwife) are meeting bi-monthly with Board level champions to
escalate locally identified issues?
• 10. Reported 100% of qualifying 2017/18 incidents under NHS
Resolution's Early Notification scheme?
2
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Proposed Dates for completion
• June 2018
Completed Board reports with Board sign-off submitted to NHS Resolution
• July 2018
National Maternity Safety Champions and Steering group to confirm final results
• July 2018
Evaluation of scheme and confirmation of approach for 2019/20
• Aug 2018
NHS Resolution to confirm and pay discounts
2
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aternity Incentive Schem
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Thank you
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Last updated : 06 April 2018
Declaration of board members and attendees interests 12 April 2018
Agenda item: 04/58
Name Role Description of interest Relevant dates
From To
Professor Steve Barnett Trust Chair Chair and Client Partner of SSG Health Ltd
Non-Executive Chairman of Finegreen Associates
Trustee and Director of the Institute of Employment Studies
Wife is CEO of Rotherham NHS Foundation Trust
Visiting Professor University of West London Business School
Honorary Visiting Professor Cranfield University School of Management
Member of the East Midlands Regional Committee for Clinical Excellence Awards
Present Present Present Present Present Present Present
Andy Barlow Divisional Director, Women’s and Children’s Services Barlow Medical Services Ltd Present
John Brougham Non-Executive Director Non-Executive Director and Chair of the Audit Committee of Technetix Ltd
2010
Present
4
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Helen Brown Deputy Chief Executive None
Professor Tracey Carter Chief Nurse and Director of Infection Prevention and
Control None
Paul Cartwright Non-Executive Director Treasurer for St Peter’s Church
Trustee and Chair of Finance and Audit Committee for The Church Lands, St Albans.
Charitable Funds for West Hertfordshire Hospitals NHS Trust
Nov 2015 Nov 2015 Nov 2015
Present Present Present
Paul da Gama
Director of Human Resources and Organisational Development
None
Virginia Edwards Non-Executive Director Trustee Peace Hospice Care
Global Action Plan; providing support to their programme called Operation TLC
Director Edwards Consulting Ltd
Husband is CEO of Nuffield Trust
Husband is a non-remunerated member of the Strategy Committee of Guys and St. Thomas’s Charitable Trust
Husband is Director of Edwards Consulting Ltd
Charitable Funds for West Hertfordshire Hospitals NHS Trust
2011 2016 2011 2011 2011 2011 2014
Present Present Present Present Present Present Present
Katie Fisher Chief Executive None
Jeremy Livingstone Divisional Director of Surgery , Anaesthetics and
Cancer Jeremy Livingstone Ltd Present
4
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onflict of interest
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Arla Ogilvie Divisional Director for Medicine Private practice Present
Jonathan Rennison Non-Executive Director Change Management and strategy support with Kings College London
Trustee Rising Tides Ltd
Director of The Yellow Chair Ltd
Edgecumbe Consulting
Association of NHS Charities
The Teapot Trust - coaching
BNET (Britain-Nigeria Education Trust)
March 2017 May 2015 August 2012 April 2015 Sept 2015 June 2016 Oct 2016
Present Present Present Present Present Present Present
Don Richards Chief Financial Officer None
Phil Townsend Non-Executive Director None
Sally Tucker Chief Operating Officer None
Dr Mike van der Watt Medical Director
Owner and Director Heart Consultants Ltd
Private Practice
Wife is Director of Hearts Consultants Ltd
Present
4
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TRUST BOARD MEETING IN PUBLIC
01 March 2018 at 9:30am - 12.00noon
Executive Terrace Meeting Room, Watford Hospital
Chair Title Attendance
Professor Steve Barnett Chair Yes
Voting members
John Brougham Non-Executive Director Yes
Helen Brown Deputy Chief Executive Yes
Tracey Carter Chief Nurse and Director of Infection Prevention and Control
Yes
Paul Cartwright Non-Executive Director Yes
Ginny Edwards Non-Executive Director Yes
Katie Fisher Chief Executive Yes
Jonathan Rennison Non-Executive Director Yes
Don Richards Chief Financial Officer Yes
Phil Townsend Non-Executive Director Yes
Dr Mike van der Watt Medical Director Yes
Non voting members
Dr Andy Barlow Divisional Director, Women’s and Children’s Yes
Paul da Gama Director of Human Resources Yes
Lisa Emery Chief Information Officer Yes
Mr Jeremy Livingstone Divisional Director, Surgery, Anaesthetics and Cancer
Yes
Dr Arla Ogilvie Divisional Director, Medicine Yes
Sally Tucker Chief Operating Officer No
In attendance
Louise Halfpenny Director of Communications Yes
Jean Hickman Trust Secretary (notes) Yes
Dr Matt Knight Consultant in Respiratory Medicine Yes
5
Tab 5 Minutes of the meeting held on 01 March 2018
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MEETING NOTES
Agenda item
Discussion Lead Dead-line
01/57 Opening and welcome
01.01 The chairman opened the meeting and welcomed the board.
02/57 Presentation on respiratory medicine
02.01 The chair welcomed Dr Matt Knight, consultant in respiratory medicine to the meeting and invited him to update the board on the work of the respiratory medicine service. Dr Knight explained that despite a significant increase in the number of patients over the past two years, the service had maintained excellent performance against the referral to treatment (RTT) standard. Key elements to this achievement had been the establishment of hot clinics and a transition to a full substantive team. Good working relationship had also been built with the clinical commissioning group. Dr Knight advised that plans to open a new respiratory centre, the development of a clinical fellowship programme and a referral management hub, together with improvements to the respiratory cancer service would further improve the service.
02.02 Phil Townsend thanked Dr Knight for the informative presentation and enquired whether the improvements were predicated on having good IT systems in place. Dr Knight responded that it was important to have quick, efficient IT and for all systems to link up with each other.
02.03 The board discussed key workforce changes that were required to bring about significant improvements and the importance of adapting jobs such as the development of nurse specialists.
02.04 The divisional director of surgery, anaesthetics and cancer raised the question of what the cancer division could do to support improvements to the respiratory cancer service. Dr Knight recognised that lung cancer was a highly complex area of medicine and suggested that improving the support infrastructure and multi-hospital disciplinary
working would help the service.
02.04 The medical director reminded the board that the current position was a significant improvement for the respiratory service following a disappointing rating in a Care Quality Commission report in 2015. The director of women’s and children’s division (a consultant in respiratory medicine) informed the board that there had been a change to the respiratory service’s financial structure and strategic driver over the past two to three years in response to a change in commissioning. The divisional director of medicine congratulated the service on its achievements and commented that every department must be responsive to change, in particular cultural changes such as working with other services.
02.05 The chair thanked Dr Knight for his excellent presentation and congratulated the respiratory team on the tremendous improvements, including gaining national recognition.
02.06 Resolution: The board noted the presentation.
OPENING
03/57 Apologies for absence
03.01 Apologies were received from the chief operating officer due to operational pressures.
04/57 Conflicts of interest
04.01 No further conflicts of interest were reported than those previously circulated.
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Agenda item
Discussion Lead Dead-line
05/57 Minutes of the meeting held on 01 February 2018
05.01 The minutes were agreed to be a true record of the meeting.
06/57 Board action log from 01 February 2018 and previous meetings and decision log
06.01 It was confirmed that the one outstanding action was on track to be completed within the required timeframe.
07/57 Chair’s report
07.01 The chair presented his report and informed the board that he would be writing to thank the people mentioned in his report for their donations of time and effort to improving the experience of patients and to congratulate staff for their achievements.
07.02 In connection with an item relating to the appointment of Dr Simon Eccles as the national chief clinical information officer, the chief information officer advised that she would be meeting with him following the board meeting.
07.03 Resolution: The board noted the report for information.
08/57 Chief Executive’s report
08.01 The board received a progress report from the chief executive. She advised that staff had been managing well throughout a recent period of cold weather and assured the board that further business continuity arrangements were in place to reduce the operational risks from a further forecast period of extreme cold weather. This included booking local hotel accommodation to reduce the need for staff to travel to and from the hospitals. The chief executive reported that the low temperatures were having a negative impact on hospital buildings causing significant operational issues, including to the heating and water supply. She noted that the surgical department had been particularly affected.
08.02 The chief executive reported that the endoscopy service had received positive informal feedback on a recent JAG inspection. Inspectors had recommended a small number of actions and the board was assured that these would be completed within two weeks.
08.03 John Brougham brought the board’s attention to the approval of external support to establish a theatre scheduling tool and asked for an explanation on how this would improve theatre efficiency. The director of surgery, anaesthetics and cancer advised that the trust’s internal work streams looked in detail at all aspects of improving theatre efficiency and the external support was required to provide a focus on scheduling, with the aim of achieving 85% for theatre utilisation. He advised that this type of detailed work had been successfully undertaken in the past and would help to reduce costs by increasing daytime theatre use and reducing weekend working. John Brougham welcomed this initiative and requested for the finance and investment committee to receive a progress paper in due course. The chief financial officer reminded the board that a development session had been arranged on 14 March 2018 which would focus on the model hospital.
JL
06/18
08.03 Paul Cartwright enquired whether the temporary change to the use of beds on Delamare Ward at St Albans was having a positive impact on patient flow. The chief executive responded that there was a slight improvement, however the beds were not being utilised as much as
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Agenda item
Discussion Lead Dead-line
they could be. She advised that theatre utilisation was increasing and assured the board that the executive was managing risk effectively to ensure that patient safety was not compromised.
08.05 Resolution: The board noted the report for information.
PERFORMANCE
09/57 Integrated performance report- month 10
09.01 In the absence of the chief operating officer, the board received a summary of the key areas of note from the chief information officer.
09.02 John Brougham was disappointed to note that the hospital standardised
mortality ratio (HSMR) had moved from ‘lower than expected’ to ‘as
expected’ and asked for assurance on the reasons for this recent change. The medical director responded that there had been coding issues in a number of cases and assured the board that this was under close investigation and the board would be updated on the outcome once it was completed. The chair commented that coding inaccuracies had been a previous issue and asked for clarification on the controls in place to address this. The chief executive advised that the issue was with the recording of the primary cause of death and assured the board that this was being reviewed and addressed by the executive team. The chief financial officer reminded the board of recent improvements to the coding process for co-morbidity cases.
09.03 Phil Townsend highlighted an increase of 3.1% from the previous month in lost supervisory hours and the chief nurse explained that this was due to the number of vacancies which resulted in wards sisters having to step into the staffing numbers. This meant that they were not able to continue to manage their usual work such as supporting junior staff, joining ward rounds and dealing with complex issues and complaints. She assured the board that there was mitigation in place to address the vacancy issue, including nurses working in bays supporting doctors on ward rounds, temporary staffing and the corporate nursing team working on wards. She provided further assurance that staffing levels were reviewed up to eight times a day in line with the safer care tool to ensure oversight and decisions relating to closing or not opening surge areas and supporting the skill mix for patient safety.
09.04 In response to Jonathan Rennison noting an increase in the number of pressure ulcers, the chief nurse was concerned by this trend seen in January. She assured the board that monthly test your care reviews were undertaken and themes and trends were carefully considered. She further assured the board that this was a focus at divisional performance reviews and for the quality and safety group, and a key focus was being undertaken in surgery where a marked increase had been seen. The chief executive pointed out that it was unrealistic to expect the trust to provide the same level of care when it was managing a large number of surge areas.
09.05 Ginny Edwards welcomed an increase in complaint responses from 52% to 76% in the previous month.
09.06 The chief financial officer updated the board on the financial position. He advised that the current deficit of £39.34m was £23.77m below plan at month 10, year to date. He advised that the trust had expected income to decrease in January 2018 due to a reduction in elective care; however this had been more than expected. Despite lower agency spending and an increase in the staffing bank, the chief financial officer advised that pay costs were £9.4m below plan year to date. Savings
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Agenda item
Discussion Lead Dead-line
were in line with plan in month 10; however they remained £7.63m behind target. The chief financial officer advised that no confirmation of the ITFF application had been received from NHS Improvement. He concluded his report by advising the board that regrettably the trust was only able to pay 20% of its bills within the required 20 days. Paul Cartwright asked whether this was having a significant impact on small suppliers and the chief financial officer assured the board that small businesses were not being put at risk.
09.07 The chair reminded the board that it would be discussing the risks and actions involved in meeting the control total in the private session of the meeting.
09.08 Resolution: The board received the report for information.
10/57 Presentation by Mitie, facilities management company
10.01 The chair informed the board that contract negotiations were still ongoing; therefore it would not be appropriate to have a presentation by Mitie. He advised that the board would discuss progress of the contract in the private session of the meeting.
10.02 Resolution: This item was deferred until the contract with Mitie had received board approval.
11/57 Quality commitment
11.01 The chief nurse presented the quality commitment, which sets out how the trust plans to build and embed a culture of quality improvement across the organisation. She advised that the commitment linked with the trust’s quality priorities and values and had been developed through extensive stakeholder engagement. The board was informed that the strategy delivery board and the clinical outcomes and effectiveness committee had fully endorsed the quality commitment. The chief nurse advised that a central improvement hub had been established to provide expertise and support a consistent quality improvement methodology which had been developed by the Institute of Health Improvement (IHI). She reported that the first step to building quality improvement capability in the organisation would be a two-day workshop, facilitated by IHI, in April 2018. The chief nurse advised that collaborative working with the Royal Free London on reducing unwarranted variation would allow the trust to further explore quality improvement opportunities.
11.02 Ginny Edwards enquired when the board would see projects and timelines for transformational improvements and queried the process for staff to feed in ideas and receive formal feedback. The chief nurse advised that the central quality improvement hub would be formally launched in April 2018 and assured the board that the strategy delivery board and clinical outcomes and effectiveness committee would monitor progress of the quality commitment. She reported that a staff management of change process was underway across the quality teams, with new job portfolios to come into force at the beginning of May 2018. The chief executive advised that staff were already informally feeding through ideas and the quality commitment would provide a framework to formulate this.
11.03 Paul Cartwright welcomed the development of the quality improvement methodology and asked how pervasive the quality commitment would be. The chief executive confirmed that the commitment would be the framework by which the trust would manage all areas of its work.
11.04 The chair fully supported the quality commitment and asked what
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Agenda item
Discussion Lead Dead-line
evidence the board would receive to demonstrate that it was having the desired impact. The deputy chief executive stated that measuring culture change was also a challenge but there were some tools that could be explored for use.
11.05 Resolution: The board approved the quality commitment.
12/57 Quarterly learning from deaths report
12.01 In line with national guidance, the medical director presented a paper to the board on the number of inpatient deaths in quarter three and those deaths which had been the subject of a case review. He advised the board that a new process had been established to comply with the guidance and reported that 446 inpatient deaths had been recorded in quarter three, two of which had been referred for structured judgement review. Both reviews had concluded that the treatment and management had led to no harm.
12.02 Ginny Edwards asked what action had been taken in response to the outcome of the reviews. The medical director confirmed that both cases had already been fully investigated prior to the judgement review and the trust had been in correspondence with the families in line with its duty of candour responsibilities.
12.03 It was acknowledged that the chair was the nominated non-executive director for learning from deaths and he confirmed he would discuss the requirements of the role with the medical director outside of the board meeting.
SB/ MVDW
04/18
12.04 Resolution: The board approved the report for publication, in line with national guidance.
13/57 Gender pay gap report 2017
13.01 The board received an annual report on the gender pay gap from the director of workforce. He advised that it had become mandatory for organisations with over 250 employees to publish data on gender pay gaps by 29 March 2018 and then annually thereafter. The board was assured that, although the report noted that on average female employees earned less and received lower bonuses than male employees, additional analysis suggested that this was as a result of the type of roles held by male and female workers.
13.02 The director of medicine raised concern that the report was misleading as it failed to take all variants into account, such as part time workers. As chair of the patient and staff experience committee, Ginny Edwards acknowledged this, but confirmed that the trust had no control over the report as the format was nationally prescribed. The chief executive assured the board that genuine gaps in pay and bonuses would be targeted and addressed by the trust executive committee.
13.03 The board discussed the process for clinical excellence awards and the medical director advised that he had reviewed and amended the process when he had taken up office to ensure it was fairer and reflected the makeup of the clinical workforce. The board agreed that any underlying issues with clinical excellence awards would be monitored by the patient and staff experience committee.
13.04 Resolution: The board approved the report for publication on the trust’s and government website.
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Agenda item
Discussion Lead Dead-line
14/57 Bi-monthly corporate risk register review
14.01 The medical director presented a report on the position with regard to the corporate risk register. He noted that when the report was extracted, 22 risks were recorded with a score of 15 and above. The medical director highlighted a risk relating to a lack of back-up mammography facilities and assured the board that a full business case was due to be discussed by the trust executive committee in March. A second risk relating to the failure of a condensate tank in the boiler house at Watford was raised and the board was assured that robust mitigation would remain in place until a long term solution had been established. It was reported that a risk relating to a lack of anaesthetic machines and monitors had been de-escalated to reflect robust mitigation.
14.02 John Brougham noted that risk number 3120 should be aligned to the safety and compliance committee and not the finance and investment committee as stated.
MVDW
04/18
14.03 Resolution: The board received the report for information.
15/57 Assurance report from finance and investment committee
15.01 The board received an assurance report on the work of the finance and investment committee from John Brougham. He advised that the committee recommended that the board ratify an NHS revenue support loan to cover funding required for February 2018. It was also noted that the board would receive reports on the plans and risk to achieving the deficit forecast and an update on the 2018/19 financial plan in the private session of the meeting.
15.02 Resolution: The board received the report for information and assurance and ratified an NHS review support loan of £11.4m.
16/57 Assurance report from clinical outcomes and effectiveness committee
16.01 The board noted a report on the work of the clinical outcomes and effectiveness committee from Jonathan Rennison which had been received verbally at the February meeting.
16.02 Resolution: The report was received for information and assurance.
17/57 Assurance report from the safety and compliance committee
17.01 Jonathan Rennison presented a report on the work of the safety and compliance committee. He reported that the committee had reviewed a performance report in detail and, in particular, the areas of poor performance. The committee received an excellent bi-annual report on safeguarding and had been updated on the management of fire safety and medical devices. The committee had welcomed a letter from NHS England confirming that the trust was fully compliant with emergency preparedness, resilience and response (EPRR) and congratulated the team for this excellent achievement. A recommendation to appoint a data protection officer had been approved.
17.02 Resolution: The board received the report for information and assurance
18/57 Assurance report from the patient and staff experience committee
18.01 Due to the close timing of the patient and staff experience committee meeting, Ginny Edward provided a verbal update. She advised that the committee had reviewed mandatory training requirements for individual roles and a report on the gender pay gap. The trust’s results in the national staff survey had also been reviewed and a national
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Agenda item
Discussion Lead Dead-line
workforce strategy consultation discussed. It had been agreed that the trust would officially respond to the consultation through the trust executive committee.
18.02 John Brougham enquired when the board would receive the outcome of the bi-annual nursing establishment review. The chief nurse confirmed that the frequency for board review had reduced nationally and the safety and compliance committee would receive a report in April 2018. John Brougham requested for the finance and investment committee to be made aware of any key recommendations or changes to the establishment.
18.03 Resolution: The board received the report for information and assurance.
19/57 Any other business
19.01 No other business was reported.
20/57 Questions from Hertfordshire Healthwatch
20.01 There was no representation from Hertfordshire Healthwatch in attendance.
21/57 Questions from our patients and members of the public
21.01 There were no patients or members of the public present.
22/57 Draft agenda for next meeting
22.01 Resolution: The draft agenda was approved.
23/57 Date of the next board meeting
23.01 The next board meeting will be held on 12 April 2018.
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Agenda item 06a/57
Action log Part 1 – 12 April 2018
Ref No.
Action from agenda item
Action Lead for completing the
action
Date to be completed
Update
1 12.03/57 Chair and medical director to discuss the requirements of the role of nominated non-executive director for learning from deaths
SB/MVDW 04/18 Completed.
2 14.02/57 To align risk number 3120 in the corporate risk register to the safety and compliance committee and not the finance and investment committee as stated in the March report.
MVDW 04/18 Completed.
3 08.03/57 The finance and investment committee to receive a update paper on the outcome of a theatre scheduling tool.
JL 06/18 Due June 2018.6
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Agenda item: 06/58
Board
meeting/decision date
Decision reference
(from minutes)
Item presented to Board for action Comments/outcome
01/03/2018 15.01/57 Assurance report from Finance and Investment CommitteeRatified an interim revenue support loan
of £11.4m
01/03/2018 13.04/57 Gender pay gap report 2017 Approved for publication
01/03/2018 12.04/57 Quarterly learning from deaths report Approved for publication
01/03/2018 11.04/57 Quality commitment Approved
01/02/2018 13.05/56 Review of corporate governance structure
Approval of the current corporate
governance structure to continue for
2018/19, subject to the proposed
refinements
07/12/2017 17.01/54 Corporate governance meeting schedule Approval of 2018/19 corporate
governance meeting schedule.
07/12/2017 18.03/54 Assurance report from the Charitable Funds Committee
The corporate trustee approved a
recommendation to appoint Kingston
Smith to undertake a review.
02/11/2017 13.03/53 The Board approved the Hertfordshire health concordat Approved
02/11/2017 15.04/53 Board assurance framework Approved
05/10/2017 13.03/52 Assurance report from Finance and Investment CommitteeRatified a £1.4 interim revenue support
loan
05/10/2017 13.03/52 Assurance report from Finance and Investment Committee
Approved £1m capital expenditure
funding for the redevelopment of the A&E
department
07/09/2017 10.02/51The board aproved the NHS England emergency preparedness, resilience and response
annual assurance. Approved
07/09/2017 13.02/51The board approved the infection prevention and control annual report 2016/17 for
publication on the Trust website Approved
06/07/2017 16.04/50 The terms of reference and work plans for the board and committees Approved
06/07/2017 22.05/50The corporate trustee approved the recommended way forward to the future management
of the charity Approved
06/07/2017 18.02/50The board approved the annual accounts, annual report, governance statement and
quality account 2016/17. Approved
01/06/2017 15.03/49 Proposed monitoring arrangements for aims and objectives Approved the approach
01/06/2017 14.04/49 Outline business case for theatre reconfiguration Approved option E
01/06/2017 17.01/49 NHS self-certification 2017/18 Approved condition G6 (3)
BOARD AND CORPORATE TRUSTEE
DECISION LOG PART 1
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01/06/2017 18.02/49 Assurance report from Finance and Investment CommitteeRatified the terms and conditions of a
£42m interim revenue support loan
04/05/2017 20a.03/48 West Herts charity strategy Approved
04/05/2017 20b.02/48 Discretionary resources policy Approved
04/05/2017 15.02/48 An interim revenue support loan of £1.964k Approved
06/04/2017 16.02/47 Interim capital support facility agreement £7.5m Rattified
06/04/2017 11.04/47 Hospital Pharmacy Transformation PlanApproved as direction of travel for
pharmacy service.
06/04/2017 16.02/47 Deficit control totals for 2017/18 of £15.4m Approved
06/04/2017 14.02/47 Aims, objectives and principle risks. Approved
06/03/2017 15.02/46 The conversion of an IRWCF loan of £26.8m to an ISLF loan. Approved
06/03/2017 18.02/46 The 2017/18 Board and Committee structure and meeting schedule Approved
06/03/2017 17.02/46Recommendation to delegate responsibility to the Audit Committee to sign off the Annual
Accounts, Annual Report and Annual Governance Statement.Approved
06/03/201715.02/46
An interim loan of £4m to cover cash flow requirements in February and March 2017
ApprovedApproved
06/03/2017 13.07/46 A graded approach to workforce metrics for future reporting. Approved
02/02/201712.01/45
The transfer of 0.29 hectares (0.72 of an acre), to Watford Borough Council in line with the
Trust's obligations under the Health Campus agreement
Approved
02/02/2017
02.13/45
Recommendation that the Watford site continue to be the location for emergency and
specialised care and the St Albans site continue to be the location for planned care as
recommeded in the SOC
Approved
02/02/201712.01/45
An interim revenue support loan of £2.3m to cover February 2017 revenue cash
requirements
Approved
12/01/201715.2/44 counter fraud policy
Approved
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oard action log from 01 M
arch 2018 and previous meetings and decision log
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Board
meeting/decision date
Decision reference
(from minutes)
Item presented to Board for action Comments/outcome
01/12/2016 10/43 Nursing, midwifery and allied health professions strategy Approved
03/11/2016 19/42c Update to terms of reference for the Board Approved
03/11/2016 18/42 The gifts, hospitality and sponsorship policy Approved
03/11/2016 13/42 Statutory annual public sector equality duty report 2015 Approved
03/11/201619/42a
Recommendation to reduce the frequency of Integrated Risk and Governance Committee
meetings
Approved
03/11/2016 12/42 Patient experience and carer strategy Approved
03/11/2016 19/42b Draft Board and Committee meeting schedule 2017/18 Approved
07/10/2016 14/41 Recommended changes to the BAF 2016/17. Approved
07/10/2016 07/41Recommendation to increase the number of scheduled Board meetings to eleven per
annum.
Approved
01/09/2016 23/40 Terms of reference for the Trust Executive Committee Approved
01/09/2016 21/40Charitable Funds annual report and annual accounts 2015/16 , £12,000 of funds of funds
to support a holistic service for patients and their carers
Approved
07/07/2016 21/39 Updated Board Assurance Framework Approved
07/07/2016 .09/39 The quality account 2015/16 Approved
07/07/2016 18/39 The end of life care strategy Approved
07/07/2016 19/39
The Board received the updated terms of reference and work plans for the Safety and
Quality Committee and the Trust Board
Approved
07/07/2016 17/39Infection prevention and control annual report 2015/16 Approved for publication
07/07/2016 16/39Funding for external advisory support to develop a strategy outline case (SOC) for the
configuration of acute hospital service
Approved
05/05/2016 17/37The Board received the updated terms of reference and work plans for 2016/17 for the
Audit, Remuneration, Workforce, Finance and Performance, Charitable Funds and
Integrated Risk and Governance Committees
Approved
07/04/2016 16/36
The Board received corporate aims and objectives for 2016/17 Approved, subject to inclusion of
comments from Board
07/04/2016 17/36
The Board received a refreshed Board Assurance Framework for 2016/17 Approved
BOARD AND CORPORATE TRUSTEE
DECISION LOG PART 1 2016/17
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Trust Board Meeting 12 April 2018
Title of the paper Chair’s report
Agenda item 07/58
Lead Executive Professor Steve Barnett, Chair
Author Jean Hickman, Trust Secretary
Executive summary (including resource implications)
The aim of this paper is to provide an update on items of national and local interest/relevance to the Board.
Where the report has been previously discussed, i.e. Committee/Group
N/A
Action required:
The Board is asked to receive the report for information.
Link to Board Assurance Framework (BAF)
[Please indicate which Principal Risk this paper relates to by double clicking on the corresponding box]
PR1 Failure to provide safe, effective, high quality care
PR2 Failure to recruit to full establishments, retain and engage workforce
PR3 Current estate and infrastructure compromises the ability to deliver safe, responsive and efficient patient care
PR4a
Underdeveloped informatics infrastructure compromises ability to deliver safe, responsive and efficient patient care – IM&T
PR4b
Underdeveloped informatics infrastructure compromises ability to deliver safe, responsive and efficient patient care – Information and information governance
PR5a
Inability to deliver and maintain performance standards for Emergency Care
PR5b
Inability to delivery and maintain performance standards for Planned Care(including RTT, diagnostics and cancer)
PR7a
Failure to achieve financial targets, maintain financial control and realise and sustain benefits from CIP and Efficiency programmes
PR7b
Failure to secure sufficient capital, delaying needed improvements in the patient environment, securing a healthy and safe infrastructure
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PR8 Failure to engage effectively with our patients, their families, local residents and partner organisations compromises the organisation’s strategic position and reputation.
PR9 Failure to deliver a long term strategy for the delivery of high quality, sustainable care
PR10
System pressures adversely impact on the delivery of the Trust's aims and objectives PR6 – business continuity has been closed (incorporated into PR1)
Trust objectives [Double click on the box to mark as appropriate]
To deliver the best quality care for our patients
To be a great place to work and learn
To improve our finances
To develop a strategy for the future
Benefits to patients/staff from this project/initiatives
Risks attached to this project/initiatives and how these will be managed 7
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Agenda Item: 07/58
Trust Board Meeting – 12 April 2018 Chair’s report Presented by: Professor Steve Barnett, Chair 1. Purpose
1.1. The aim of this paper is to provide an update on items of national and local
interest/relevance to the board.
2. NATIONAL NEWS AND DEVELOPMENTS 2.1. As local elections will be taking place on 03 May 2018, the trust is now in a period called
‘purdah’. ‘Purdah’ came into force on 27 March 2018 and runs until the election has been completed.
2.2. During this pre-election time, the board meeting agenda will be confined to matters that need a decision or require oversight. Non-specialist acute trusts to receive a combined quality and use of resources rating
2.3. The Care Quality Commission’s (CQC) will now award all non-specialist acute trusts that undergo a use of resources assessment, a trust-level rating that combines quality and use of resources.
2.4. Use of resources assessments will be considered as a sixth key question alongside quality ratings. Like the CQC’s five quality questions, use of resources will be given a rating of outstanding, good, requires improvement or inadequate.
Spring Statement 2018
2.5. As the Chancellor had announced in 2017 that major tax and spending changes would be made at the Budget in the autumn; the Spring Statement contained no new policy announcements. It did however provide an update on the overall health of the economy, the Office for Budget Responsibility (OBR) forecasts on progress made since the Autumn Budget 2017.
2.6. The Chancellor hinted that there may be more money for the public sector in the
November Budget if public finances continued to improve. The outlook was more optimistic than that set out in the Budget in November, with the Chancellor unveiling a minor boost to the growth outlook and a fall in the borrowing forecast.
Funding to modernise NHS buildings and services
2.7. In March, Jeremy Hunt, the Secretary of State for Health and Social Care, announced
that forty NHS hospitals and community services would receive £760 million to modernise and transform their buildings and services in the year of the NHS’s 70th birthday.
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2.8. The Shropshire, Telford and Wrekin sustainability and transformation partnership (STP) will receive £300 million to transform local hospital services. The remainder of the money will be awarded to 39 smaller projects, including:
£6 million to upgrade services of eight trusts across Yorkshire
£8 million for a new health and wellbeing centre to join up local NHS services in Kent
£13 million for two new urgent care centres in Newton Abbot and Torquay, and refurbishment of Torbay Hospital’s A&E department
several million pounds for local NHS services in London, including one project worth up to £11 million
2.9. The government is also releasing £150 million to support the NHS’s work to become more efficient. This additional money will be used to:
improve the use of a digital programme that helps the NHS use its workforce better
enable more efficient use of energy in hospitals, which could save the NHS £12 million a year in the first 3 years
improve pharmacy IT and administration systems to reduce medication errors and improve patient safety
Improving maternity care
2.10. The Secretary of State for Health and Social Care has announced that the majority of
women will receive care from the same midwives throughout their pregnancy, labour and birth by 2021. The first step towards achieving this will see 20% of women benefiting from a ‘continuity of carer’ model by March 2019. Research suggests that women who use this model are less likely to miscarry, to lose their baby or to have a premature baby.
2.11. To help achieve this, 3,000 extra midwives will be trained over four years. The plan is to have 650 more midwives in training next year with increases of 1,000 in the subsequent years.
2.12. There will also be further investment in maternity support staff, including:
professionalising the Maternity Support Worker (MSW) role. This is a defined role and national competency framework will be developed and a voluntary accredited register will be established to provide assurance to the public that they are appropriately trained to high standards
working with the Royal College of Midwives and other partners to develop new training routes into midwifery. This will help talented support workers to develop and move quickly to become registered midwives and help the midwifery profession attract and retain talented staff
3. LOCAL NEWS AND DEVELOPMENTS 3.1. Sadly, Katie Fisher will be leaving the Trust at the end of June 2018 to lead a healthcare
charity which provides specialised secure mental healthcare services to the NHS and the Ministry of Justice.
3.2. Katie has been a first class chief executive and will be sorely missed. Under her leadership the trust has been taken out of special measures, improved upon a wide range of key performance indicators and increased staff satisfaction rates in the last two national surveys. As well as the improvement in performance indicators, Katie has also supported the trust to become a clinically led organisation with a strong focus on quality.
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3.3. A campaign has begun to recruit a new chief executive and Helen Brown, the current
deputy chief executive, will act as chief executive from July 2018.
Opening of cardiac and MRI scanner suite
3.4. Richard Harrington, MP for Watford, officially opened a new cardiac imaging suite at Watford in March 2018. The suite, which was installed in April 2017, includes cardiac MRI and cardiac CT scanners offering access to advanced cardiac imaging technology in a refurbished environment.
3.5. Previously the trust was sending patients to other centres mainly in London for specific scans; however this new development means that these scans can now be performed in Watford, therefore improving the experience of patients.
Staff bank – flexible working pilots
3.6. In October 2017, the Secretary of State announced a pilot scheme which would focus on reducing agency spend and improve the experience of bank staff. This would include the use of mobile phone booking apps and prompter payment.
3.7. The trust has been recommended as a pilot site (in collaboration with the remaining trusts in the Herts Consortium). This will offer an opportunity for the trust to develop staff bank best practice, help reduce agency spend, and be recognised as a leader in the use of technology to deliver safe and efficient flexible workforce solutions.
Joint advisory group for gastro-intestinal endoscopy inspection
3.8. The endoscopy service at Hemel Hempstead and Watford Hospitals were assessed in March 2018 by the Joint advisory group (JAG) against national endoscopy standards of clinical quality, quality of patient experience, workforce and training. The JAG assessors were impressed with a number of areas of exemplary practice which they will use as a gold standard example to share with other endoscopy units.
3.9. The trust will receive a formal report on the inspection in due course.
Thank you 3.10. Thank you to the following people for their kind donations of time and effort to improve
the experience of our patients and staff
Isobel Mason, one of the few nurse consultants in gastroenterology in the country, who gave a highly informative and inspiring talk about nurse-led services at the Royal Free London NHS Foundation Trust
Beauty therapy students from West Herts College who offered beauty treatments to staff, volunteers, patients, carers and visitors at Watford hospital
Tate Recruitment who donated Easter eggs to children across various patient areas and to staff working over Easter in the emergency department
Carl Mitchell for raising over £2,000 by running a 12 mile ‘Tough Mudder’ race in aid of starfish ward
Recognising and celebrating our staff
3.11. Well done to the following staff and teams for their outstanding work since the last board
meeting:
Aldenham ward and blue and yellow wards in the Acute Admissions Unit for achieving an ACE (accredited clinical environment) award
The stroke team and the employee relations team for being shortlisted for a Healthcare People Management Association award
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Michelle Brooks for organising a fundraising pampering evening in March 2018 in aid of the special care baby unit
Sarratt and Bluebell wards for organising an afternoon tea party for patients to celebrate nutrition and hydration week
The following overseas nurses for passing their objective structured clinical examination: - Ancey (Aldenham ward) - Arun (AAU L1 purple) - Jade (AAU L1 blue) - Rachana (Ridge ward) - Charissa (AAU L3 B/Y) - Angelique (Elizabeth ward)
4. BOARD UPDATE 4.1. The trust held a development session on 14 March 2018 as part of its board
development programme. The session provided an opportunity for board members to meet with the senior team at the Royal Free London NHS Foundation Trust to discuss partnership working.
5. KEY MEETINGS
Presented the ward accreditation certificates
Met with Bim Afolami, MP
Met with Mike Jackson, chair of Watford Labour party; Chris Ostrowski, parliamentary candidate for Watford and Jagtar Singh Dhindsa, mayoral candidate
Met with Manny Lewis, managing director, Watford Council,
Visited orthopaedic outpatient clinic and level 5 wards with Wendy Wilson, patient representative
Met with Collette Wyatt-Lowe, chair, Hertfordshire Health and Wellbeing Board
Met with Natalie Rotherham and Seamus Quilty, Hertfordshire county council’s health scrutiny committee
Attended the sustainability and transformation partnership chair’s meeting
Attended the Hertfordshire county council’s scrutiny quality review meeting
Met with the chair and CEO of West Suffolk NHS Foundation Trust
Presented two staff awards
RECOMMENDATION
5.1. The Board is asked to receive the report for information. Professor Steve Barnett Chair April 2018
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Page 1 of 7
Trust Board Meeting
12 April 2018
Title of the paper Chief Executive’s report
Agenda item 08/58
Lead Executive Katie Fisher, Chief Executive Officer
Author Jean Hickman, Trust Secretary
Executive summary (including resource implications)
The aim of this paper is to provide an overview of the work and key decisions taken by the trust executive committee since the previous board meeting.
Where the report has been previously discussed, i.e. Committee/Group
N/A
Action required: The Board is asked to receive the report for assurance that the trust executive is effectively managing the business of the trust.
Risk to Board Assurance Framework (BAF)
[Please indicate which Principal Risk this paper relates to by double clicking on the corresponding box]
PR1 Failure to provide safe, effective, high quality care
PR2 Failure to recruit to full establishments, retain and engage workforce
PR3 Current estate and infrastructure compromises the ability to deliver safe, responsive and efficient patient care
PR4a
Underdeveloped informatics infrastructure compromises ability to deliver safe, responsive and efficient patient care – IM&T
PR4b
Underdeveloped informatics infrastructure compromises ability to deliver safe, responsive and efficient patient care – Information and information governance
PR5a
Inability to deliver and maintain performance standards for Emergency Care
PR5b
Inability to delivery and maintain performance standards for Planned Care(including RTT, diagnostics and cancer)
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PR7a
Failure to achieve financial targets, maintain financial control and realise and sustain benefits from CIP and Efficiency programmes
PR7b
Failure to secure sufficient capital, delaying needed improvements in the patient environment, securing a healthy and safe infrastructure
PR8 Failure to engage effectively with our patients, their families, local residents and partner organisations compromises the organisation’s strategic position and reputation.
PR9 Failure to deliver a long term strategy for the delivery of high quality, sustainable care
PR10
System pressures adversely impact on the delivery of the Trust's aims and objectives PR6 – business continuity has been closed (incorporated into PR1)
Trust objectives [Double click on the box to mark as appropriate]
To deliver the best quality care for our patients
To be a great place to work and learn
To improve our finances
To develop a strategy for the future
Benefits to patients/staff from this project/initiatives
Risks attached to this project/initiatives and how these will be managed 8
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Agenda Item: 08/58
Trust Board Meeting – 12 April 2018 Chief Executive’s report Presented by: Katie Fisher, Chief Executive 1. PURPOSE
1.1. The aim of this paper is to provide an overview of the work and key decisions taken by
the trust executive committee since the previous board meeting.
2. LOCAL NEWS AND DEVELOPMENTS
Emergency pressures 2.1. Although we are officially in spring the trust continues to manage significant ‘winter
pressures’. The trust reached a critical situation in early March 2018 with no beds for new admissions and patient waiting unacceptable times in the emergency department and for planned surgery. The trust had 117 additional beds open in clinical areas, including unit, that are normally used as assessment areas in order to manage the ongoing demand. This meant that patients were being moved around to accommodate new admissions from the emergency department; leading to a need to adequately staff the areas with nursing staff being moved and the use of temporary staff to keep staffing at a safe level.
2.2. To address this and alleviate the pressure, in March 2018 the trust activated a total‘re-set’ approach to the admission and discharging of patients. This radical approach included arranging for every adult inpatient at Watford hospital to have a clinical review by a multi-disciplinary team; ensuring that patients are ready for discharge as soon as they are assessed as medically fit; and considering whether a patient could wait in the patients’ lounge rather than on a ward when they are ready to leave hospital
2.3. To support this approach, all non-urgent meetings were cancelled for a week to allow all
frontline staff to be out on the wards. 2.4. There was a concerted focus on ensuring that the patients’ lounge at Watford and the 18
reablement beds on De La Mare ward at St Albans were also being used effectively, in order to improve the patient flow.
2.5. This approach, combined with the use of additional consultants in the emergency department and ‘hot clinics’ (where patients receive instant assessment by a senior clinician) resulted in a reduction in admissions and an increase in the number of patients discharged. This has allowed the trust to close a number of ‘surge’ beds and to improve the four hour A&E target. Before the re-set, the trust had been admitting more patients than it had been discharging; however this trend is now reversing.
.
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2.6. The trust executive committee is reviewing the lessons learnt from this exercise and
considering which actions have contributed to the improvement in order to sustain the progress.
2.7. This achievement was only possible due to the magnificent efforts of staff and their unwavering commitment to provide the very best care for patients in the face of relentless pressure.
New soft facilities management contract
2.8. Following a competitive tender process, the trust has entered into a contract with Mitie
Cleaning and Environmental Services Limited to provide a range of services including cleaning, catering, portering, pest control, linen and helpdesk services.
2.9. The services will extend across the three main hospitals, as well as a new physiotherapy outpatient unit in Abbotts Langley.
2.10. Under the contract, which started on 1 April 2018, 400 people are transferring to Mitie from the current service provider. Employees will benefit from a pay increase as all staff will receive at least the Real Living Wage, as well as a range of Mitie rewards which include staff discounts.
2.11. Mitie will be investing in new technology, including new digital software to support better communicate and robotic cleaning which uses a mapping system to guide it round the hospital, completing pre-programmed cleaning duties and freeing up staff to focus on more complex tasks. Patients will benefit from the latest in meal delivery with the introduction of a new heating and chilling unit which allows easy preparation of personalised menu choices for patients.
2.12. The board will receive a presentation on the services provided by Mitie in the private
session of the board meeting and will have an opportunity to sample some of the food received by patients. Non-emergency patient transport
2.13. Following East of England Ambulance Service being awarded a caretaker contract to provide non-emergency patient transport in Bedfordshire, Luton and Hertfordshire in 2017, the Service has set up a call centre which now operates at weekends. The trust is continuing to request that this is commissioned as a 24/7 service to allow the trust to efficiently manage its discharges and outpatient appointments.
2.14. East of England Ambulance Service will also be facilitating inpatient transfers to London trusts. Currently there is no transport provision for inpatients requiring an outpatient appointment, diagnostic or day case treatment at a London trust.
Paper switch off
2.15. In line with the trust’s policy on paper reduction, from 01 May 2018, the trust will no longer accept paper referrals for a first appointment with a consultant. All referrals to consultants will be made through the NHS Electronic Referral Service.
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Patient information service 2.16. Due to a focus over the past year on improving patient information, the trust now has an
extensive library of over 300 high quality leaflets available to patients and the public on the trust’s website.
3. LEADERSHIP CHANGES 3.1 Maxine McVey, deputy chief nurse left the trust in February 2018 after 19 years to take
up the post of deputy director of nursing at Frimley Health NHS Foundation Trust. David Thorpe joined the trust on 02 April 2018 from Colchester Hospital University NHS Foundation Trust as the deputy chief nurse.
3.2 Collette Manion, will join the trust on 14 May as the director of midwifery. Collette is
currently working at North Middlesex University Hospital NHS Trust and has extensive experience as a head of midwifery and a deputy chief nurse.
3.3 Karen Walker will take up the post of head of nursing for children’s services from 04
June 2018. Karen is a very experienced children’s nurse and has worked in a variety of senior roles as well as wider organisational roles at University College London Hospitals NHS Foundation Trust.
3.4 Dave Coley has taken up the post of Director of Procurement. He is based at the
Gatehouse, Welwyn Garden City. 4. COMMUNICATIONS REPORT
Media
4.1. The main recent coverage centred on reports about the launch of a new public
consultation on Hemel Hempstead Hospital’s Urgent Treatment Centre. Herts Valleys CCG is looking at the future of the facility. But although the public consultation could restore 24/7 opening times, critics say that there will be an inferior service to the one provided just 14 months ago. Additionally, the Gazette and Express reported that our maternity service has been given a significantly improved rating from new mothers. These women rated maternity services at Watford Hospital as: 9 out of 10 for labour and birth; 8.7 out of 10 for staff during labour and birth and 7.4 out of 10 for care in hospital after the birth.
4.2. Other articles and mentions in the media during February included:
Mike Penning called for the abolition of hospital car parking charges. He says it is “completely unacceptable” that patients, visitors, and staff, are forced to pay just to park their car.
The St Albans and Harpenden Review reported that plans to create a new community health facility have been given the green light. The new facility will house some of Hertfordshire Community NHS Trust’s (HCT) community health services. The services include those currently provided at St Albans Principal Health Centre on Civic Close, as well as the leg ulcer clinic and podiatry service located at St Albans City Hospital.
The Gazette and Express reported that the GPs out-of-hours service is no longer running in Dacorum. Patients now have to travel to Watford after 11.15pm, as part of a change branded a “clear deterioration” of services by patients. The newspaper states that this is a series of service reductions which go back a decade.
ITV News picked up on our story that a woman unexpectedly gave birth in a hospital car park after she was unable to get to the maternity unit on time.
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Communications data
Website
Month’s Figures 17/18
Month’s Figures 16/17
Total Quarter 1
Total Quarter 2
Total Quarter 3
Running Quarter 4
Running total 17/18
Total 16/17
Total Page Views
424,998 448,967 1,364,707 1,414,842 1,321,512 944,795 5,045,866 4,901,513
Number of unique visitors
37,248 39,674 106,195 107,937 110,278 81,181 483,897 370,658
Top five pages visited on internet site (excluding home page and vacancy pages): 1. Watford wards and departments
2. parking
3. About/contact
4. Services/pathology
5. About/Watford General Hospital (our hospitals page)
Internal Communications
February 2018
Total Quarter
1
Total Quarter 2
Total Quarter 3
Quarter 4 (to date)
Running total 17/18
Number of e-newsletters (e-update)
8 15 26 23 8 80
Number of CEO briefings
3 12 19 16 5 55
Number of Herts & minds newsletters
0 1 1 1 0 3
February 2018 Positive coverage Neutral coverage Negative coverage
National coverage 1 0 1
Coverage (Watford) 1 4 2
Coverage (Dacorum) 0 2 2
Coverage (St Albans) 1 0 0
Other local 0 0 0
Letters coverage 3 0 2
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Freedom of Information
February 2018
Total Quarter
1
Total Quarter
2
Total Quarter
3
Running Quarter
4 (to date)
Running total 17/18
Total 16/17
Number of FoIs received
55 153 169 154 113 589 662
Compliance within 20 day deadline
70% 95.0% 88.6 88.6%
74% 82% 94.3%
No of FoIs received from media outlets
3 24 24 12 12 69 100
Social Media
Followers Posts Likes Retweets
February 2018 6,155 117 789 445
The most popular Tweet was: “Congratulations to Samuel Van Emden who celebrated the end
of his leukaemia treatment by ringing the end of treatment bell with his family!” with 159 likes,
31 retweets and 4 comments
Followers Posts Likes Reach Shares Comments
February 2018 1,593 64 567 69,837 426 20
The most popular Facebook post was: “Say hello to this bundle of joy who couldn't wait to get
here as she was born in our car park at Watford General today. Sending best wishes to mother
and baby and a HUGE thank you to our staff who helped out with the arrival of baby Austin!”
with 241 likes, 28 shares and it reached 5,881 people.
5. RECOMMENDATION
5.1. The Board is asked to receive the report for assurance that the trust executive committee is effectively managing the business of the trust.
Katie Fisher Chief Executive April 2018
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Trust Board Meeting12 April 2018
Title of the paper Integrated Performance Report (February activity)
Agenda item 09/58
Lead Executive Sally Tucker, Chief Operating Officer
Author Jane Shentall, Director of Performance
Executive summary
(including resource implications)
The Integrated Performance Report covers the March reporting period (Februarydata). For this reporting period, the Board is asked to particularly note the following performance changes since the last reporting period:
Safe, Effective, Caring:∑ HSMR remains “as expected” although the rate has fallen from 101.4 to 97.5∑ Reduced % of patient safety incidents that were harmful, from 12.3% to 9.1%∑ Mixed sex accommodation breaches significantly improved, at 3 for the month ∑ 8 cases of Clostridium difficile reported, with a year to date total of 26 which is
above the ceiling target of 23∑ A&E (94.4%) FFT positive score is just below target (95%) while inpatient
(95.6%), Day Case (99.2%) and maternity (95.9%) are above target ∑ Drop in complaints performance (from 76.3%) to 36.6%∑ VTE risk assessments are improving, although at 92.7% are below target (95%) ∑ Combined C-section rates (elective & non-elective) remain within the ceiling
target (28%) at 26.25%∑ Fall in performance against both stroke indicators – 43.3%(target 90%)
admitted to Stroke unit within 4 hours, and 80% of patients spent 90% of their time there (target 80%)
Responsive:∑ RTT (incomplete) performance worsened again, to 85.1% (85.7% last month)∑ 41 x 52 week breaches were reported (last month 20)∑ Fewer patients not treated within 28 days (16) this month (vs 20 in January)∑ Diagnostic waiting time performance remains compliant at 99.9%∑ ED 4 hour wait performance deteriorated to 71.3% (72.3% previously)∑ Ambulance turnaround delays improved by 20% between 30-60 minutes and
delays over 60 minutes 16.8%∑ 2ww, 2ww breast symptomatic, 31 day first, 31 day subsequent, 62 day first and
62 day screening performance all above target.
Well Led:∑ Staff turnover (rolling 3 months) better than last month (17.1%) at 16.4%∑ Vacancy rate fell for the 3rd month consecutively and is now to 10.3%∑ % Bank and agency pay are within target∑ Appraisal rates have fallen further, now at 80%∑ Further improvement in FFT response rates for inpatients, day case and A&E
although all remain below target but improved on previous month with the exception of Maternity is above target (35%) at 59.9%.
Further detail is provided in the executive summary and relevant exception reports, including performance trends.
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Where the report has been previously discussed
Trust Executive Committee (Performance) 27.3.2018
Action required:
∑ The report is provided for information and discussion.
Link to Board Assurance Framework (BAF)
PR1 Failure to provide safe, effective, high quality care
PR2 Failure to recruit to full establishments, retain and engage workforcePR5a Inability to deliver and maintain performance standards for Emergency
CarePR5b Inability to delivery and maintain performance standards for Planned
Care(including RTT, diagnostics and cancer)PR7a Failure to achieve financial targets, maintain financial control and
realise and sustain benefits from CIP and Efficiency programmesPR7b Failure to secure sufficient capital, delaying needed improvements in
the patient environment, securing a healthy and safe infrastructurePR8 Failure to engage effectively with our patients, their families, local
residents and partner organisations compromises the organisation’s strategic position and reputation.
PR10 System pressures adversely impact on the delivery of the Trust's aims and objectives
PR6 – business continuity has been closed (incorporated into PR1)
Trust objectivesTo deliver the best quality care for our patientsTo be a great place to work and learn
To improve our finances
Benefits to patients/staff from this project/initiatives The Integrated Performance Report provides a view of performance across all key metrics in the areas of Safe, Effective, Caring, Responsive and Well LedRisks attached to this project/initiatives and how these will be managed
The Integrated Performance Report is reviewed monthly at the Trust Executive Committee prior to submission to the Board.Individual performance indicators are also reviewed at divisional level at monthly Performance meetings, where associated risks and issues are discussed and documented, and relevant actions tracked.Data quality is regularly reviewed both internally and by the Trust’s auditors.
9
Tab 9 Integrated performance report - month 11
2 of 114Trust Board Meeting in Public-12/04/18
Integrated Performance
Report
March 2018
(February data)
1
9
Tab 9 Integrated perform
ance report - month 11
3 of 114T
rust Board M
eeting in Public-12/04/18
Well ledReporting sub committee – PSE
ResponsiveReporting sub committee – TEC
Safe Effective CaringReporting sub committees – COE and S&C
2
Areas requiring performance improvement• VTE risk assessment was below threshold (pages 4 & 18) • Admissions to stroke ward within 4 hours was below the performance standard and worse than the national average (pages 4 & 14) • There were 3 mixed sex accommodation breaches (pages 3 & 24)• Harm free care (new and all harms), as measured through the Safety Thermometer was worse than the performance standard but new harms were better than the national average (pages 4 & 20) • Complaints responded to within agreed timescales was worse than the 85% external performance threshold and the internal improvement trajectory (pages 3 & 15)• Clostridium difficile was worse than the monthly threshold (5 cases) and the year to date threshold (26 vs 22) (pages 3 & 16)
New to category this month:
Areas requiring performance improvement• A&E 4 hour wait performance was below standard (pages 5 & 30) • Ambulance turnaround times' performance was worse than standard (pages 5 & 30)• The RTT incomplete indicator was worse than the standard (pages 5 & 25)• Patients not treated within 28 days of their last minute cancellation was below standard (pages 6 & 26)• The Trust recorded forty-one 52 week RTT breaches (page 5)• Formal DToCs were below standard (pages 6 & 31)
New to category this month:
Areas requiring performance improvement• The staff turnover rate (rolling 12 months) was below the performance standard (pages 7 & 32)• Staff turnover (rolling 3 months) was worse than target (pages 7 & 32)• The vacancy rate was worse than the performance standard (pages 7 & 32)• Appraisals were worse than target(pages 7 & 33) • Mandatory training was worse than target (pages 7 & 33)• Friends and Family response rate for A&E was below threshold (pages 7 & 35)• Inpatient FFT response rate was worse than the target (pages 7 & 35)
New to category this month:
Areas of good performance • There were no cases of MRSA bacteraemia (pages 3 & 16)• Day case FFT % positive indicator was better than the standard (pages 3 & 36)• There were no medication errors causing serious harm (pages 4 & 18)• Maternity FFT % positive indicator was in line with the standard (pages 3 & 36)• No never events were reported (pages 4 & 16)• The percentage of patients receiving a caesarean section was better than the performance threshold (pages 4 & 24)• Patients spending 90% of their time on the stroke unit was equal to the performance standard (pages 4 & 14)
New to category this month:• HSMR mortality was better than the performance target (pages 3 & 13)• Inpatient FFT % positive indicator was better than the standard (pages 3 & 35)
Areas of good performance • The 2WW cancer indicator achieved the performance standard (provisional) (pages 5 & 27)• Cancer 62 GP and 31 subsequent drug and surgery indicators are delivering to the performance standard (provisional) (pages 5 & 28 - 29)• Hospital initiated outpatient cancellations under 6 weeks performed better than the performance standard(pages 6 & 26) • Diagnostic wait times achieved the performance standard (pages 5 & 26)• The cancer 31 first indicator is provisionally better than the performance standard (pages 5 & 28)
New to category this month:• The cancer breast symptomatic and the 62 day screening indicator achieved the performance standard (provisional) (pages 5 , 27 & 29)
Areas of good performance • The sickness rate was in line with target (pages 7 & 32)• Temporary costs and overtime as % of total pay bill was better than target (pages 7 & 32), including and excluding unfunded beds (two indicators)• Bank pay was within the new target range of 8 %– 12% (pages 7 & 32)• Agency pay was better than target (pages 7 & 32)
New to category this month:• Maternity Friends and Family response rate was better than target (pages 7 & 36)
Executive Summary
Feb-18 13
Jan-18 11
Dec-17 11
Achieving
Feb-18 8
Jan-18 10
Dec-17 10
Not achieving
Better than
national
average
Feb-18 8
Jan-18 7
Dec-17 11
Worse than
national
average
Feb-18 9
Jan-18 10
Dec-17 5
NB. Indicators achieving relate only to where targets have been set - as seen on the indicator summary. Ratings showing the number of indicators better or worse than the national average relate to only those indicators where the national average
was available. Indicators which are identified in the main pack as provisional may lead to changes to achieving/not achieving counts previous months in Executive Summary.
Feb-18 11
Jan-18 9
Dec-17 12
Achieving
Better than
national
average
Feb-18 8
Jan-18 7
Dec-17 8
Worse than
national
average
Feb-18 6
Jan-18 7
Dec-17 6
Feb-18 6
Jan-18 5
Dec-17 5
Achieving
Better than
national
average
Feb-18 6
Jan-18 5
Dec-17 5
Worse than
national
average
Feb-18 4
Jan-18 5
Dec-17 5
Feb-18 10
Jan-18 11
Dec-17 11
Not achieving
Feb-18 10
Jan-18 12
Dec-17 9
Not achieving
NB. The sum of indicators achieving and not achieving may not be equal between months due to some indicators being reported with a lower frequency than monthly
9
Tab 9 Integrated perform
ance report - month 11
4 of 114T
rust Board M
eeting in Public-12/04/18
Indicator Summary
3
Data Quality RAG keyRed – Data accuracy is not known, it is incomplete and inconsistent with relevant standardsAmber – Data is assumed to be complete and accurate, although there may be limitations or unresolved queriesGreen – Data is complete, accurate and consistent with the standards set for the specific indicator
Exception indicators keyRed for a minimum of two data points and amber for one, out of the latest three data pointsRed for the latest data point
l
u
Domain a Indicator Target a Dec-17 Jan-18 Feb-18 a YTD Actual YTD Target aExecutive
LeadMonth
Included
in
Detailed
Reports
National
/ Locala
National
avg.
National
avg.
Period
Trend
Data
Quality
RAG
SHMI (Rolling 12 months) 100 89.5 91.9 92.2 MD Aug-17 Y National 100 Aug-17G
HSMR - Total (Rolling three months) 100 96.2 101.4 97.5 MD Nov-17 Y National 100 Nov-17G
Crude Mortality Rate (Non elective
ordinary)**3.6% 3.4% 3.5% 3.3% 2.8% 3.6% MD Feb-18 Y National 2.91% (East
of Eng.)Nov-17
G
l 30 Day Emergency Readmissions - Combined * 4.0% 8.0% 6.8% 7.0% 7.3% 4.0% MD Feb-18 Y National 11.4% 2011-12G £
Marginal tariff reimbursement, possible
penalties
30 Day Emergency Readmissions - Elective * n/a 3.7% 2.3% 3.0% 3.0% n/a MD Feb-18 Y National n/aG £
Marginal tariff reimbursement, possible
penalties
30 Day Emergency Readmissions - Emerg * n/a 11.1% 10.8% 10.9% 11.0% n/a MD Feb-18 Y National n/aG £
Marginal tariff reimbursement, possible
penalties^
Number of patients with a length of stay > 14
days *tbc 352 355 316 3721 tbc MD Feb-18 Local n/a
G £Reduction in reimbursement vs largely
fixed costs. No penalty levied.
Staff FFT % recommended care tbd NHSI^ 61.5% 59.0% 64.5% 62.4% tbd NHSI^ DoW Sep-17 Y National n/aG
Inpatient Scores FFT % positive 95% 96.5% 94.7% 95.6% 93.8% 95% CN Feb-18 Y National 95.7% Jan-18G
A&E FFT % positive 95% 89.1% 93.5% 94.4% 91.9% 95% CN Feb-18 Y National 86.4% Jan-18G
Daycase FFT % positive 95% 97.8% 98.6% 99.2% 98.7% 95% CN Feb-18 Y National n/aG
Maternity FFT % positive 95% 100.0% 95.0% 95.9% 94.9% 95% CN Feb-18 N National 97.1% Jan-18G
l
% Complaints responded to within one month
or agreed timescales with complainant85% 52.0% 76.3% 46.8% 54.5% 85% CN Feb-18 N Local n/a
R
Complaints - rate per 10,000 bed days tbd NHSI^ 25.9 36.8 36.6 35.2 tbd NHSI^ CN Feb-18 N National n/aR
Reactivated complaints 3 8 4 76 n/a CN Feb-18 N Local n/aR
Proportion of complaints with verbal
communication at the beginning of the
process
88.5% 87.8% 77.6% 74.1% CN Feb-18 N LocalR
l Mixed sex accommodation breaches 0 10 164 3 235 0 CN Feb-18 N National57 Trusts
breachingJan-18
G £Penalties from CCG. £250 per day per
service user.
l Clostridium Difficile 1 1 6 5 26 22 CN Feb-18 Y National 2.5 average Jan-18G £
Penalties from CCG, fines from other
statutory authorities. £10,000 per case
above threshold.
MRSA bacteraemias 0 0 0 0 1 0 CN Feb-18 Y National n/aG £
Penalties from CCG, fines from other
statutory authorities. £10,000 in respect of
each incidence in the relevant month.
E. Coli Bacteraemia tbc 2 2 8 38 tbc CN Feb-18 Y National n/aG
Safe
, Eff
ecti
ve, C
arin
g
* Performance may change for the current month due to data entered after the production of this report
** Crude mortality threshold UCL upper control limit (2 standard deviations from mean)
tbd NHSI^ - threshold/target to be determined by Trust Development Agency guidance when available
NB. Where national avg. blank - information not currently available
Financial impact
^Calculation of emergency re-admissions penalty – Re-admission rate is applied to the value of all admitted activity. 25% of this is
then applied on the basis that this proportion is avoidable.
9
Tab 9 Integrated perform
ance report - month 11
5 of 114T
rust Board M
eeting in Public-12/04/18
Indicator Summary
4
Data Quality RAG keyRed – Data accuracy is not known, it is incomplete and inconsistent with relevant standardsAmber – Data is assumed to be complete and accurate, although there may be limitations or unresolved queriesGreen – Data is complete, accurate and consistent with the standards set for the specific indicator
Exception indicators keyRed for a minimum of two data points and amber for one, out of the latest three data pointsRed for the latest data point
l
u
Domain Indicator Target Dec-17 Jan-18 Feb-18 YTD Actual YTD TargetExecutive
LeadMonth
Included
in
Detailed
Reports
National
/ Local
National
avg.
National
avg.
Period
Trend
Data
Quality
RAG
Never events 0 1 0 0 4 0 MD Feb-18 Y National n/aG £
Penalties from CCG, fines from other
statutory authorities, prosecution^
Serious incidents - number* tbd NHSI^ 3 5 3 37 tbd NHSI^ MD Feb-18 Y National n/aG
% of patients safety incidents which are
harmful*n/a 8.6% 12.3% 9.1% 10.9% n/a MD Feb-18 Y National n/a
G
Medication errors causing serious harm * 0 0 0 0 1 0 MD Feb-18 Y National n/aG
l CAS Alerts: Number issued each month n/a 10 12 8 8 n/a CN Feb-18 Y National n/aG
CAS alerts not acknowledged within 48 hours 0 0 0 0 0 0 CN Feb-18 National n/aG
Number of falls* 96 123 131 1177 CN Feb-18 Y LocalG
Number of falls with harm* 14 22 18 222 CN Feb-18 Y LocalG
Number of G3 pressure ulcers (Hospital
acquired)0 4 9 3 31 0 CN Feb-18 Y Local
G
Number of G4 pressure ulcers (Hospital
acquired)0 0 0 0 1 0 CN Feb-18 Y Local
G
l
Safety Thermometer Harm Free Care (acquired
within and outside of Trust)*/**95.0% 93.0% 91.3% 91.5% 91.6% 95.0% CN Feb-18 Y National 94.1% Feb-18
G
Safety Thermometer % New Harm Free Care
(acquired within Trust)*/**tbd NHSI^ 97.7% 97.5% 98.9% 98.2% tbd NHSI^ CN Feb-18 Y National 97.9% Feb-18
G
Safety Thermometer New Harm Free Care:
Catheter & UTI New Harms*/**tbd NHSI^ 2 1 0 20 tbd NHSI^ CN Feb-18 Y National
WHHT 0.0
vs 0.29Feb-18
G
l VTE risk assessment* 95.0% 88.9% 91.2% 92.7% 91.3% 95.0% MD Feb-18 Y National 95.4% Q3 2017A
Caesarean Section rate - Combined* 28.0% 28.3% 25.4% 26.25% 27.6% 28.0% MD Feb-18 Y Local 26.7%Apr15-
Aug15 A
Caesarean Section rate - Emergency* 15.0% 18.3% 14.6% 15.9% 16.3% 15.0% MD Feb-18 Y Local 15.3%Apr15-
Aug15 A
Caesarean Section rate - Elective* 11.0% 10.0% 10.8% 10.3% 11.3% 11.0% MD Feb-18 Y Local 11.4%Apr15-
Aug15 A
Maternal deaths 0 0 0 0 0 0 MD Feb-18 N National n/aG
lPatients admitted directly to stroke unit
within 4 hours of hospital arrival *90.0% 46.5% 48.0% 43.3% 61.1% 90.0% COO Feb-18 Y National 60.2% Jul-17
G
Stroke patients spending 90% of their time on
stroke unit *80.0% 69.8% 82.0% 80.0% 82.4% 80.0% COO Feb-18 Y National 85.7% Jul-17
A
* Performance may change for the current month due to data entered after the production of this report
tbd NHSI^ - threshold/target to be determined by Trust Development Agency guidance when available
** Indicators reported from NHS Safety Thermometer
Safe
, Eff
ecti
ve, C
arin
g
NB Exception reports not provided for FFT scores
NB. Where national avg. blank - information not currently available
Financial impact
^Recovery of cost of procedure or episode plus any additional charge incurred for
corrective procedure or care in consequence to the event.
9
Tab 9 Integrated perform
ance report - month 11
6 of 114T
rust Board M
eeting in Public-12/04/18
Indicator Summary
5
Data Quality RAG keyRed – Data accuracy is not known, it is incomplete and inconsistent with relevant standardsAmber – Data is assumed to be complete and accurate, although there may be limitations or unresolved queriesGreen – Data is complete, accurate and consistent with the standards set for the specific indicator
Exception indicators keyRed for a minimum of two data points and amber for one, out of the latest three data pointsRed for the latest data point
l
u
Domain Indicator Target Dec-17 Jan-18 Feb-18YTD
ActualYTD Target
Executive
LeadMonth
Included
in
Detailed
Reports
National
/ Local
National
avg.
National
avg.
Period
Trend
Data
Quality
RAG
l Referral to Treatment - Admitted* 90.0% 69.2% 66.9% 65.1% 70.2% 90.0% COO Feb-18 Y Local 75.9% Jan-18G
l Referral to Treatment - Non Admitted* 95.0% 88.3% 87.5% 88.1% 88.7% 95.0% COO Feb-18 Y Local 89.0% Jan-18G
l Referral to Treatment - Incomplete* 92.0% 86.4% 85.7% 85.1% 88.4% 92.0% COO Feb-18 Y National 88.2% Jan-18G £
CCG penalty of £100 in respect of each
excess breach above the threshold
uReferral to Treatment - 52 week waits -
Incompletes0 0 20 41 0 0 COO Feb-18 National
1869 (all
Trusts)Jan-18
G
Diagnostic wait times 99.0% 99.8% 100.0% 99.9% 99.3% 99.0% COO Feb-18 Y National 97.7% Jan-18G £
CCG penalty of £200 in respect of each
excess breach above the threshold
l ED 4hr waits (Type 1, 2 & 3) 95.0% 77.4% 72.3% 71.3% 80.3% 95.0% COO Feb-18 Y National 85.0% Feb-18G £
CCG penalty of £120 in respect of each
excess breach above the threshold (cap
off 8% of attendances)
ED 12hr trolley waits 0 0 0 0 0 0 COO Feb-18 Y National371 (all
Trusts)Feb-18
G £ CCG penalty £1,000 per incidence
l
Ambulance turnaround time between 30 and
60 mins0 435 409 327 4,319 0 COO Feb-18 Y Local n/a
R £CCG penalty £200 per service user
waiting over 30 mins
l Ambulance turnaround time > 60 mins 0 153 166 138 1,792 0 COO Feb-18 Y Local n/aR £
CCG penalty £1,000 per service user
waiting over 60 mins
Cancer - Two week wait * 93.0% 94.7% 95.8% 97.1% 95.5% 93.0% COO Feb-18 Y National 94.9% Q3 17/18G £
CCG penalty breaches per qtr in excess
of tolerance is £200 for each breach.
Cancer - Breast Symptomatic two week wait * 93.0% 95.8% 92.1% 96.8% 94.0% 93.0% COO Feb-18 Y National 95.1% Q3 17/18G £
CCG penalty breaches per qtr in excess
of tolerance is £200 for each breach.
Cancer - 31 day * 96.0% 96.7% 98.5% 100.0% 98.6% 96.0% COO Feb-18 Y National 97.7% Q3 17/18G £
CCG penalty breaches per qtr in excess
of tolerance is £1,000 for each breach.
Cancer - 31 day subsequent drug * 98.0% 100.0% 100.0% 100.0% 100.0% 98.0% COO Feb-18 Y National 99.5% Q3 17/18G £
CCG penalty breaches per qtr in excess
of tolerance is £1,000 for each breach.
Cancer - 31 day subsequent surgery * 94.0% 100.0% 100.0% 94.4% 99.0% 94.0% COO Feb-18 Y National 95.6% Q3 17/18G £
CCG penalty breaches per qtr in excess
of tolerance is £1,000 for each breach.
Cancer - 62 day * 85.0% 89.0% 86.5% 86.6% 87.5% 85.0% COO Feb-18 Y National 83.0% Q3 17/18G £
CCG penalty breaches per qtr in excess
of tolerance is £1,000 for each breach.
Cancer - 62 day screening * 90.0% 83.3% 81.8% 100.0% 88.4% 90.0% COO Feb-18 Y National 90.7% Q3 17/18G £
CCG penalty breaches per qtr in excess
of tolerance is £1,000 for each breach.
*RTT and cancer performance for latest month is provisional and subject to validation
NB. Where national avg. blank - information not currently available
Res
po
nsi
veFinancial impact
9
Tab 9 Integrated perform
ance report - month 11
7 of 114T
rust Board M
eeting in Public-12/04/18
Indicator Summary
6
Data Quality RAG keyRed – Data accuracy is not known, it is incomplete and inconsistent with relevant standardsAmber – Data is assumed to be complete and accurate, although there may be limitations or unresolved queriesGreen – Data is complete, accurate and consistent with the standards set for the specific indicator
Exception indicators keyRed for a minimum of two data points and amber for one, out of the latest three data pointsRed for the latest data point
l
u
Domain Indicator Target Dec-17 Jan-18 Feb-18 YTD Actual YTD TargetExecutive
LeadMonth
Included
in
Detailed
Reports
National
/ Local
National
avg.
National
avg.
Period
Trend
Data
Quality
RAG
Urgent operations cancelled for a second time 0 0 0 0 0 0 COO Feb-18 Y National n/aG
lNumber of patients not treated within 28 days
of last minute cancellation0 12 20 16 94 0 COO Feb-18 Y National
10 (avg. all
Trusts)Q3 17/18
G
u Delayed Transfers of Care (DToC)* 3.5% 2.1% 4.3% 4.1% 5.2% 3.5% COO Feb-18 Y National 6.0% Feb-16G
Delayed Tranfers of Care (DToC) beddays used
in month735 866 1,045 12,867 COO Feb-18 Y National n/a
G
l Outpatient cancellation rate 8.0% 10.6% 11.6% 11.9% 11.2% 8.0% COO Feb-18 Y Local n/aG
Outpatient cancellation rate within 6 weeks^ 5.0% 3.7% 4.7% 4.0% 4.1% 5.0% COO Feb-18 Y Local n/aG
l Patient initiated cancellations (all) 14.3% 11.5% 11.9% 12.7% COO Feb-18 Y LocalG
Hospital + Patient initiated cancellations (all) 24.9% 23.1% 23.7% 23.9% COO Feb-18 Y Local n/aG
^ Excluding valid cancellations (cancellations to provide earlier appointments or where appointment no longer required, cancellations due to where patients have died, cancellations to appointments made in
error and cancellations where there was a change to a clinic template without a change to a patient's appointment date, time or site)
NB. Where national avg. blank - information not currently available
*DToC benchmark estimated by total delayed patients nationaly as percentage of occupied general and accute beds
Res
po
nsi
ve
9
Tab 9 Integrated perform
ance report - month 11
8 of 114T
rust Board M
eeting in Public-12/04/18
Indicator Summary
7
Data Quality RAG keyRed – Data accuracy is not known, it is incomplete and inconsistent with relevant standardsAmber – Data is assumed to be complete and accurate, although there may be limitations or unresolved queriesGreen – Data is complete, accurate and consistent with the standards set for the specific indicator
Exception indicators keyRed for a minimum of two data points and amber for one, out of the latest three data pointsRed for the latest data point
l
u
Domain Indicator Target Dec-17 Jan-18 Feb-18 YTD Actual YTD TargetExecutive
LeadMonth
Included
in
Detailed
Reports
National
/ Local
National
avg.
National
avg.
Period
Trend
Data
Quality
RAG
l Staff turnover rate (rolling 12 months) 12.0% 16.4% 16.9% 16.3% 16.3% 12.0% DoW Feb-18 Y National 13.5% (Beds
and Herts orgs)Dec-15
G
Staff turnover rate (rolling 3 months) 12.0% 16.6% 17.1% 16.4% 15.6% 12.0% DoW Feb-18 Y National 13.5% (Beds
and Herts orgs)Dec-15
G
Nurse Band 5 Turnover Rate 25.6% 25.6% 25.6% 25.9% DoW Feb-18 Y Local n/aG
% staffleaving within first year (excluding
medics and fixed term contracts)19.6% 20.3% 20.3% 19.1% DoW Feb-18 Y National n/a
G
Sickness rate 3.5% 3.5% 3.5% 3.5% 3.2% 3.5% DoW Feb-18 Y National 3.8% (EoE
orgs)Dec-15
A
l Vacancy rate 9.0% 11.7% 10.9% 10.3% 11.8% 9.0% DoW Feb-18 Y National 11% (local
survey)Dec-15
G
l Appraisal rate (non-medical staff only) 90.0% 85.4% 83.8% 80.00% 80.0% 90.0% DoW Feb-18 Y National 85% (local
survey)Dec-15
G
l Mandatory Training 90.0% 86.9% 86.1% 86.1% 88.8% 90.0% DoW Feb-18 Y Local 86% (local
survey)Dec-15
A
% Bank Pay** 8% - 12% 9.8% 10.8% 10.6% 9.9% 8% - 12% DoW Feb-18 Y Local n/aG
% Agency Pay** 8.0% 7.3% 6.4% 5.85% 7.9% 8.0% DoW Feb-18 Y Local 11.4% (local
survey)Dec-15
G
Temporary costs and overtime as % of total
paybill** (Inc. unfunded beds)22.6% 17.6% 17.7% 16.9% 18.2% 22.6% DoW Feb-18 Y National n/a
G
Temporary costs and overtime as % of total
paybill** (Excl. unfunded beds)7.0% 5.5% 5.2% 7.2% DoW Feb-18 Y National n/a
G
l Inpatient FFT response rate 50.0% 15.9% 19.0% 26.9% 22.3% 50.0% CN Feb-18 Y National 23.3% Jan-18G
l A&E FFT response rate 15% 2.7% 3.4% 5.5% 4.4% 15.0% CN Feb-18 Y National 12.2% Jan-18G
Daycases FFT response rate tbd NHSI^ 25.7% 27.5% 32.8% 30.1% tbd NHSI^ CN Feb-18 Y National n/aG
l Staff FFT response rate+ 50% 15.7% 11.8% 19.4% 15.6% 50% DoW Sep-17 Y National n/a
G
Staff FFT % recommended work 66% 58.5% 51.1% 53.8% 52.8% 66% DoW Sep-17 Y National n/aG
Maternity FFT response rate 35% 32.3% 25.4% 59.9% 39.1% 35% CN Feb-18 N National 22.5% Jan-18G
*Perfomance for current month may change due to data entry post production of this report
*Medication errors causing serious harm data for latest month is provisional and subject to validation. Temporary costs and overtime performance is provisional for the current month
NB. Exception reports not provided for FFT scores ** Trajectory set as target
NB. Where national avg. blank - information not currently available
+ Staff FFT reports latest quarterly positions in monthly columns (eg. Q1, Q2 and Q3 = month 1, 2, and 3)
Wel
l Led
tbd NHSI^ - threshold/target to be determined by Trust Development Agency guidance when available
9
Tab 9 Integrated perform
ance report - month 11
9 of 114T
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eeting in Public-12/04/18
Finance (Overview)
8
Operational performanceCurrent deficit of £43.67m is £27.71m adverse to plan as at M11 YTD. Unallocated CIP accounts for £11.33 of this, £7.58m due to NHS revenue, £5.71m to other revenue (mostly STF foregone), and £4.14m of pay costs (after above CIP element removed).
Recovery plans will continue to be pursued up to the year end and beyond, reflecting a move towards multi-period planning while retaining a necessary focus on near-term results and operational performance.
Savings and outlook for FY18Savings achieved at £8.91m up to M11, in line with plan, i.e. projects costed vs actual delivery), and behind target by £9.98m (where we wanted to be at this point in the year). 2017/18 Trust savings target is £21.9m, of which £13.7m has been assigned to divisions and £10.29m identified.
Achievement of the £13.7m is unlikely, although £10.3m represents a major achievement based on challenging circumstances. 2018/19 CIP planning continues and is well ahead of this time last year.
Operational performanceRevised forecast of £35m accepted by NHSI, compared to agreed 2017/18 control total of £15m. Base forecast of £46.6m reflects the impact of elective decisions in the last couple of months, operational factors including surge, and ongoing discussions with HVCCG.
£m Plan Actual Var
Surplus / (Deficit) (0.4) (4.3) (3.9)
£m
Surplus / (Deficit) (16.0) (43.7) (27.7)
Breakeven
£m % Budget
Medicine (0.1) (4)
Unscheduled Care (5.7) (37)
Surgery (9.1) (73)
Women's (1.9) (10)
BPPC Clinical Support 0.3 5
Estates & Facilities 0.7 3
Corporate 0.6 1
Other (12.5)
Total (27.7)
FY18 YTD Variance by Division
Financial Overview as at 28 February 2018
Statutory / Regulatory Duties
The Trust has a deficit plan of £15m
for FY18.
CRL The Trust has not exceeded its Capital
Resource Limit.
Month 11 Income & Expenditure
Year to Date
EFL The Trust has managed spend w ithin its
External Financing Limit.
10 Days' Cash Cash at 28/2/18 equated to 9 days'
spend
Month 11 performance - 12% on number,
12% on value (95% target)
Financial Risk Rating FY18
0
5
10
15
Fe b Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan
Forecast Cash £m
F'cast cash
10 days' cash
0
500
1,000
1,500
2,000
2,500
3,000
3,500
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Fe b Mar
Savings £'000
Actuals
Target
0
20
40
60
80
100
Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb
Rolling BPPC Payment Performance
Target
No.
Value
-50
-45
-40
-35
-30
-25
-20
-15
-10
-5
0Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Income & Expenditure FY18 £m
Actuals
Plan
BaseForecastRecoveryForecast
3
GG
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Tab 9 Integrated perform
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10 of 114T
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Finance (I&E)
9
Statement of Comprehensive Income (I&E)
Engagement with Commissioners• Contractual HVCCG activity continues to form the bulk of all income. Negotiations around final 2017/18 are in the concluding stages, revolving around PBR vs Block considerations.• CQUIN involves formal monitoring and operational controls, assuming 90% achievement after adjusting for prior year disputes.• FY19 QIPP discussed in twice-weekly meetings.
Operational performanceNHS income was £7.6m below plan YTD (£1.7m below in month), with a favourable variance in Non-Elective (£2.8m) offset by Elective (£4.9m, primarily Surgery), Outpatients (£2.5m) and Other (£2.2m).Other income was £5.7m adverse YTD (£0.9m in month) primarily due to STF income assumptions offset by favourable car parking income.
Outlook for FY18The current income forecast reflects all known and anticipated pressures (e.g. elective directive, tender outcomes), any STF income forgone as a result of missing the original control total of £15m, and winter pressures.Other service pressures clearly impact the Trust and are quantified where possible.
Budget Actual Var Budget Actual Var
Volumes
3,492 3,327 (165) Elective 42,806 39,690 39,633 (57) 38,198
3,978 3,519 (459) Non elective 49,525 45,340 45,515 175 45,563
37,580 33,645 (3,935) Outpatient 433,803 424,879 403,844 (21,035) 391,355
9,463 8,777 (686) A&E 117,791 107,837 107,093 (744) 107,027
4,493 3,657 (835) Elective 55,461 50,742 45,849 (4,893) 48,566
8,112 7,965 (147) Non elective 100,978 92,445 95,255 2,810 87,645
5,668 5,339 (329) Outpatient 70,191 64,234 61,741 (2,493) 64,479
1,288 1,257 (31) A&E 16,032 14,677 14,500 (178) 13,435
1,107 919 (188) Critical care 13,781 12,616 12,000 (616) 12,446
3,453 3,305 (148) Other NHS revenue 42,978 39,346 37,141 (2,206) 37,253
24,121 22,442 (1,678) TOTAL NHS REVENUES 299,421 274,061 266,485 (7,575) 263,824
22 (4) (25) Private Patients 259 237 208 (29) 231
1,314 389 (924) Other non-NHS clinical income 11,306 9,992 4,281 (5,711) 12,604
1,335 385 (950) TOTAL Non NHS Clinical 11,565 10,229 4,489 (5,740) 12,835
850 1,062 212 Education & Training 9,694 8,886 9,084 198 8,613
1,291 1,262 (29) Other Revenue 15,341 14,043 14,669 626 15,381
2,140 2,324 183 TOTAL OTHER REVENUE 25,035 22,929 23,754 825 23,994
27,596 25,151 (2,445) NET HOSPITAL REVENUE 336,020 307,219 294,729 (12,490) 300,652
£000's
Month 11 (Feb)Prior Year
Actual
YTD FY18
Budget
£000's£000's £000's £000's £000'sNHS REVENUE£000's £000's
9
Tab 9 Integrated perform
ance report - month 11
11 of 114T
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eeting in Public-12/04/18
Finance (I&E)
10
Statement of Comprehensive Income (I&E)
CIP schemesCIP schemes are a combination of expenditure, income, and transformational schemes.All cross-cutting CIP themes are closely monitored through formal meetings and operational actions.
Targeted assistance from SD & PMO colleagues is helping to generate a wide range of CIP ideas alongside the means and expertise to implement them in the best possible way.
Operational performance Pay costs were £11.4m adverse YTD (Medical £4.2m adv, Other Clinical £1.5m adv, Sci / Tech / Prof £0.6m adv, Nursing £0.7m adv & Unidentified CIP £7.2m, offset by Non-Clinical £2.9m fav). Focus on agency management continues agency cost trend established in FY17, £1.1m behind plan YTD (see following slide).
Non-pay costs were £3.8m adverse YTD – Increased outsourcing and drugs overspends + CIPs were offset by favourable depreciation and clinical services.[Further detail is given in the main Finance Report.]
Outlook for FY18Current and recovery actions are continually assessed as part of general good practice alongside a formal process with NHSI. Mitigating actions, incluse of the Model Hospital and internal SDO are at various stages of progress.
Budget Actual Var Budget Actual Var
18,603 18,468 135 Permanent / Bank Staff 223,337 204,798 197,662 7,136 180,578
506 1,149 (643) Agency 6,227 5,690 16,961 (11,271) 25,007
(1,438) (1,438) Unidentified pay savings (8,466) (7,246) (7,246)
17,671 19,617 (1,945) TOTAL PAY 221,097 203,241 214,623 (11,381) 205,585
1,745 1,812 (67) Drugs 21,050 19,223 20,710 (1,488) 19,789
2,681 2,109 571 Clinical services 32,069 29,415 26,721 2,693 27,610
5,816 5,146 670 Non-clinical services 70,860 65,235 67,336 (2,101) 61,327
(859) (859) Unidentified non-pay savings (5,084) (4,085) (4,085)
9,383 9,068 315 TOTAL NON-PAY 118,896 109,787 114,768 (4,980) 108,727
542 (3,533) (4,075) EBITDA (3,973) (5,809) (34,662) (28,852) (13,659)
720 589 131 Depreciation & Amortisation 8,650 7,931 6,791 1,139 6,615
128 153 (25) Interest 1,545 1,416 1,655 (239) 1,682
72 50 22 Dividends Payable 872 800 561 239 1,623
(378) (4,325) (3,947) Surplus / (Deficit) (15,040) (15,956) (43,669) (27,713) (23,579)
Month 11 (Feb)Prior Year
Actual
YTD FY18
Budget
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11
Finance (Agency)Agency spend trajectory
Blue – 2015/16 £36.8m, large
proportion of pay costs on
agency spend; agency caps
and other measures
implemented in-year
Red - This year, where we
need to be to achieve target
expenditure of £17.0m. YTD
results M11 £1.1m behind plan
with acknowledgement that FY
plan unlikely to be achieved in
full (still approx £8m reduction
on 2016/17). Green shows
current actuals and forecasts.
Purple - 2016/17 £26.5m, a
>£10m decrease on 2015/16
but still a high proportion of pay
spend compared to peers.
Month 1A Month 2A Month 3A Month 4A Month 5A Month 6A Month 7A Month 8A Month 9A Month 10A Month 11A Month 12F
Required trajectory 17/18 1,860 3,438 4,996 6,741 8,163 9,772 11,354 12,586 13,817 14,877 15,938 15,979
Trajectory based M11 1,860 3,438 4,996 6,741 8,163 9,772 11,355 13,090 14,541 15,813 16,961 18,351
Cumulative plan 17/18 1,701 3,571 5,102 6,462 7,823 9,183 10,713 12,074 13,434 14,625 15,815 17,000
Cumulative actual 16/17 2,605 5,416 7,655 9,846 11,932 14,004 16,635 18,938 21,560 23,847 24,973 26,501
Cumulative actual 15/16 2,772 5,712 8,744 11,930 15,236 18,418 21,978 25,157 28,255 31,149 34,046 36,827
Required trajectory 17/18 1,860 1,578 1,558 1,745 1,422 1,609 1,583 1,232 1,230 1,060 1,060 39
Trajectory based M11 1,860 1,578 1,558 1,745 1,422 1,609 1,583 1,735 1,451 1,272 1,149 1,390
Months plan 17/18 1,701 1,871 1,530 1,360 1,360 1,360 1,530 1,360 1,360 1,190 1,190 1,190
Months actual 16/17 2,605 2,811 2,239 2,191 2,086 2,072 2,631 2,303 2,621 2,288 1,126 1,528
Months actual 15/16 2,772 2,940 3,032 3,186 3,306 3,182 3,561 3,179 3,098 2,894 2,898 2,780
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Tab 9 Integrated perform
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13 of 114T
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Detailed reports
12
9
Tab 9 Integrated perform
ance report - month 11
14 of 114T
rust Board M
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Performance relative to targets/ thresholds
Executive lead Clinical lead Operational lead
Feb-18 4 4
Jan-18 3 5
Dec-17 4 4
Hospital
Standardised
Mortality
Ratio
(HSMR)*
Summary
Hospital
Mortality
Indicator*
Not achieving
Reporting sub committee - S&C &
COEC
Safe,
effective,
caring Achieving
Crude
mortality rate
(non-
elective)*
*Dr Mike Van der Watt
Tracey Carter
0
30
60
90
120
Apr
May Jun Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
May Jun Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
2015/16 2016/17 2017/18
HSMR (overall) HSMR (weekend) Threshold (HSMR overall)
0
30
60
90
120
Apr 2012 to
Mar 2013
Jul 2012 to
Jun 2013
Oct 2012 to
Sep 2013
Jan 2013 to
Dec 2013
April 2013
to Mar 2014
July 2013 to
June 2014
Oct 2013 to
Sept 2014
Jan 2014 to
Dec 2014
Apr 2014 to
Mar 2015
Jul 2014 to
Jun 2015
Oct 2014 to
Sep 2016
Jan 2015 to
Dec 2015
Apr 2015 to
Mar 2016
Jul 2015 to
Jun 2016
Oct 2015 to
Sep 2016
Jan 2016 to
Dec 2016
Apr 2016 to
Mar 2017
Jul 2016 to
Jun 2017
SHMI (Rolling 12 months) Actual SHMI (Rolling 12 months) 100
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
Apr
May Jun Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
May Jun Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
May Jun Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
2015/16 2016/17 2017/18
Crude Mortality Non-Elective Actual Mean UPL 2 standard devs LPL 2 standard devs
13
Hospital mortality
For the 12 month period (January 2017 to December 2017), the Trust’sHSMR of 96.5 was in the ‘as expected’ range. The Trust is reviewingthe clinical coding of outlier groups to identify if the appropriatediagnosis and relative risk has been applied.
The Trust is 1 of 7 within the Shelford peer group of 11 that sit withinthe ‘as expected’ range.
The Summary Hospital Mortality Indicator’s (SHMI) latestperformance (for Jul 16 to Jun 17) was 92.16 and ‘as expected’ (band2), placing the Trust 23rd nationally.
The Trust continues to hold monthly specialty/departmental MortalityReview meetings, cases from which are then discussed at a bi-monthlyTrust wide Mortality Review, chaired by the Medical Director. The casenote review process is currently being reviewed in order to align withthe recent publication, ‘National Guidance on Learning from Deaths’.
9
Tab 9 Integrated perform
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Stroke 60 mins , s troke care and STeMI 150 mins* (to fol low)
% Emergency
re-admissions
within 30
days
following an
elective or
emergency
spell*
Patients
admitted
directly to
stroke unit
within 4
hours of
hospital
arrival*
Stroke
patients
spending 90%
of their time
on stroke
unit*
0%
2%
4%
6%
8%
10%
12%
14%
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
2015/16 2016/17 2017/18
30 Day Emergency Readmissions - Elective % 30 Day Emergency Readmissions - Emergency %
Combined Performance Combined Target
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
2015/16 2016/17 2017/18
Performance Target Mean Upper control limit (3 sd) Lower control limit (3 sd)
0%
20%
40%
60%
80%
100%
120%
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
2015/16 2016/17 2017/18
Performance Target Mean Upper control limit (3 sd) Lower control limit (3 sd)
14
Emergency ReadmissionsCombined readmission rates, including both emergency and electiveadmissions, includes all patients with more than one admission to thehospital within a period of 30 days, regardless of whether the secondadmission was related.
Both elective and emergency re-admission rates have risen but thecombined rate remains lower than the national average
StrokePerformance against the 4 hour admission to the stroke unit target is43.3%, worse than 46.5% in the previous month.
The YTD figure of 61.1% remains above the national average of 60.2 % foradmissions to the stroke unit within 4 hours.
High attendance activity continues, resulting in capacity constraintsrestricting timely access to the stroke beds.
Stroke patients who arrive via pre-alert ambulances are immediatelyseen by the stroke team on arrival. Other potential stroke patientssometimes experience longer waits in ED, especially during times ofincreased capacity pressure. When the waiting time to be assessed in EDis long there is a resultant delay in timely referral to the stroke team forspecialist assessment.
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Tab 9 Integrated perform
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Number of
reactivated
complaints
% Complaints
responded to
within one
month or
agreed
timescales
with
complainant
Safe,
effective,
caring (continued)
Complaints -
rate per
10,000 bed
days
0
10
20
30
40
50
60
Ap
r
May Jun
Jul
Au
g
Sep
Oct
No
v
Dec Ja
n
Feb
Mar
Ap
r
May Jun
Jul
Au
g
Sep
Oct
No
v
Dec Ja
n
Feb
Mar
Ap
r
May Jun
Jul
Au
g
Sep
Oct
No
v
Dec Ja
n
Feb
Mar
2015/16 2016/17 2017/18
Complaints - rate per 10,000 bed days Complaints - rate per 10,000 bed days
Mean Upper control limit (3 sd)
Lower control limit (3 sd)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Ap
r
May Jun
Jul
Au
g
Sep
Oct
No
v
Dec Ja
n
Feb
Mar
Ap
r
May Jun
Jul
Au
g
Sep
Oct
No
v
Dec Ja
n
Feb
Mar
Ap
r
May Jun
Jul
Au
g
Sep
Oct
No
v
Dec Ja
n
Feb
Mar
2015/16 2016/17 2017/18
Compliants timely response Target Mean
Upper control limit (3 sd) Lower control limit (3 sd) Trajectory
-30
-20
-10
0
10
20
30
40
50
60
Ap
r
May Jun
Jul
Au
g
Sep
Oct
No
v
Dec Ja
n
Feb
Mar
Ap
r
May Jun
Jul
Au
g
Sep
Oct
No
v
Dec Ja
n
Feb
Mar
Ap
r
May Jun
Jul
Au
g
Sep
Oct
Nov
Dec Ja
n
Feb
Mar
2015/16 2016/17 2017/18
Reactivated complaints Threshold Mean
Upper control limit (3 sd) Lower control limit (3 sd)
15
Complaints rate per 10,000 bed days69 new complaints were received in February, of which 33% (23) relate to Surgery, Anaesthetics and Cancer (SAC), 28% (19) relate to Medicine, 17% (12) relate to Emergency Medicine (EM), 16% (11) relate to Women’s and Children (WACS), 4% (3) relate to CSS, 1% (1) relate to Environment. There were none for Corporate or Finance this month. In 28% of all complaints the patient was unhappy with their treatment; half of these were in connection with unplanned care (ED, COE, General Medicine). This month, Trauma and Orthopaedics received the highest number of complaints overall. The next highest is communication with nearly 14% of all complaints (and again, T&O featured higher than usual this month) . Staff attitude was the next highest subject at 12% and two thirds of these related to the medical staff, again Trauma and Orthopaedics were the highest.
% Complaints responded to within one month or agreed timescales with complainant In February 46.8% of complaints were responded to on time. 56 responses were sent in total. There is a target to respond to 85% of complaints on time.
Complaints responded to on time, by division, are as follows:**NOTE – USC and Emergency Medicine reporting changed during this period.
Five complaints were reactivated in February. Each of the reactivated complaints relate to the patient being dissatisfied with their care. At the time of the original complaint, 2 of the 5 were responded to on time.
The number of complaints over 6 months old has reduced.
N/A denotes – no complaints valid for reply to this month.
Oct - 17 Nov – 17 Dec – 17 Jan - 18 Feb – 18Trust wide 60% 55% 52% 76% 47%
Medicine 91% 91% 100% 75% 60%USC/Emergency Medicine 35% 32% 31% 75% 43%
SAC 71% 43% 55% 56% 19%
WACS 33% 67% 22% 100% 100%
Environment 50% 100% N/A 100% 50%
CSS 100% N/A 100% 100% 100%
Corporate 100% 100% 100% N/A 50%
Target Feb 18
% of complainants with verbal communication at the beginning of process (called within 3 working days of receipt of complaint)
95% by Q4 77.6%
% of complaints acknowledged within 3 working days 100% 100%
% of complaints taken longer than 6 months to investigate (figure taken at the end of Jan 2018)
>5% 3%
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Tab 9 Integrated perform
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Executive lead Clinical lead Operational lead
*Dr Mike Van der Watt
Tracey Carter
Safe,
effective,
caring
MRSA
bactaraemias
and E. Coli
Bacteraemia
Clostridium
Difficile
Never
events*
Reporting sub committee - S&C &
COEC
Apr
May
Jun
JulAug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
JulAug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
JulAug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
2015/16 2016/17 2017/18
MRSA bacteraemias Actual 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0
MRSA bacteraemias Target 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
E. Coli Bacteraemia 3 3 2 3 2 1 1 2 5 0 3 7 1 1 1 4 2 2 5 1 4 4 2 2 1 1 3 8 3 2 4 4 2 2 8
0
1
2
3
4
5
6
7
8
9
0
5
10
15
20
25
30
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
2015/16 2016/17 2017/18
Clostridium Difficile Actual Clostridium Difficile Target
Clostridium Difficile Actual YTD Clostridium Difficile Target YTD
Actual YTD (Excl. cases with no lapses in care)
0
1
2
3
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
2015/16 2016/17 2017/18
Never events Actual Never events Trajectory Never events Target
16
Performance relative to targets/ thresholds
Feb-18 2 4
Jan-18 4 2
Dec-17 3 3
Achieving Not achieving
Clostridium difficile Infection (CDI)6 cases were reported in February. The full year target ceiling for WHHT apportioned CDIis 23 – the year to date actual is 27.
The rybotyping for each of the 6 February cases are all individually different. 5 caseswere reported in Medicine, and the remaining case in Surgery at SACH. The SACH casewas identified on DLM Ward and linked by ‘time/date/place’ to the DLM case reported inJanuary. Both cases were reablement patients, but despite this rybotype results suggestthat transmission on DLM was not of concern.
Of the 5 cases in Medicine, 2 were on Tudor where rybotypes were different, thereforetransmission on Tudor is not of concern. The remaining 3 cases in medicine were onthree different wards. All have different rybotyping, once again supporting noassociation with each other and transmission was not of concern .
RCA’s have been undertaken for all 6 cases. Key learning from RCA’s relates toinappropriate sampling .
There has been agreement with Herts Valleys CCG that there was no identified lapse ofcare in 1 case of CDI. 4 further cases were submitted to HVCCG for consideration inJanuary, the outcome is awaited. A further 12 cases are to be presented to the HVCCGappeals panel on 21 & 28 March 2018. 3 cases were agreed on the 21 March as no lapsein care, bringing the total number of no lapses in care to 4.
The IPC team continue with antimicrobial rounds and weekly Clostridium difficile rounds.There is also increased targeted IPC support, audit, power training to key clinical areas.
MRSA bacteraemia (MRSAb)The full year target ceiling for MRSAb is 0 avoidable cases. A pre-48hr MRSAb wasreported in January. A CCG lead Post Infection Review (PIR) has been completed withWHHT support and this has been assigned to ‘Third Party’.
E. Coli bacteraemia (E colib)8 cases of post 48hrs E colib were reported in February, up from 2 the previous month.The CCG’s target this year is a 10% reduction equating to 36 cases. There is no target forWHHT. The IPCT intend to increase the organisation’s focus on E.Coli bacteraemias,deploying a similar strategy/process and focus to that of C.diff and MRSAb. The IPCT isrepresented on the WHHT continence group & supports the review of post 48hrs E colibRCAs.
Never eventNo never events were recorded in February 2018.
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Tab 9 Integrated perform
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Medication
errors causing
serious harm*
% of reported
patient safety
incidents that
are harmful
Serious
incidents
0%
5%
10%
15%
20%
25%
30%
35%
40%
Ap
r
Ma
y
Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
2015/16 2016/17 2017/18
Actual Target
Upper control and lower control limit to be added
-5
0
5
10
15
20
25
30
Ap
r
Ma
y
Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
2014/15 2015/16 2016/17
Actual Target to follow UPL will be used Upper control limit (3 sd)
Lower control limit (3 sd) Mean
0
1
2
3
4
5
Ap
r
Ma
y
Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
2015/16 2016/17 2017/18
Actual Target
17
Serious Incidents
3 Serious Incidents (SIs) were declared in February 2018, 2 fewer than in January 2018• 1 in emergency medicine relating to a safeguarding allegation• 2 in the Medicine division – one fall and one related to a hospital acquired infection.
At the end of February 2018 the Trust had 29 open SIs, of which 17 had been completed andwere with commissioners pending formal closure on StEIS. At the end of February 2018there were 12 ongoing SI investigations, all of which were within the deadline forcompletion.
Learning from SIs
The following actions and processes are in place to ensure learning from SIs and provideassurance that learning has taken place and changes have been implemented:
45 day review meetings allow the SI draft report to be discussed and challenged by therelevant clinical and management teams prior to the action plan being completed. Therewere 2 45-day meetings held in February 2018.
Each action plan is developed, signed off and monitored by the division leading theinvestigation into the incident.
The SI review group (SIRG), chaired by the Medical Director, review all closed SI action planswhere senior divisional representation provides assurance and evidence that actions havebeen implemented before the SI is formally closed internally. The last SIRG meeting tookplace in February 2018. Five action plans were reviewed and 2 of these were closed; theoutstanding evidence for those action plans which were not closed will be followed upas part of the SIRG action log. A further 5 action plans were closed in the SIRG action log– these are action plans which had been discussed at SIRG before but not closed at thetime due to outstanding evidence. The next SIRG meeting is scheduled to take place on19 March 2018.
% of patient safety incidents which are harmful
9.12% of incidents reported in February 2018 were recorded as harmful, a reduction from12.3% in January 2018.
There has been a decrease in the number of incidents scored as moderate or above from 33reported in January 2018 to 19 reported in February 2018. Of those 9 still require harmvalidation and are therefore subject to change.
Medication incidents causing serious harmNo medication errors were reported as causing serious harm in February 2018.
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Executive lead Clinical lead Operational lead*Dr Mike Van der Watt
Tracey Carter
Safe, effective,
caring
VTE risk
assessment*
Reporting sub committee - S&C & COEC
CAS alerts:a) number issued per month
(not target)
b) number where
acknowledgement overdue* (target = 0)
(Class 4: for information only and
class 2: Action within 48 hours) AprMayJun JulAugSepOctNovDecJanFebMarAprMayJun JulAugSepOctNovDecJanFebMarAprMayJun JulAugSepOctNovDecJanFebMar
2015/16 2016/17 2017/18
a) CAS alerts issued 7 4 4 8 19 8 12 8 12 6 5 4 1 22 24 14 11 11 10 7 5 7 4 1 6 11 16 5 16 5 6 6 10 12 8
b) CAS alerts target 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
b) CAS alerts overdue 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0
5
10
15
20
25
30
80%
85%
90%
95%
100%
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
2015/16 2016/17 2017/18
VTE risk assessment Actual VTE risk assessment Target Mean
Upper control limit (3 sd) Lower control limit (3 sd)
18
Performance relative to targets/ thresholds
Feb-18 1 4
Jan-18 1 4
Dec-17 1 4
Achieving Not achieving
CAS alertsAll alerts issued by CAS in February 2018 were acknowledged within the 48hr deadline.
8 alerts were issued in February 2018: • 3 Estate & Facilities alerts • 5 Medical Device Alerts .
1 of the Medical Device alerts is now closed and was not applicable to the trust. The remaining 4 Medical Device alerts have been sent to the divisions and actions are underway.
All of the Estate and Facilities alerts actions have now been completed and are awaiting sign off.
There were no breaches during February 2018 and all alerts with deadlines were closed on time.
VTE There has been some improvement in VTE risk assessment compliancebut more work is required to target non-compliant areas.
Issued by CAS 8
Breached n month 0
Currently overdue 0
CAS alerts not acknowledged within
48hrs 0
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Hospital
acquired
pressure ulcers
Falls and falls
with harm
0
5
10
15
20
25
30
35
Ap
r
May Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Mar
Ap
r
May Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Mar
Ap
r
May Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Mar
2015/16 2016/17 2017/18
Hospital acquired pressure ulcers Hospital acquired pressure ulcers (G3) avoidable
Hospital acquired pressure ulcers (G4) avoidable
0
20
40
60
80
100
120
140
Ap
r
May Jun
Jul
Au
g
Sep
Oct
No
v
Dec Ja
n
Feb
Mar
Ap
r
May Jun
Jul
Au
g
Sep
Oct
No
v
Dec Ja
n
Feb
Mar
Ap
r
May Jun
Jul
Au
g
Sep
Oct
No
v
Dec Ja
n
Feb
Mar
2015/16 2016/17 2017/18
Nu
mb
er
of
falls
Number of falls Number of falls with harm
19
Hospital acquired pressure ulcersIn February 21 new pressure ulcers were recorded, affecting 19patients:• 1 x grade 1• 17 x grade 2• 3 x grade 3
The avoidability of the grade three pressure ulcers has not yet beenconfirmed due as RCAs are underway but not yet completed.
The grade 2 pressure ulcers are validated by the Matrons for the clinical areas but not differentiated between avoidable and unavoidable. The number recorded is an improved picture from January (22).
A Trust wide improvement plan is in place to ensure continuing focus onreducing pressure damage as part of harm free care. A revised BestShot care plan is in place. The Harm Free Care team are linking withDivisions to refocus support. Skin Champion training days have beenorganised.
High Risk prompt posters are being trialled in surgery. The educationteam support key areas with tissue viability competencies for staff.Enhanced support and focus with the surgical division is underway.
Some significant improvements have been made, with over 36%reduction in grade 3 pressure ulcers between April and December 2017.
Falls and falls with harmIn February there were 129 inpatient falls with 18 resulting in harmacross 18 clinical areas, one resulting in severe harm an decrease fromJanuary. Falls with harm remains low in comparison to numbers of falls.
The campaign to address falls continues with the creation of FallChampions, and with the multidisciplinary falls group.
Joint working with Community teams is in place, reviewing falls andcommon themes.
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NB. Indicator reported at WHHT from April 2017
Children's
Safety
Thermometer:
Harm Free Care
Adult Safety
Thermometer:
Harm Free Care
and New Harms
80%
82%
84%
86%
88%
90%
92%
94%
96%
98%
100%
Ap
r
Ma
y
Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
2015/16 2016/17 2017/18
Harm Free Care (acquired within and outside of Trust)
Harm Free Care (acquired within and outside of Trust) Target
New Harm Free Care (acquired within Trust)
New Harm Free Care (acquired within Trust) national average
0%
20%
40%
60%
80%
100%
120%
Ap
r
Ma
y
Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
2015/16 2016/17 2017/18
Harm Free Care Actual Harm Free Care national average
20
Adult Safety ThermometerThe Adult Safety Thermometer is a measurement tool for improvement thatfocuses on the four most commonly occurring harms in healthcare: pressureulcers, falls, UTI in patients with a catheter and VTEs. Data is collected through apoint of care survey on a single day each month on all patients. ‘Harm free’ care isdefined by the absence of harm in these four areas. In February, Harm Free Carewas 91.5%, below the national target of 95%. This includes harms acquired bothinside and outside of the Trust.New Harm Free care (harms acquired in the Trust) for February 2018 was 98.9%,which is above the national average of 97.9%.
Nine Month Review of Harms.Since August no patient has experienced more than 1 harm. There has been adecrease in February in the safety thermometer numbers for new pressure ulcers,decreasing from 7 to 4. Old pressure ulcers have increased from 34 to 40.An increase has been seen in Falls but falls with harm has remained at 1.
Children and Young People's Services Safety ThermometerHarm includes patients with a PEWS completed: triggered but not escalated,extravasation (leakage of a fluid out of its container), patients in pain at the timeof survey and any pressure ulcer or any moisture lesion. Harm free care was100% in January for Acute Children’s Services, compared to 85.7% nationally. Ananalysis of the February 2018 survey demonstrated that all patients had a set ofobservations and had been assessed for an Early Warning Score in the last 12hours. Of those patients with an intravenous (IV) device, extravasation was notobserved in any patient . There were no reports of pressure ulcers or moisturelesions and no patient reported pain at the time of survey.
Harm Free Actions• Urology Steering group monitoring E-coli in conjunction with Infection
Prevention and control with continued monitoring of cathethers• Focus on the Pressure Ulcer improvement plan with Divisions.• Collaborative working with community on harms.• Falls collaboration with community teams• Falls Lanyard cards being brought re lying and standing blood pressure• Harm free Care tweets with key messaging• Targeted ward teaching• Implemented pain assessment recording on PEWs charts.
Indicator Jun17 Jul17 Aug17 Sep17 Oct17 Nov17 Dec17 Jan18 Feb18
Number of patients with two
harms 1 1 2 - - - - - -
New pressure ulcers 3 4 5 5 8 6 5 7 4
Old pressure ulcers 34 51 56 50 27 26 25 34 40
Number of falls 3 9 13 14 10 12 13 9 18
Number of falls with harm 1 2 3 4 1 - 3 1 1
Catheters 74 117 86 99 114 107 87 89 98
Catheter & New UTI 1 5 4 3 - 2 2 1 -
New VTE 2 3 3 4 2 7 3 5 1
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21
Ward scorecard – key themesWhat is causing the variance in Trust performance
Safety Alerts – There has been a slight decrease in February ( 51 ) compared with January (56 ). Safety alerts are mainly due to the number of falls, pressureulcers, and the percentage of extremely likely Friends and Family response rates in clinical areas. The areas with a high numbers of falls are Bluebell, AAUBY3Sarratt, Tudor and Stroke. Sarratt (5) and Langley (3) had the highest number of pressure ulcers.Process Alerts: February showed a reduction to 116 from January (131). The majority of alerts are due to overall Test Your Care results, 12 of 35 clinical areas’results were 90% or lower. There appears to be a direct link between process – risk assessment and care planning and an increase in safety outcomes inrelation to pressure ulcers, demonstrated by the Safety thermometer data.Summary:• Paediatrics - no safety alerts.• Maternity - no safety alerts.• Ten clinical areas are demonstrating a higher trend of alerts for February compared to January.• Surgery have seen a drop in alerts for February• The staffing slide outlines the impacts across ward areas related to vacancies and lower fill rates and the opening of surge areas.
What actions have been taken to improve performance
• Trial of text messaging for patients attending ED for feedback for FFT. Awareness of FFT raised across the Trust through the leadership academy programme• Introduction of speciality specific FFT forms in Outpatients .• Reviewing support mechanisms for staff such as care certificates, Band 6 and Band 7 development courses.• Targeted ward teaching on Falls prevention and management• Bed rail audit to be shared for learning• Falls lanyard cards for lying/ standing BP – being purchased• Multi disciplinary teams reviews in clinical areas with high numbers of falls• Targeted training in relation to Pressure ulcers with wards – purchased a body map that highlights pressure points• Pressure Ulcer focus with Surgery identifying support and actions• Harm Free Care promotion such as Newsletters, Mr B Harmfree – key messages, and Trolley dashes and use of simulation.• Targeted monitoring on practice and cleaning by infection control around C- Diff• Safer Care tool being implemented.• Ward Accreditation being undertaken by all ward areas
Changes in outcomes
• Improvements have been made with a >36% reduction in grade 3 pressure ulcers during April – December 17 compared to 2016.• Falls with harm has remained low
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22
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23
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C-section rate
Mixed sex
accommodation
13%
9% 11%
11%
9% 11%
11%
11% 15
%11
%11
%11
%8% 11
%11
%10
%9%
16%
11%
8%13
%10
% 14%
15%
13%
12%
11%
10%
11%
11% 14
%12
%10
%11
%10
%
18%
21%
17%
19%
19%
16% 21
%20
%22
%20
%20
%20
%21
% 21%
19%
18%
20%
18%
22%
24% 16
%18
% 16%
14%
17%
18%
13%
17%
13% 17%
19%
17%
18%
15%
16%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Ap
r
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Ma
r
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Ma
r
2015/16 2016/17 2017/18
Caesarean Section rate - Elective Actual Caesarean Section rate - Emergency Actual
Caesarean Section rate - Combined Target
0
20
40
60
80
100
120
140
160
180
Ap
r
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Ap
r
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Ap
r
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
2015/16 2016/17 2017/18
MSA breaches Actual MSA breaches Target
24
C-section rateThe caesarean section rate for February remains within required parameters.
The policy regarding how to manage women who require C Sections has beenwritten and is to be shared with consultants and Midwifery staff for final andagreement. It will then go through the Trust ratification process.
Mixed sex accommodation (MSA)The number of reported breaches decreased significantly in February.
The monitoring and management of patients requiring step down from ITUis reviewed daily as part of the regular operational management meetings,with the intention of reducing where possible, the number of mixed sexaccommodation breaches that occur. Advance planning for complex patientsrequiring side-room capacity is reviewed as part of these meetings.
The Trust policy on mixed sex accommodation has been reviewed and ratified.
The completion of the RCA template provided by HVCCG is being undertaken inITU and the CCG are supporting the Trust with regular monitoring visits.
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Responsive
Reporting sub committee - TEC
Executive lead Clinical lead Operational lead
Sally Tucker Jeremy Livingstone Divisional Managers
Access indicators - RTT, diagnostics, cancelled operations
and outpatient appointments
Incomplete
pathways
within 18
weeks
Completed
pathways
within 18
weeks
Incomplete
pathways WL
profile
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
Apr
May Ju
n
Jul
Aug Se
p
Oct
Nov
Dec Jan
Feb
Mar
Apr
May Ju
n
Jul
Aug Se
p
Oct
Nov
Dec Jan
Feb
Mar
Apr
May Ju
n
Jul
Aug Se
p
Oct
Nov
Dec Jan
Feb
Mar
2015/16 2016/17 2017/18
Admitted performance Non admitted performance
Non admitted target Admitted target
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2015/16 2016/17 2017/18
52+ 3 1 - - - - - - - - - - 2 1 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 20 41
26 < 52 701 657 528 358 349 358 347 347 455 550 492 636 649 761 892 984 1,03 987 990 892 964 884 782 659 661 647 625 748 892 993 921 935 1231 1405
18 - <26 1,62 1,35 1,48 1,29 1,23 1,15 1,10 1,10 1,38 1,34 1,24 1,62 1,83 1,68 2,07 2,21 2,17 2,26 1,96 1,83 1,96 1,65 1,53 1,43 1570 1522 1638 1757 1971 2082 2026 2017 2157 2115
<18 20,7 21,1 21,4 19,6 18,9 17,8 17,4 17,4 17,3 17,2 18,8 19,6 19,2 20,0 22,9 21,7 21,8 21,0 20,5 19,9 19,3 19,1 19,2 20,7 20780212182217822550226292274922580222432150621131
% of PTL within 18 weeks 89.9% 91.3% 91.4% 92.2% 92.3% 92.2% 92.3% 92.3% 90.4% 90.1% 91.6% 89.7% 88.6% 89.1% 88.5% 87.2% 87.2% 86.6% 87.4% 88.0% 86.9% 88.3% 89.2% 90.9% 90.3% 90.7% 90.7% 90.0% 88.8% 88.1% 88.5% 88.3% 86.4% 85.7%
82%
84%
86%
88%
90%
92%
94%
0
5,000
10,000
15,000
20,000
25,000
30,000
% p
atie
nts
wit
hin
18
we
eks
Nu
mb
er
of
pat
ien
ts
80%
82%
84%
86%
88%
90%
92%
94%
Apr
May Ju
n
Jul
Aug Se
p
Oct
Nov
Dec Jan
Feb
Mar
Apr
May Ju
n
Jul
Aug Se
p
Oct
Nov
Dec Jan
Feb
Mar
Apr
May Ju
n
Jul
Aug Se
p
Oct
Nov
Dec Jan
Feb
Mar
2015/16 2016/17 2017/18
Performance Mean Upper control limit (3 sd)
Lower control limit (3 sd) Target Trajectory
25
Performance relative to targets/ thresholds
Feb-18 5 2
Jan-18 5 2
Dec-17 5 2
Achieving Not achieving
RTTFebruary’s performance, at 85.06%, shows a further decrease. The most recentnational data available (January) shows that the Trust’s performance that month wasbelow the national average (88.2%). Performance at the L&D (91.0%) and RFH (83.0%)was also below the national standard of 92%. The median waiting time at WHHT (iethe weeks half the patients on an RTT pathway were waiting) was worse than thenational position (8.0 vs 7.6 weeks) and worse than the 92nd percentile wait time(23.1 vs 21.3 weeks).
Although urgent care demand is starting to ease, the impact on performance overrecent months has been significant and recovery will take some considerable time.This has been the most significant factor in the number of 52 week breaches, whichhad increased to 41 at month end. The majority of these breaches are inOrthopaedics.
Service18 Weeks
Plus
% Under 18
WeeksService
18
Weeks
Plus
% Under 18
Weeks
GENERAL MEDICINE 0 100.00% CARDIOLOGY 74 95.48%
ANAESTHETICS 0 100.00% ORTHOTICS 8 95.38%
CRITICAL CARE MEDICINE 0 100.00% GASTROENTEROLOGY 57 95.17%
PAED CLINICAL HAEMATOLOGY 0 100.00% GYNAECOLOGY 43 95.06%
STROKE MEDICINE 0 100.00% PAED EPILEPSY 3 95.00%
TRANSIENT ISCHAEMIC ATTACK 0 100.00% PAED ENDOCRINOLOGY 2 94.59%
MEDICAL ONCOLOGY 0 100.00% PAEDIATRICS 39 94.41%
NEONATOLOGY 0 100.00% RESPIRATORY MEDICINE 27 94.38%
OBSTETRICS 0 100.00% PAED GASTROENTEROLOGY 7 93.64%
GYNAECOLOGICAL ONCOLOGY 0 100.00% COLORECTAL SURGERY 32 92.45%
ORTHOPTICS 0 100.00% UPPER GI SURGERY 6 92.00%
ORTHODONTICS 1 98.57% HEPATOLOGY 5 90.74%
BREAST SURGERY 6 98.40% PAED OPHTHALMOLOGY 15 90.20%
PAED DERMATOLOGY 1 98.15% RHEUMATOLOGY 44 90.16%
GERIATRIC MEDICINE 3 97.30% ORAL SURGERY 138 87.66%
PAEDIATRIC UROLOGY 4 97.26% NEUROLOGY 131 86.87%
NEPHROLOGY 1 97.22% VASCULAR SURGERY 25 84.18%
CLINICAL ONCOLOGY 1 96.88% ENT 312 83.82%
PAED CARDIOLOGY 1 96.77% UROLOGY 248 80.35%
DIABETIC MEDICINE 3 96.63% TRAUMA & ORTHOPAEDICS 804 76.68%
OTHER 2 96.23% OPHTHALMOLOGY 686 72.35%
CLIN HAEMATOLOGY 10 95.74% GENERAL SURGERY 541 71.97%
DERMATOLOGY 85 95.65% PAIN MANAGEMENT 220 70.86%
ENDOCRINOLOGY 12 95.56% Total 3597 85.06%
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Diagnostics
Patients not
treated within
28 days of last
minute
cancellation
and urgent
operations
cancelled for
2nd time
Hospital
outpatient
cancellations
all and %
cancelled*
within 6 weeks * Ex c l udi ng v a l i d c a nc e l l a t i ons
( c a nc e l l a t i ons t o pr ov i de e a r l i e r
a ppoi nt me nt s or whe r e a ppoi nt me nt no
l onge r r e qui r e d, c a nc e l l a t i ons due t o
whe r e pa t i e nt s ha v e di e d, c a nc e l l a t i ons
t o a ppoi nt me nt s ma de i n e r r or a nd
c a nc e l l a t i ons whe r e t he r e wa s a c ha nge
t o a c l i ni c t e mpl a t e wi t hout a c ha nge t o
a pa t i e nt ' s a ppoi nt me nt da t e , t i me or
si t e )
0
5
10
15
20
25
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
2015/16 2016/17 2017/18
Patients not treated within 28 days of last minute cancellation
Trajectory (28 day standard)
Target (28 day standard)
Mean
0%
2%
4%
6%
8%
10%
12%
14%
16%
Apr
May Jun
Jul
Au
g
Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
May Jun
Jul
Au
g
Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
May Jun
Jul
Au
g
Sep
Oct
Nov
Dec Ja
n
Feb
Mar
2015/16 2016/17 2017/18
Outpatient cancellation rate Actual Outpatient cancellation rateTarget
Mean Upper control limit (3 sd)
Lower control limit (3 sd) Outpatient cancellation rate within 6 weeks
96.0%
96.5%
97.0%
97.5%
98.0%
98.5%
99.0%
99.5%
100.0%
100.5%
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
2014/15 2015/16 2016/17
Performance Trajectory Target
Mean Upper control limit (3 sd) Lower control limit (3 sd)
26
Hospital cancellations – patients not treated within 28 days of last minute cancellation
There were 16 breaches of the 28 day rebooking requirement. These were in GeneralSurgery, Orthopaedics, ENT, Ophthalmology and Oral Surgery. Breaches were theresult of capacity (bed) pressures, equipment availability and patient choice.
Hospital cancellations – patients cancelled within 6 weeks and overall
Short notice, hospital initiated cancellation remains below the Trust tolerance (5%) at4.7% (excluding valid cancellations and patient initiated cancellations).
NB: Total cancellation rate does not equate to unfilled capacity.
Diagnostic wait times
Performance against the 6 week waiting time standard has been maintained,..
All cancellations Under 6 weeks All cancellations Under 6 weeks
11.9% 4.0% 11.9% 9.8%
Total cancellations: 23.7%
Hospital initiated Patient initiated
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Responsive
Reporting sub committee - TEC
Executive lead Clinical lead Operational lead
Sally Tucker Jeremy Livingstone Divisional managers
Recovery plan/ existing actions and update
Breast
symptom two
week
standard
CWTs
Two week
standard
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
May Jun
Jul
Au
g
Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
2015/16 2016/17 2017/18
Two week wait performance Two week wait target
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
2015/16 2016/17 2017/18
Breast Symptomatic performance Breast Symptomatic target
27
2wwThe provisional position for February is compliant at 97.1%
Breast symptomaticThe provisional position for February is compliant at 96.8%. There were 155 cases and 5 breaches.
Performance relative to targets/ thresholds
Feb-18 6 1
Jan-18 6 1
Dec-17 6 1
Achieving Not achieving
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31 day
subsequent
surgery
standard
31 day
subsequent
drug standard
31 day
standard
93%
94%
95%
96%
97%
98%
99%
100%
Apr
May Ju
n
Jul
Aug Se
p
Oct
Nov
Dec Jan
Feb
Mar
Apr
May Ju
n
Jul
Aug Se
p
Oct
Nov
Dec Jan
Feb
Mar
Apr
May Ju
n
Jul
Aug Se
p
Oct
Nov
Dec Jan
Feb
Mar
2015/16 2016/17 2017/18
Cancer - 31 day Performance Cancer - 31 day Target
82%
84%
86%
88%
90%
92%
94%
96%
98%
100%
102%
Apr
May Jun
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar
Apr
May Jun
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar
Apr
May Jun
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar
2015/16 2016/17 2017/18
Cancer - 31 day subsequent surgery Performance Cancer - 31 day subsequent surgery Target
80%
85%
90%
95%
100%
Ap
r
May Ju
n
Jul
Aug Se
p
Oct
Nov
Dec Jan
Feb
Mar
Ap
r
May Ju
n
Jul
Aug Se
p
Oct
Nov
Dec Jan
Feb
Mar
Apr
May Ju
n
Jul
Aug Se
p
Oct
Nov
Dec Jan
Feb
Mar
2015/16 2016/17 2017/18
Cancer - 31 day subsequent drug Performance Cancer - 31 day subsequent drug Target
28
31 day first
The position for February is currently compliant at 100%.
31 Day subsequent – Drug
The position for February is provisionally compliant at 100%
31 day subsequent –Surgery
Performance is compliant at 94.4%
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62 day
screening
standard
62 day
standard
number of
104+ day
waiters
62 day
standard
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Apr
May Ju
n
Jul
Aug Se
p
Oct
Nov
Dec Jan
Feb
Mar
Apr
May Ju
n
Jul
Aug Se
p
Oct
Nov
Dec Jan
Feb
Mar
Apr
May Ju
n
Jul
Aug Se
p
Oct
Nov
Dec Jan
Feb
Mar
2015/16 2016/17 2017/18
Cancer - 62 day Performance Cancer - 62 day Trajectory Cancer - 62 day Target
0%
20%
40%
60%
80%
100%
120%
Apr
May Ju
n
Jul
Aug Se
p
Oct
Nov
Dec Jan
Feb
Mar
Apr
May Ju
n
Jul
Aug Se
p
Oct
Nov
Dec Jan
Feb
Mar
Apr
May Ju
n
Jul
Aug Se
p
Oct
Nov
Dec Jan
Feb
Mar
2015/16 2016/17 2017/18
Cancer - 62 day screening Performance Cancer - 62 day screening Target
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Cancer 62 day patients waiting 104 days+ 24 3 3 4 4 2 3 3 2 0 1 1 2 3
Cancer 62 day PTL (total) 1466 1338 1284 1331 1312 1456 1521 1720 1392 1251 1254 1475 1425 1622
0
5
10
15
20
25
30
0
200
400
600
800
1,000
1,200
1,400
1,600
1,800
2,000
Nu
mb
er
of
pat
ien
ts w
aiti
ng
10
4+
day
s
Nu
mb
er
of
pat
ien
ts o
n P
TL
29
62 day GP – urgentThe provisional position for February is compliant at 86.6% , with 58 treatments and 7.5 breaches. More treatments are expected to be added and some breaches are still to be validated. The final position is expected to be compliant.
General themes:• Some delays within MDTs although most are now having a weekly clinical
review with clinician • Insufficient number of patients seen in the first 7 days • Long delays in obtaining information from tertiary centres – there is a plan to
implement conference calls with more partners.
Actions: The focus on PTL tracking continues with training and setting up tertiary centre conference calls.
104 day waitsActive – in February there were 3 patient pathways >104 days; 2 x H&N 1 x Urology.
Closed – 3 pathways over 104 days were closed in February2 H&N pathways (1 was on the 62 day pathway and the other consultant upgrade)1 x Lung (on 62 day pathway)
62 day screening Performance is provisionally compliant at 100 %
Tumour type Jan Feb
Breast 92 91.7
Gynaecological 100 100
Haematological 100 -
Head and Neck 50 0
Lower Gastrointestinal 64.7 66.7
Lung 40 60
Sarcoma 100 100
Skin 97.2 100
Upper Gastrointestinal 84.6 81.8
Urological 80 83.3
Total 86.5 86.6
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Responsive
Reporting sub committee - TEC
Executive lead Clinical lead Operational lead Performance relative to targets/ thresholds
Sally Tucker Dr Rachel Hoey Divisional managers
Feb-18 1 4
Jan-18 1 4
Dec-17 1 4
A&E
* Please note that the A&E trajectory is a working trajectory and awaiting final approval
Ambulance
turnaround
time
Emergency flow indicators
- A&E, ambulance
turnaround and DToC Achieving Not achieving
70%
75%
80%
85%
90%
95%
100%A
pr
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
Dec Ja
n
Feb
Mar
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
Dec Ja
n
Feb
Mar
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
Dec Ja
n
Feb
Mar
2015/16 2016/17 2017/18
Performance Target Mean Upper control limit (3 sd) Lower control limit (3 sd)
0
100
200
300
400
500
600
Ap
r
May Jun
Jul
Au
g
Sep
Oct
No
v
Dec Ja
n
Feb
Mar
Ap
r
May Jun
Jul
Au
g
Sep
Oct
No
v
Dec Ja
n
Feb
Mar
Ap
r
May Jun
Jul
Au
g
Sep
Oct
No
v
Dec Ja
n
Feb
Mar
2015/16 2016/17 2017/18
Ambulance turnaround 60 mins+ Ambulance turnaround between 30 and 60 mins Target
A&E performance in February remained at a similar level at 72.1% compared to 72.3%the previous month. Minors performance fell to 88.5% from 89.6%. CED performanceshowed signs of recovery with performance at 92.8%, up from 90.8%. February saw ahigh number of flu admissions constraining flow through the hospital.
There was an extended Business Continuity Incident in the month, due to ongoingcapacity issues.
Work is underway to clarify pathways and improve compliance with the 30 minutetarget for Internal Professional Standards (review of A&E patients by specialty teams).Streaming of patients is occurring much earlier in the patient pathway althoughactivity is limited when assessment areas are used for bedded patients at times ofpeak pressure.
Focus continues on ensuring full use of the Emergency Surgical Assessment Unit(ESAU), Medical Assessment Area (MAU), Ambulatory Care (ACU) and Frailty,although at times of increased pressure and capacity issues these are used as beddedareas which significantly limits streaming opportunities. ACU has been re-located tocontinue to provide this service.
The ambulance response times project has continued to impact positively on handover times with regular meetings with EEAST and new ways of working have beenimplemented. Work is on-going to ensure a consistent approach to the STARRprocess. The Directorate continues to try and provide Trust paramedics to supportimproved off load times.
An activity comparison of the current financial period with the same period last year has shown:• Type 1 attendances are up by 1.2%.• Ambulance arrivals are down by 4.7%.• Admission rate from A&E (excluding ambulatory and frailty) is unchanged.• Discharges (Trust wide) are up by 3.7%
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Delayed Transfers of CareDToC patients represented 4.1% of occupied beds in February, a slightdecrease from 4.3% in January, measured using the nationally reportedmethod. This is based on a snapshot of the number of patients waiting at apoint in time in the month, expressed as a percentage of beds.
The total beds occupied by DToC patients is a helpful measure to illustratethe impact of DToC because it includes all patients waiting in the month. InJanuary DToC patients consumed 1045 bed days, the equivalent of 37.3 beds.
There are regular audits of both DToC and other stranded patients (over 7day length of stay) to identify issues and remove avoidable causes of delay.
Ongoing escalation to system partners via the A&E Delivery Board continues,with significant resource directed to generating additional capacity andimproving discharge processes.
Streamlined processes for data monitoring and reporting have beenintroduced, as well as daily “live” patient monitoring with board briefingswith the discharge planning nurses. Lead roles have been developed inrelation to self-funded patients, and continuing healthcare (CHC)assessments, and a number of staff have been re-allocated to different areasto tackle issues relating to a build up of referrals.
12 hour
trolley waits
Delayed
Transfers of
Care (DToC)
0
10
20
30
40
50
60
0%
2%
4%
6%
8%
10%
Ap
r
Ma
y
Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
2015/16 2016/17 2017/18
Beds used by DToC patients in month DToCs DToC target
Apr
May
Jun
JulAug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
JulAug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
JulAug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
2015/16 2016/17 2017/18
Performance 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Target 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0
1
2
Performance Target
0
10
20
30
40
50
60
Nu
mb
er
of
be
ds
May-16
Jun-16
Jul-16
Aug-16
Sep-16
Oct-16
Nov-16
Dec-16
Jan-17
Feb-17
Mar-17
Apr-17
May-17
Jun-17
Jul-17
Aug-17
Sep-17
Oct-17
Nov-17
Dec-17
Jan-18
Feb-18
Total number of beds used by DToC patients 41.2 32.7 31.8 43.2 45.0 41.3 35.1 35.2 42.7 47.3 52.8 51.6 47.9 47.6 44.0 37.5 38.3 35.3 32.9 23.7 27.9 37.3
NHS Days 12 21 25 31 24 29 23 23 17 20 25 26 25 21 19 21 24 25 24 19 20 26
DHSS Days 18 15 11 18 19 16 12 16 21 23 28 27 28 27 18 20 21 19 16 12 16 24
Days (BOTH) - - - - - 0 2 0 1 - 0 0 1 0 - 0 0 0 - - 0 0
Beds used by DTOC patients: DHSS vs NHS
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Well led
Reporting sub committee - PSE
Executive lead Clinical lead Operational lead
Paul da Gama
Sickness rate
Staff turnover
and vacancy
rate
% bank,
agency and
temporary
pay
Workforce indicators - staff turnover, sickness, bank & agency,
vacancy, appraisal, and mandatory training
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
2015/16 2016/17 2017/18
Staff turnover Performance Staff turnover Trajectory Staff turnover target
Vacancy rate Performance Vacancy rate Trajectory Vacancy rate Target
0%
5%
10%
15%
20%
25%
30%
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
2015/16 2016/17 2017/18
% Bank Pay performance % Bank Pay Trajectory % Agency Pay performance
% Agency Pay Trajectory Temporary costs performance Temporary costs Trajectory
2.0%
2.5%
3.0%
3.5%
4.0%
4.5%
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
2015/16 2016/17 2017/18
Sickness rate performance Sickness rate target Sickness rate Trajectory
Mean Upper control limit (3 sd) Lower control limit (3 sd)
Jan sickness hard
32
Turnover and VacanciesThe overall vacancy rate showed a decrease to 10.3% in February (from 11.7% inDecember). Whole time equivalent (wte) staff in post increased by 30wte overFebruary, to 4331wte, while the establishment remained constant. The vacancy ratefor qualified Nursing & Midwifery posts decreased in February, from 14.5% to13.9%. For Band 5 Nurses, the rate reduced from 17.7% to 16.3%. However, this rateincludes nurses who are awaiting their PIN numbers, once these staff are taken out ofthe staffing numbers, the rate is 27%. Recruitment activity has continued to build up alarge pipeline of new N&M. There are approximately 160 ‘pipeline’ overseas nurses,of which 31 are due to start by mid April. A further overseas recruitment trip is set forIndia in May. WHHT is working with NHSI to reduce the turnover rate within Band 5nursing, and rates have reduced over the last 5 months, from over 27% to 22.9%currently. The 12-month rolling turnover rate for registered nurses and midwives is17.1% which has decreased from 17.5% last month. The overall Trust turnover rate is16.3%, an decrease from last month (16.9%). WHHT has the eighth highest turnover(of 11 organisations) compared to Herts & Beds peers and is above the regionalaverage of 15.9%, although this is largely due to band 5 nurse turnover. Over the last2 years, turnover has shown a modest downward trend, although Band 5 nursing asnoted above, is relatively high.
% Bank and Agency ExpenditureAgency spend in February decreased to £1.15m (£1.27m in Jan). This spendrepresented 5.9% of the overall pay-bill (target 8%). Agency spend has reducedconsiderably over the last couple of years, with spend in 2016/17 being £10m lessthan 2015/16. Renewed work continues to reduce agency costs via the AgencySteering Group, and through partnership working across Herts & Beds, with theshared staff bank being the latest initiative. Work is also being undertaken withLondon NHS organisations to help benchmark agency rates. YTD spend of £15.8m isabove the trajectory required to meet annual targets, with a M11 projected totalagency expenditure of £18.4m compared to a required total (set by the Trust) of£17.0m. This compares favourably though to the cap set by NHSI in2017/18 ofc£24m. Bank spend as a percentage of payroll is currently 10.6%.
Sickness rateThe sickness absence rate remains low at 3.32%, and is in line with the Trust target of 3.5%. The Trust is currently well below the Herts & Beds average of 4.3% at the end of Quarter 3. Over the last 2 years, sickness absence has fluctuated between 3.8% and 2.8%. Average sickness absence in 2015/16 was 3.4%, whereas in 2016/17 it was fractionally lower at 3.2%. It has averaged just over 3.1% in the current year to date.
Performance relative to targets/ thresholds
Feb-18 3 4
Jan-18 3 4
Dec-17 2 5
Achieving Not achieving
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Number of
staff leaving
within first
year (excluding
medics and fixed term
contracts)
Mandatory
training
Appraisal rate (non medical staff only)
60%
65%
70%
75%
80%
85%
90%
95%
100%
Apr
May Jun
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar
Apr
May Jun
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar
Apr
May Jun
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar
2015/16 2016/17 2017/18
Essential training Mandatory Training Performance Mandatory Training Target
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Apr
May Jun
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar
Apr
May Jun
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar
Apr
May Jun
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar
2015/16 2016/17 2017/18
Appraisal rate Performance Appraisal rate Target Appraisal rate Trajectory
Mean Upper control limit (3 sd) Lower control limit (3 sd)
0%
5%
10%
15%
20%
25%
0
50
100
150
200
250
Apr
May Jun
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar
Apr
May Jun
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar
Apr
May Jun
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar
2015/16 2016/17 2017/18
Number of staff % of new staff
33
Appraisal – non medical staffFebruary’s rate, at 80%, is below the 90% compliance rate for the fourth monthrunning. There continues to be a significant challenge in maintaining focus andensuring appraisal dates are aligned to staff increments, particularly given the activitydemands on staff over the Winter period. HRBPs continue their work with Divisionsto develop trajectories and monitor and achieve compliance consistently above the90% target. The next month has significant numbers of staff requiring anappraisal,(167) and so it is important that these are taken account of in plans over thenext month HR Business Partners are also working with managers, producing bi-weekly reports to support the transition to effective alignment of appraisals toincrements and to plan the completion of all outstanding appraisals. Currently 34% ofstaff incremental dates are aligned to appraisal dates
Mandatory training Mandatory training compliance is currently at 86%, the same as last month. TEC havebeen provided with an overview of issues related to the reporting of mandatorytraining data and the impact on the compliance figures. A working group has been setup to manage this work and has started to put in place actions that address theallocation of core training needs to job roles recorded in ESR and address complianceof new starter overseas Nurses, Junior doctors on rotation and Consultants. The newHead of Education, Learning and Development has taken over this group and anupdate on progress will be given shortly. The working group is reviewing options toaddress the above issues.
Number of staff leaving within first yearThe overall rate was 19.8% in February, an decrease compared to last month. A year ago the figure was 18.7%.
The Trust is closely monitoring staff leaver information via the web-based exit leaversystem, particularly regarding reasons for leaving. The latest summary (Q3) has justbeen reported onto the Divisions as part of their workforce reports. The key reasonfor leaving remained unchanged, being career related and personal growth. Thereconnect sessions following corporate induction continue, bringing new startersback together and offering an opportunity to resolve any issues and gatherinformation to further improve staff experience in the first year in post. Otherinitiatives include a flexible pool, rotation schemes and using retention conversationsto help reduce staff leaving for career reasons unnecessarily. Also commencing is akey piece of work called ‘Careers Matters’, a best in class careers advisory service.Key work is also under way to support retention of Band 5 nurses, where there is thehighest turnover, although as stated this has fallen over the last 6 months. Fromaround 29% to around 23% currently. This also forms a part of the Nursing retentionproject with NHSI, where Band 5 nursing leavers have been identified as a keyworkforce to seek to improve engagement with and reduce turnover.
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The Board Assurance Framework shows key workforce indicators in the context of current performance, performance 12 months and 3 months ago, Trust workforce targets, the distance to these targets and a RAG rating based on 5 scales. It also has benchmarking data taken from NHS healthcare providers in the Hertfordshire and West Essex and Bedford, Luton and Milton Keynes STPs.
The RAG rating is based on distance to targets – if current performance is within 0% to20% (or exceeds) its target then the RAG rating is green. If performance is within 60% –80% of target then the rating is yellow. This is repeated at 20% intervals for amber andbrown until performance is over 80% from the target when the RAG rating is red. If 2indicators are rated red, then the overall rating is red. If all indicators are rated green,or one is amber then the overall rating is green. Any other combination is amber.
The performance indicators were changed for November to reflect more relevant anddetailed areas of the workforce. The new indicators include Band 5 Nurse Vacancy, andBand 5 Nurse Turnover, reflecting the focus on recruitment and retention inconjunction with NHSI. Nursing Band 5 vacancy and turnover areas are identified as theTrusts highest workforce risk factors. WHHT is working with NHSI to reduce theturnover rate within Band 5 nursing, and rates have reduced over the last 5 months,from over 27% to 22.9% currently. For vacancies, the vacancy rate for qualified Nursing& Midwifery posts decreased in February, from 14.5% to 13.9%. For Band 5 Nurses, therate reduced from 17.7% to 16.3%. However, it should be noted that this rate includesnurses who are awaiting their PIN numbers, once these staff are taken out of thestaffing numbers, the rate is 27%.
Appraisals are below target at 80% and mandatory training compliance is 86%. Theconfidence for data accuracy for training compliance is rated amber, work is ongoing toensure complete accuracy.
The Trust has achieved its target of a sickness rate less than 3.5% (3.32%)
The current agency pay bill percentage is 5.9%, below the 8% target.
The 12 month turnover rate is 16.3%, which has increased slightly compared to 3months ago, but is slightly lower than one year ago. It is also above the benchmarkaverage.
The latest Q2 FFT score shows a slight increase compared to Q1, and the current scoreis within 20% of the target.
Benchmark averages are taken from Q3 17/18 data and are from 11 nearby NHSorganisations.
Trust targets reflect benchmarking of targets of other comparable acute Trusts,including those rated as ‘outstanding’ by the CQC. Appraisal and Core Trainingcompliance targets are now 90% rather than 95% previously. Agency costs as a % of paybill has changed from 10% to 8% as this reflects the Trust’s NHSI agency target
Workforce BAF scorecard
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Executive lead Clinical lead Operational lead
Well ledTracey Carter and Paul
Da Gama
Reporting sub committees - PSQ and PSE
Staff scores (%
reccommended
and not
recommended)
and response
rate
A&E scores (%
positive and
negative) and
response rate
Safe, effective,
caring
Friends and family
Inpatient scores
(% positive and
negative) and
response rate 0%
20%
40%
60%
80%
100%
120%
Ap
r
May Jun
Jul
Au
g
Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Ap
r
May Jun
Jul
Au
g
Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Ap
r
May Jun
Jul
Au
g
Sep
Oct
Nov
Dec Ja
n
Feb
Mar
2015/16 2016/17 2017/18
Inpatient Scores FFT % positive performance Inpatient FFT response rate Inpatient FFT response rate Target
0%
20%
40%
60%
80%
100%
120%
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
Ma
y
Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
2015/16 2016/17 2017/18
A&E FFT response rate performance A&E FFT % positive Performance A&E FFT response rate Target
0%
10%
20%
30%
40%
50%
60%
70%
Mar
Apr
Ma
y
Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
May Jun
Jul
Au
g
Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
Ma
y
Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
2015/16 2016/17 2017/18
Staff FFT % recommended work Performance Staff FFT response rate Performance
Staff FFT response rate target
Positive performance targets to follow
35
Inpatients
There has been a noticeable improvement in the response rate and in those notrecommending the Trust, with a more modest increase in the recommended rate.
A&EResults have improved again this month, in all aspects, with a higher response rate andnumber of patients recommending the Trust and a reduction in the number notrecommending the service.
Staff Staff Friends and Family test for Q4 ran between 26 February – 5th March 2018.
Over 650 questionnaires were completed and results are to be reviewed at the beginningof May. These will be looked at in relation to both previous friends and family results andthe recent staff survey results.
In the meantime consideration is being given to using staff friends and familyquestionnaires as part of the ward accreditation process and in an attempt to align staffand patient experience.
Well led
Feb-18 0 3
Jan-18 0 3
Dec-17 0 3
Achieving Not achieving
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dupe
Daycases scores
(% positive and
negative) and
response rate
Maternity (Q2)
scores (%
positive and
negative) and
response rate
Outpatient
scores (%
positive and
negative) and
response rate
0%
20%
40%
60%
80%
100%
120%
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
2015/16 2016/17 2017/18
Daycase FFT % positive Performance Daycases FFT response rate Performance
0%
20%
40%
60%
80%
100%
120%
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
Ma
y
Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
Ma
y
Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
2015/16 2016/17 2017/18
Outpatient FFT % positive Performance Outpatient FFT response rate Performance
0%
20%
40%
60%
80%
100%
120%
Apr
May Jun
Jul
Au
g
Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
May Jun
Jul
Au
g
Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
May Jun
Jul
Au
g
Sep
Oct
Nov
Dec Ja
n
Feb
Mar
2015/16 2016/17 2017/18
Maternity FFT % positive Performance Maternity FFT response rate Performance
DaycaseThe Trust is now measuring both the main DSU at SACH and also the Surgicaladmission lounge at WGH.
OutpatientsThere has been a further increase in responses and the recommended rate and nochange in those not recommending the Trust.
Maternity Question 2There has been a significant improvement in response rates with correspondingimprovement in the recommended rate and reduction in number of those whowould not recommend.
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Safer staffingIndicator Performance (February) Threshold Trend Forecast next month
% Nursing hours versus planned 91.0% >95% Up >95%
Care hours per patient day 7.7 n/a Stable 7.2
Indicator by shift and skill mix Shift RN Care staff
% Nursing hours versus planned Day 78.3% 112.9%
Night 85.8% 103.2%
Care hours per patient day All 4.6 3.2
What actions have been taken to improve performance
Enhanced care needs team commenced 13 May 2017 – recruiting to theteam continues, continued use of temporary staff at night to support the team.
Local and international recruitment initiatives continue. Trust Recruitment Group formed
Shared bank approach across four Trusts commenced 31st July. Project plan to address the retention rate of band 5s External Visit requested by Chief Nurse looking at Safe Staffing now
rescheduled for April 2018. Safe Care has now been Implemented in Adult and Paediatric inpatient
wards
What is causing the variance
Overall the Trust % fill rate for February was 91%, an increase of 0.4% from last month and below the national threshold of 95%. The fill rate within Medicine was 95.4%, an increase of 3.5%from last month. In Surgery the fill rate was 82.8%, a decrease of 8.2% from last month. Overall the fill rate in WACS was 92.5%, an increase of 6.2% from last month. On further analysismaternity fill rates were 96.7%, an increase of 1.3% from last month and paediatrics fill rate was 84.7%, an increase of 12.9% from last month. The low fill rates in paediatrics are mainlynursery nurse shifts day and night due to recruitment and retention. This is currently being reviewed by the Head of Nursing as part of the establishment review, covering skill mix and roleredesign. The number of shifts rag rated green were 44.6%, a decrease of 22.9 % from last month. 53.6% of shifts were rated amber, a decrease of 22% from last month. 35 shifts were ragrated red, a decrease of 0.9% from last month. A total of 4 red flagged shifts of less than 2 registered nurses were recorded. No harm to patients was reported and mitigations were put inplace, e.g. moving staff to the areas, supervisory band 7s working, specialist and corporate nursing education supporting staffing in order to maintain patient care and safety, and datix formswere completed. A total of 184 shifts (30.5%) were red flagged for registered nurses more than 8 hours less than planned. A number of areas have fill rates below 80% - Flaunden and Oxhey.From 12 February onwards, the Trust was in Business continuity having surged in to a number of areas in the organisation such as - MAU, COB, ESAU, Ambulatory Care, Cath Lab, New CDU, OldCDU, Castle. Oxhey, Tudor and Elizabeth had additional patient beds opened. Patients were cared for in these areas through redeployment of substantive staff and temporary staff from NHSP(bank and agency). A Total of 77, 556 hours requested via NHSP with overall fill rate of 84.4% (41.9% NHSP and 42.5% agency). Enhanced care needs continue to be provided by the Trustenhanced care team and bank/agency. Overall Trust Supervisory Hours lost in October was 33.9%. Safe care has now been implemented in all the adult and paediatric inpatient areas andpatient acuity and staffing is now reported daily . Care Hours per patient day continue to be reported monthly as part of UNIFY.
96.2%
96.9%
97.6%97.3%
94.3%
95.2%95.0%
93.0%
90.9%
92.2%
90.9%90.6%
91.0%
5.0
5.5
6.0
6.5
7.0
7.5
8.0
8.5
9.0
90%
91%
92%
93%
94%
95%
96%
97%
98%
Car
e H
ou
rs P
er
Pat
ien
t D
ay
Pe
rce
nta
ge o
vera
ll p
lan
ne
d v
s. a
ctu
al n
urs
ing
ho
urs
Percentage overall planned vs. actual nursing hours & CHPPD
Care Hours Per Patient Day (CHPPD) % Fill Rate Threshold - fill rate
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38
End of Life CareNumber of patients who are referred to the palliative care team and who have an identified preferred place of death
In 2008 the End of Life Care Strategy (Department of Health) was published and one ofthe insights from this was that people weren’t supported to die in their place of choice;and although progress has been made, this has been evidenced in many other reports.In July 2014 just over 50% of respondents to the National Survey of Bereaved People(VOICES-SF) felt that their relative had died in a place of their choice (Office of NationalStatistics, 2014).There is now a national focus on reducing the numbers of patientsdying in hospital and offering everyone who is approaching the end of their life theopportunity to express and share their preference for where they want to die as wellas any goals that are important to them (National Palliative and End of Life CarePartnership, 2015).
In February, 94 referrals were made to the Trust Specialist Palliative Care Team. Of the 94 patients referred, 55 did not have capacity to make decisions about Advance Care Planning (ACP), seven referrals were inappropriate/discharged back to the ward before ACP completed and for seven patients the ACP was not appropriate to be discussed.Therefore of the 25 patients appropriate for ACP all 25 had an identified PPD.
There were four patients who died in hospital although home was their preferredplace of death. This was due to a delay in C/C Process (Funding) for one patient and anunexpended deterioration for the other three patients.
Q1
2015/
16
(avg
per
mont
h)
Q2
2015/
16
(avg
per
mont
h)
Q3
2015/
16
(avg
per
mont
h)
Q4
2015/
16
(avg
per
mont
h)
Q1
2016/
17
(avg
per
mont
h)
Q2
2016/
17
(avg
per
mont
h)
Q3
2016/
17
(avg
per
mont
h)
Jan-
17
Feb-
17
Mar-
17
Apr-
17
May-
17
Jun-
17Jul-17
Aug-
17
Sep-
17
Oct-
17
Nov-
17
Dec-
17
Jan-
18
Total referrals 63 59 67 71 75 69 78 98 111 120 103 96 108 84 72 90 120 112 93 94
-
20
40
60
80
100
120
140
Nu
mb
er
of
refe
rral
s p
er
qu
arte
r
Referrals to Trust Specialist Palliative Care Team
Q1 201
5/16
(avg
per mo
nth)
Q2 201
5/16
(avg
per mo
nth)
Q3 201
5/16
(avg
per mo
nth)
Q4 201
5/16
(avg
per mo
nth)
Q1 201
6/17
(avg
per mo
nth)
Q2 201
6/17
(avg
per mo
nth)
Q3 201
6/17
(avg
per mo
nth)
Jan-17
Feb-17
Mar-17
Apr-17
May-17
Jun-17
Jul-17
Aug-17
Sep-17
Oct-17
Nov-17
Dec-17
Jan-18
Nursing Home 0 3 5 6 5 6 2 3 11 9 6 6 5 4 5 2 5 4 5 8
Hospital 0 3 4 6 10 5 9 19 20 17 6 16 3 6 10 8 6 10 3 1
Hospice 0 11 15 12 10 13 1 15 7 8 12 10 10 9 8 6 16 14 23 14
Home 28 10 12 15 18 13 6 13 15 11 6 10 17 10 13 9 16 10 6 15
Impaired capacity to state a preference 12 14 13 22 17 12 23 35 28 27 23 29 29 23 21 20 26 18 47 42
% with identified preference 54.6% 58.8% 66.9% 82.0% 79.6% 73.0% 69.5% 94.3% 65.1% 51.1% 81.6% 100.0 79.5% 52% 71% 82% 88% 77% 100% 100%
0
10
20
30
40
50
60
70
80
90
0%
20%
40%
60%
80%
100%
120%
Nu
mb
er
of
refe
rral
s b
y id
en
tifi
ed
pre
fere
nce
Pe
rce
nta
ge o
f re
ferr
als
Number and percentage of referras with identified preference for preferred place of death, excluding patients unable to state preference, inappropriate referrals or deaths prior to being seen or transferred
back to other HCP’s
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Trust data quality, by exceptionData Quality RAG keyRed – Data accuracy is not known, it is incomplete and inconsistent
Amber – Data is assumed to be complete and accurate, although there may be limitations or unresolved queries
Green – Data is complete, accurate and consistent with the standards set for the specific indicator
39
Domain a Indicator a
Data
Quality
RAG
a Description of issues Improvement action plan Target date for 'Green' rating
Safe, Effective, CaringDischarges between 8am and 12pm*
(main adult wards excl AAU) A
Safe, Effective, Caring% Complaints responded to within one month or agreed
timescales with complainant
R
Operational and clinical pressures has meant it has been
challenging to find the time for clinical and operational staff to
respond to concerns on time.
The Unscheduled Care Division are recruiting a 0.5 WTE
position to assist clearing the backlog.
The team are recruiting a new complaints manager and have
approach NHSP and agencies to fill the vacancy.
The Surgery Division has held a complaints workshop to
address backlog. The same will be done in Unscheduled Care.
The Women and Children’s Division are recruiting a post to
deal with complaints. The Environment and Medicines Division
have improved their response times considerably.
Recruitment expected to be completed by end of Summer.
Improvements are hoped to be seen by end of 2017.
Safe, Effective, Caring Complaints - rate per 10,000 bed days
R Capturing complaints across the Trust.
All complaints are captured and triaged daily. All complaints
are logged daily and there are systems in place to capture all
complaints received through the CEO, executive assistants,
through NHS net and on social media. Reminders are sent to all
staff about forwarding complaints received in clinical areas.
There is a system for auditing all new complaints taken through
triage on the following day. This risk is being minimised as much as possible.
Safe, Effective, Caring Reactivated complaints
R Increase in reactivated complaints
We telephone every reactivated complaint to talk through
concerns. We consider if someone independent needs to
investigate. We send reactivated complaints to external
investigators in complex cases. We invite complainants to
meetings to discuss their concerns.
We now record the reason for reactivated complaints and will
audit this. We have asked Healthwath Hertfordshire to review
a pool of complaints and provide feedback. We will ask that
they include a small pool of reactivated complaints also. This risk is being minimised as much as possible.
Safe, Effective, Caring Hospital Acquired Pressure Ulcers - Grade 3A
Safe, Effective, Caring Number of Falls*A
Safe, Effective, Caring VTE risk assessment*A
Paper based VTE forms used for assessing compliance by clinical
coding team. Evidence elsewhere within notes demonstrating
compliance not on form not previously identified.
Clinical Advisory Group has approved new process for coding
team to assess VTE compliance. Electronic system required to
improve compliance to green.
July 2017 (Amber). Electronic system date of implementation TBC
(for Green)
Safe, Effective, Caring Caesarean Section rate - Combined*A
Perception that there is a difference between caesarean section
rate on CMiS compared to what has been clinically coded
Review of clinically coded notes and comparison to CMiS to
review discrepancies July 2017
Safe, Effective, Caring Caesarean Section rate - Emergency*A As above As above As above
Safe, Effective, Caring Caesarean Section rate - Elective*A As above As above As above
Safe, Effective, Caring Stroke patients spending 90% of their time on stroke unit *A
Responsive Ambulance turnaround time between 30 and 60 minsR Identified inaccuracies in timing of Ambulance Service data Ongoing work with ambulance service TBA
Responsive Ambulance turnaround time > 60 minsR As above Ongoing work with ambulance service TBA
Well Led Sickness rate
A
1. Potential for under reporting
2. There can be issues with data recorded on ESR but this will be
fixed with the implementation of the new ESR 2 system.
1. HR undertook a number of audits to look into areas who were
reporting 0% sickness throughout 2016 and have implemented
learning from those audits, including a new process for
capturing absences if medical staff.
2. implementation of the new ESR 2 system.
September 2017 (linked to the ESR implementation). There will
also be ongoing audits to ensure that absence data is still being
accurately recorded
Well Led Mandatory TrainingA
1. Potential for reporting inconsistencies on ESR in certain staff
groups A project group has been set up to investigate and correct
reporting issues Feb-18
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Trust Board Meeting 12 April 2018
Title of the paper Strategy update
Agenda item 10/58
Lead Executive Helen Brown, Deputy Chief Executive
Author Helen Brown, Deputy Chief Executive
Executive summary (including resource implications)
This report provides an update on the current position in relation to a range of longer-term service changes and strategic developments. It will briefly outlines progress regarding the following:
1. Your Care Your Future ~ integrated care and pathway re-design. 2. Stroke 3. Vascular 4. Strategic Outline Case for the Redevelopment of Acute Hospital Services 5. Hemel Hempstead Strategic Outline Case 6. Car Parking Strategic Outline Case 7. Royal Free London Group / WHHT partnership 8. Pathology
Where the report has been previously discussed, i.e. Committee/Group
Updates on specific issues have been provided to the trust executive committee and other relevant forums.
Action required:
The Board is asked to receive the report for information and assurance.
Link to Board Assurance Framework (BAF)
PR1 Failure to provide safe, effective, high quality care
PR2 Failure to recruit to full establishments, retain and engage workforce
PR3 Current estate and infrastructure compromises the ability to deliver safe, responsive and efficient patient care
PR4a
Underdeveloped informatics infrastructure compromises ability to deliver safe, responsive and efficient patient care – IM&T
PR4b
Underdeveloped informatics infrastructure compromises ability to deliver safe, responsive and efficient patient care – Information and information governance
PR5a
Inability to deliver and maintain performance standards for Emergency Care
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PR5b
Inability to delivery and maintain performance standards for Planned Care(including RTT, diagnostics and cancer)
PR7a
Failure to achieve financial targets, maintain financial control and realise and sustain benefits from CIP and Efficiency programmes
PR7b
Failure to secure sufficient capital, delaying needed improvements in the patient environment, securing a healthy and safe infrastructure
PR8 Failure to engage effectively with our patients, their families, local residents and partner organisations compromises the organisation’s strategic position and reputation.
PR9 Failure to deliver a long term strategy for the delivery of high quality, sustainable care
PR10
System pressures adversely impact on the delivery of the Trust's aims and objectives PR6 – business continuity has been closed (incorporated into PR1)
Trust objectives To deliver the best quality care for our patients
To be a great place to work and learn
To improve our finances
To develop a strategy for the future
Benefits to patients/staff from this project/initiatives
Continuous improvement in care pathways.
Improved physical environment from which care is provided.
Risks attached to this project/initiatives and how these will be managed
Financial risks relating to pathway redesign: detailed mapping is being undertaken and a standard methodology developed.
Limited funding availability to support the development costs of major capital business projects: progress will be limited until funding sources are confirmed and so, where possible, internal resource is being deployed to support these programmes.
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Agenda item: 10/58
Trust Board Meeting – 12 April 2018 Strategy Update Presented by: Helen Brown, Deputy Chief Executive
1. Purpose
1.1 This report provides an update on the current position in relation to a range of longer-term service changes and strategic developments.
2. Your Care Your Future ~ integrated care and pathway re-design
2.1 The Trust continues to work with partners on the redesign of a range of planned and unplanned care pathways.
2.2 Over the past 2 months the primary focus has been on working with HVCCG to agree the activity impact of pathway changes planned for 2018/19 as part of the negotiation of the 2018/19 contract (Quality, Innovation, Prevention and Productivity (QIPP) elements). A brief summary for each pathway is attached as appendix one for information.
2.3 This years QIPP has focused on three key areas
Review of local prices, including a locally agreed ambulatory care unit tariff.
Pathway redesign and /or transfer of commissioning (either through multi provider partnerships or open market tendering)
Volume reductions through a combination of GP demand management schemes, application of low priority treatments and agreement of first to follow up ratios
Application of six key questions to each scheme along with defined activity schedules and associated finances has enabled 15 of schemes to be agreed with a commitment to a plan to agree further schemes in year as contract variations
2.4 There are three active procurements in process for development of community services - dietetics, ophthalmology and ENT. All procurements will see a reduction in WHHT outpatient commissioned activity through PbR. Bid/no bid decisions require rapid turnaround as a result of tight procurement timetables set by HVCCG (tender process launched 26th March 2018 with a submission deadline of bids by the 4th May 2018). The dietetics procurement has a relatively limited impact for the Trust. There a more significant
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implications for ENT & Ophthalmology services. The surgical division is preparing a briefing paper to TEC on the 11th April to support bid / no bid recommendation - a verbal update will be provided to part 2 of the Board on the 12th April.
2.5 The new community gynaecology service went live as planned on 03/04/18. WHHT, RFH and Luton and Dunstable clinicians are working through a sub contract arrangement with the Hertfordshire Community Gynaecology service led by Dr Kedia.
3. Stroke
3.1 Work has continued with HVCCG with a view to WHHT taking the overall co-ordinating lead across a WHHT and HCT provider partnership for the delivery of an integrated stroke pathway.
3.2 The focus over the past month has been to confirm the level of funding associated specifically with stroke care, to inform negotiations regarding future affordability and service development options.
4. Vascular
4.1 Work continues with E&NH Trust to develop the operating model and implementation plan for the vascular hub, with the current focus being to consider clinical pathways for complex vascular patients requiring care at the hub site and also the associated care pathways f
4.2 or spoke sites.
4.3 Internally, a paper has been reviewed by the Clinical Advisory Group regarding the implications for vascular services and for other clinical specialties. A more detailed update will be provided to the Trust Board once the work is further progressed.
5. Your Care, Your Future - strategic outline case (SOC) for the redevelopment of acute hospital services
5.1 The main acute transformation / redevelopment SOC continues to be reviewed by NHS Improvement following the standard business case review process. Given the scale of investment required Department of Health review and approval will also be required.
5.2 A meeting is scheduled with NHS Improvement for 1st May 2018, at their request, to discuss the strategic outline case and gain their feedback as to the approach proposed. A verbal update will be provided to Board members on the outcome of this discussion at the May 2018 Board meeting.
5.3 Meanwhile, the strategy team have also further developed interim plans, following a successful bid for additional capital funding via the Independent Trust Financing Facility. A paper has also been submitted to the Clinical Advisory Group to confirm principles for investment during 2018-19 with external support currently being sought to help expedite business case development to ensure the programme can be taken forward in a timely way.
5.4 Finally, a clinical engagement event was convened at the start of the month, to which all clinical leads were invited and at which experience from the new hospital development at Chase Farm was shared, along with discussion regarding the development of future clinical pathways.
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6. Hemel Hempstead strategic outline case (SOC)
6.1 As previously reported joint work is underway with HVCCG, WHHT clinical teams and other partners to develop in more detail the proposed clinical model for Hemel Hempstead & Dacorum.
6.2 The target timeline for the SOC completion has slipped by approximately 6 weeks. It is anticipated that the SOC will be finalised for review by FIC in June or July 2018, followed by Trust Board review in July or September.
7. Car Parking Strategic Outline Case
7.1 Formal confirmation of NHS I approval of the Car Parking Strategic Outline case was received in February. The approval letter set out expectations of issues to be covered within the outline business case. The letter has been shared with Watford Borough Council and the team continue to meet with the LABV to progress the detailed work required for OBC.
7.2 The business case recognises the significant improvement in car parking facilities that will be available to staff and patients, but seeks to ensure any price changes are reasonable.
7.3 Subject to all issues being resolved satisfactorily with the LABV the OBC will be presented to the FIC in April 2018, followed by Trust Board review in May 2018.
8. Pathology 8.1 The pathology SOC approved by the Board in November has been submitted to NHS I for
review and approval. Responses to a series of clarification questions have also been submitted. Work on the outline business case has commenced at risk.
8.2 The key issues for the development of the OBC will be recommending an option for service delivery that is capable of matching all likely options for future acute service redevelopment. The OBC will also consider in more detail the types of collaboration that might best suit the Trusts model of care, should collaboration become a likely option.
9. Royal Free London (RFL) partnership
9.1 A joint Board development session was held with the RFL on the 14th March 2018. A progress update on the overall development of the group model was provided by Dominic Dodd, RFL group chairman and Board members received updates on progress with the current workplan. The future development of our partnership was discussed and agreement in principle was made that WHHT would become a formal clinical partner to the RFL group during 2018/19, subject to a further dialogue with staff on the implications and expected benefits.
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9.2 It was noted that clinical partners retain a fully autonomous board and leadership team and that this is not a step on the road to a full merger or acquisition. The Group model is based on NHS organisations collaborating to deliver improvements in the quality and sustainability of local services. At the heart of the group model is a shared commitment to reducing unwarranted clinical variation through the development and implementation of best practice clinical pathways across the group. There are also significant opportunities for WHHT to accelerate its digital transformation programme through working with the RFL Global Digital Exemplar.
Helen Brown Deputy Chief Executive April 2018
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Trust Board Meeting 12 April 2018
Title of the paper
Corporate aims and objectives 2018 - 2020
Agenda Item 11/58
Lead Executive
Helen Brown, Deputy Chief Executive
Author(s)
Helen Brown, Deputy Chief Executive
Executive Summary
Following a board seminar discussion in February 2018 and review by the trust executive committee in March 2018, the board is asked to consider the attached draft aims and objectives for 2018 – 2020. Jane Shentall, Director of Performance, will review the reporting arrangements to ensure that the objectives are reflected in the integrated performance report and a progress tracking mechanisms is established. The board assurance framework is currently being re-developed and will reflect the primary risks to delivery of the objectives. The BAF will be presented to the board in June 2018.
Where the report has been previously discussed, i.e. Committee/ group
Board development session – February 2018 Trust executive committee – March 2018
Action required:
The Board is asked to approve the 2018-2020 aims and objectives
Links to the board assurance framework
[Please indicate which Principal Risk this paper relates to by double clicking on the corresponding box]
PR1 Failure to provide safe, effective, high quality care
PR2 Failure to recruit to full establishments, retain and engage workforce
PR3 Current estate and infrastructure compromises the ability to deliver safe, responsive and efficient patient care
PR4a Underdeveloped informatics infrastructure compromises ability to deliver safe, responsive and efficient patient care – IM&T
PR4b Underdeveloped informatics infrastructure compromises ability to deliver safe, responsive and efficient patient care – Information and information governance
11
Tab 11 2018/19 corporate aims and objectives
1 of 114Trust Board Meeting in Public-12/04/18
PR5a Inability to deliver and maintain performance standards for Emergency Care
PR5b Inability to delivery and maintain performance standards for Planned Care(including RTT, diagnostics and cancer)
PR7a Failure to achieve financial targets, maintain financial control and realise and sustain benefits from CIP and Efficiency programmes
PR7b Failure to secure sufficient capital, delaying needed improvements in the patient environment, securing a healthy and safe infrastructure
PR8 Failure to engage effectively with our patients, their families, local residents and partner organisations compromises the organisation’s strategic position and reputation.
PR9 Failure to deliver a long term strategy for the delivery of high quality, sustainable care
PR10 System pressures adversely impact on the delivery of the Trust's aims and objectives PR6 – business continuity has been closed (incorporated into PR1)
Trust objectives
[Double click on the box to mark as appropriate]
To deliver the best quality care for our patients
To be a great place to work and learn
To improve our finances
To develop a strategy for the future
11
Tab 11 2018/19 corporate aims and objectives
2 of 114 Trust Board Meeting in Public-12/04/18
OBJECTIVE Detailed objectiveLINKED STRATEGIES &
ACTION PLANS
Metrics / monitoring
mechanismBOARD ASSURANCE
Lead
Executives
1.1 To sustain expected or better than expected
performance on key mortality indicators (SHMI and
HSMR)
Learning from deaths action
planSHMI & HSMR CoEC MvDW
1.2. Top quartile performance for harm free care by
2020Quality Account
Nationally specified harm free
care metrics CoEC MvDW / TC
2.1 Working with the RFL group, implement a
minimum of 8 standardised ‘ in hospital’ pathways per
year, with demonstrable improvement in consistency of
care and improved outcomes.
Royal Free Partnership
Work Plan
Pathway specific metrics to be
agreed on a pathway by
pathway basis
MvDW
2.2 To work with partners to redesign ‘end to end’ care
pathways, integrate care and reduce unnecessary visits
to hospital for our patients. (Full programme to be
agreed with the CCG via the QIPP Board)
Joint QIPP work plan HB
2.3 To develop patient centred planned and
ambulatory care pathways [note 1]ST
a. surgical and cancer services – maximising the St
Albans City Hospital site. JL / AD
b. medical services – maximising the Hemel
Hempstead General Hospital site. AO / AD
c. women's and children's services AB / AD
3.1 Develop / commission QI training programme for
clinical and support staff to ensure consistent QI
approach embedded across the organisation and staff
skills and capability strengthened.
Quality Account
Number of staff trained in wHw
QI methodology (detailed
metrics TBC)
CoEC TC
3.2 To roll out our ward accreditation scheme to all
wards in 2018/19. All wards achieving ‘silver’ by 2020.Quality Account
% Wards achieving silver rating
or higher.CoEC TC
4.1 Business case, agreed way forward and
implementation IT infrastructure improvement. FIC
4.2 Business case approved and funding secured for
implementation of an Electronic Health Records.FIC
4.3 Implement scanning and electronic document
management for medical records. (One year
programme commencing Q2)
CoEC
4.4 Implement digital dictation / voice recognition.
(Phased programme over 2 years). CoEC
4.5 Implement electronic order communications for
pathology (March 19) CoEC
4.6 Implement remote access to radiology and other
specialty images. (March 2019) CoEC
4.7 Meet the compliance requirements of GDPR and
appoint data protection officer (May 2018) GDPR implementation plan
Information governance
breachesS&C
6.1 Work with divisions and specialties to agree
research activity giving equality of access to research
6.2 Exceed Clinical Research Network Recruitment
targets6.3 Increase income from NIHR commercial research
(target 20% increase over 2 years)NIHR research income
6.4 Increase applications to funders of research,
particularly the NIHR and NIHR partner grants
(minimum 3 bids per annum).
Number of applications for
research grants
#
#
#
#
7.1 To achieve improved scores in the 2018 & 2019
staff surveys for the following questions, aiming to be
top quartile by 2019:
To increase the percentage of staff believing that
the organisation provides equal opportunities for
career progression or promotion to 86%
Maintain staff survey question on ‘Does your
organisation take positive action on health and well-
being’ at above 90%. Improve ‘I look forward to going to work’
question to 65%
Increase satisfaction with the opportunities for
flexible working patterns question to 60%
Improve ‘I would recommend my organisation as
a place to work’ question to 63%
Improve ‘If a friend or relative needed treatment
I would be happy with the standard of care provided by
this organisation’ question to 66%
CoECOverarching metrics to be
defined (e.g. % non face to face
OP activity, split of activity by
site) & specific metrics to be
agreed on a pathway by
pathway basisTrust Strategy / Interim
estate strategy
#
#
#
#
#
#
#
To implement & embed our ‘quality commitment’ and ‘west
Herts way’ quality improvement methodology
AIM
ON
E: B
EST
QU
ALI
TY C
AR
E
1
.
To deliver excellent clinical outcomes for our patients
- mortality
- harm free care
Full suite of quality and outcome indicators reported in the
Integrated performance report.
2
.
To implement best practice, integrated care pathways and
reduce unwarranted clinical variation in care and outcomes.
#
#
#
#
#
#
#
To improve our IT and move towards full digitisation.
IT strategy implementation
plan (to be developed in
Q1)
Business cases to set out
expected benefits and
measures. Post project reviews
to report on benefits delivery.LE / SG
CoEC ST/AO/JL
AIM
TW
O: A
GR
EAT
PLA
CE
TO W
OR
K A
ND
LEA
RN
#
#
#
#
#
#
#
To further develop the Trust’s participation in Research and
DevelopmentR&D work programme
CRN recruitment numbers by
division / specialty
CoEC MvDW
To have happy, healthy, well supported staff who feel able to
deliver great care and ‘make a difference’ in an inclusive
environment and to be a clinically led organisation.
#
#
#
#
#
#
#
To improve our emergency care pathway and discharge
processes.
5. Implementation of Emergency Care transformation
programme including SAFER discharge.
Emergency Care
Transformation Plan
ED capacity breaches
% streaming (admitted and non
admitted)
Internal professional standards
% performance
Bed capacity breaches
% discharges via discharge
lounge
Reduction in IP LOS > 21 days
Workforce Strategy & staff
survey action plan
Medical engagement action
plan
Annual staff survey results &
local temperature checks.
Analysis of key questions in staff
survey by professional group
(Band 8a and above).
PSECMvDW, TC,
PdG
11
Tab 11 2018/19 corporate aims and objectives
3 of 114Trust Board Meeting in Public-12/04/18
7.1 To improve scores for senior clinical staff in the
2018 and 2019 staff surveys for the following
questions:
- I am able to make improvements in my work area
(57% org and 55% sector)
- Senior managers here try to involve staff in important
decisions. (38% org / 33% sector)
- Senior managers act on staff feedback. (38% org / 31%
sector)
#
#8.1 To reduce the overall trust vacancy rate to 9%
Recruitment & Retention
action planIPR metrics PSEC PdG
8.2 To reduce the vacancy rate for Band 5 nurses to
16%8.3 Turnover rates to reduce to 14% by 01/04/19
and 12% by 01/04/20
8.4 To have in place a number of ‘new’ roles:WTE ANPs
WTE Nurse associate roles
16-20 new Advanced Nurse Practitioners –
Creation of 30 new Nurse Associate roles
15 new support ODP roles
#
#
9.1 To become a University Hospital Status by April
2020. (to be developed) University Status achieved PSEC MvDW / PdG
9.2 Apprenticeships: To be drawing down at least 80%
of the apprenticeship levy by 31/3/2020, with
apprenticeships available to both existing and new staff
in both clinical and non-clinical fields. To have a pass
rate in line with national requirements.
Apprenticeship Levy Action
PlanApprenticeship Levy draw down PdG
9.3 Educational Compliance: To maintain core and
essential training levels at 90% Workforce Strategy
Core and essential training %
compliancePdG
9.4 Leadership and Management Sessions: To have in
place clear development options for every banding of
role within the Trust.
Workforce Strategy
Numbers of staff accessing
leadership and management
training by grade
PdG
9.5 To have instituted a coaching service within the
Trust that provides, on demand, leadership,
professional and/or career coaching to all staff
requiring it, either on self or manager referral with
coaches to be drawn from volunteers within the Trust,
trained and supervised to ICF standards and the service
underpinned by Trust policy.
Workforce Strategy
WTE staff who have received in
house coaching
Number of sessions coaching
per month
WTE staff trained to provide
coaching
PdG
9.6 specific staff survey metrics relating to
development Workforce Strategy
Analysis of key questions in staff
survey by professional group PdG
10.1 Deliver our in year financial plan. Finance planYear end financial outturn vs
plan.FIC
10.2 Demonstrate year on year improvement in the
Trust’s underlying financial position and performance
against key value for money metrics. ( E.G. model
hospital, Carter metrics)
CIP
Improvement of Underlying
deficit (vs Plan).
Key metrics TBC
FIC
11.1 proactively communicate and engage with local
communities and stakeholders in the development and
delivery of services, continuing to build confidence and
trust of the local community.
stakeholder strategy stakeholder strategy metrics
PSEC / Acute
Redevelopment
Programme Board
11.2 Demonstrate active engagement in the HWE STP STP programme n/aTrust Board All
11.3 Continue to actively participate in and support the
development of the West Hertfordshire provider
collaborative.
n/a n/a Trust Board DR
11.4 Work with HVCCG to test new contractual forms
that share risk and support innovation. QIPP plan
% contract income covered by
new contracting modelsFIC DR / FG
11.5. To formalise our partnership with the Royal Free
Group and deliver the agreed work plan.
(see also objective 2.1)
Royal Free Partnership
Work PlanAs set out in RFL benefits log. Trust Board HB / all
12.1 Deliver 2018/19 priority one capital programme. Capital programmeCapital expenditure vs plan
Estate compliance metricsFIC HB / PH
12.2 Development control plans and business cases to
deliver the strategic priorities set out within the interim
estate strategy. Secure funding via STP and ITTF
applications and explore full range of alternative
funding options. (ED phase two, Theatres FBC, neonatal
& maternity, business cases to optimise WGH, SACH
and HHGH.)
Interim estate strategy
implementation plan
DCPs x 3
Agreed programme, business
cases completed & additional
funding secured
Trust Board HB
12.3 New multi-storey car parking at WGH (business
cases completed and approved, construction
commenced. Target opening 2020.)
Interim estate strategy
implementation plan
Multi-storey car park @ WGH in
construction phase by 2020. FIC DR
12.4 Outline business case/s, approvals and agreed
way forward for long term redevelopment of our
hospitals.
Programme Plan to be
developed following SOC
approval.
Business cases approvals & clear
programme in place for WGH,
SACH and HHGH.
Trust BoardHB
[i] Links / co-dependent with capital and interim estate strategy.
To become an excellent organisation for employee development.
AIM
TW
O: A
GR
EAT
PLA
CE
TO W
OR
K A
ND
LEA
RN
To have happy, healthy, well supported staff who feel able to
deliver great care and ‘make a difference’ in an inclusive
environment and to be a clinically led organisation.
Workforce Strategy & staff
survey action plan
Medical engagement action
plan
Annual staff survey results &
local temperature checks.
Analysis of key questions in staff
survey by professional group
(Band 8a and above).
PSECMvDW, TC,
PdG
To reduce vacancy rates & reduce our reliance on agency
workers.
AIM
TH
REE
:
IMP
RO
VE
OU
R
FIN
AN
CES
#
#
#
#
#
#
To deliver best value care. DR
AIM
FO
UR
: A S
TRA
TEG
Y F
OR
TH
E FU
TUR
E
#
#
#
#
#
#
#
To work with local stakeholders and partner organisations to
identify where, by working together, we can improve care for
our patients.
#
#
#
#
#
#
#
To improve the quality of our estate & implement our service
driven estate strategy
11
Tab 11 2018/19 corporate aims and objectives
4 of 114 Trust Board Meeting in Public-12/04/18
Trust Board Meeting
12 April 2018 Title of the paper
Board Assurance Framework 2017/18 - closure report
Agenda Item
12/58
Lead Executive
Helen Brown, Deputy Chief Executive
Author(s)
Jean Hickman, Trust Secretary
Executive Summary
The aim of this paper is to assure the board on the progress made to mitigate the strategic risks within the board assurance framework (BAF) during 2017/18.
Where the report has been previously discussed, i.e. Committee/ group
All lead committees
Action required:
The board is asked to note the progress made to meeting the actions within the BAF.
Links to the board assurance framework
[Please indicate which Principal Risk this paper relates to by double clicking on the corresponding box]
PR1 Failure to provide safe, effective, high quality care
PR2 Failure to recruit to full establishments, retain and engage workforce
PR3 Current estate and infrastructure compromises the ability to deliver safe, responsive and efficient patient care
PR4a Underdeveloped informatics infrastructure compromises ability to deliver safe, responsive and efficient patient care – IM&T
PR4b Underdeveloped informatics infrastructure compromises ability to deliver safe, responsive and efficient patient care – Information and information governance
PR5a Inability to deliver and maintain performance standards for Emergency Care
PR5b Inability to delivery and maintain performance standards for Planned Care(including RTT, diagnostics and cancer)
PR7a Failure to achieve financial targets, maintain financial control and realise and sustain benefits from CIP and Efficiency programmes
PR7b Failure to secure sufficient capital, delaying needed improvements in the patient environment, securing a healthy and safe infrastructure
12
Tab 12 Board assurance framework update
1 of 114Trust Board Meeting in Public-12/04/18
PR8 Failure to engage effectively with our patients, their families, local residents and partner organisations compromises the organisation’s strategic position and reputation.
PR9 Failure to deliver a long term strategy for the delivery of high quality, sustainable care
PR10 System pressures adversely impact on the delivery of the Trust's aims and objectives PR6 – business continuity has been closed (incorporated into PR1)
Trust objectives
[Double click on the box to mark as appropriate]
12
Tab 12 Board assurance framework update
2 of 114 Trust Board Meeting in Public-12/04/18
Agenda Item: 12/58
Trust Board meeting – 12 April 2018
Board Assurance Framework 2017/18 – closure report Presented by: Helen Brown, Deputy Chief Executive
1. Purpose
1.1 The aim of this paper is to provide an update on the key strategic risks to the trust delivering its aims and objectives. The paper provides the board with an overview of the latest position at the end of the 2017/18 financial year with regard to the progress made to mitigate the strategic risks within the board assurance framework (BAF).
2. Background
2.1 A BAF is a framework of the strategic and operational objectives across the trust and provides a totality of assurance activity relating to the organisation’s principal risks.
2.2 The responsibility for each principal risk is assigned to an individual executive with oversight by a designated lead committee. Risk scores are graded from blue (completed and embedded) to red. All actions required to mitigate risks to gaps in controls and assurance are drawn into a spreadsheet to make the data accessible and manageable.
3. BAF 2017/18
3.1 During 2017/8, the overall BAF was reviewed by the board in June and November 2018. The board approved the following changes to the principal risks: PR1. Failure to provide safe, effective, high quality care. The responsibility for this principal risk was shared between the safety and compliance committee and the clinical outcomes and effectiveness committee. PR5b. Inability to deliver and maintain planned care standards. The RAG rating increased from amber to amber/red to reflect a deteriorating RTT picture. PR7b. Failure to secure sufficient capital, delaying needed improvements in the patient environment, securing a healthy and safe infrastructure. The RAG rating was reduced from red to amber/red to reflect a review and recommendation by the project appraisal unit around capital spend authorisation. PR8. Failure to engage effectively with our patients, their families and local residents and partner organisations compromises the organisation’s strategic position and reputation. The responsibility for this principal risk was moved to the patient and staff experience committee.
12
Tab 12 Board assurance framework update
3 of 114Trust Board Meeting in Public-12/04/18
3.2 Lead committees regularly reviewed the delivery of BAF actions within their area of responsibility in 2017/18 and escalated areas of concern to provide the board with assurance on the progress being made. The actions from 2017/18 have either been closed or will be carried over to the 2018/19 BAF.
3.3 Please see the table below for a summary of the status of the actions.
3.4 Please see appendix 1 for full details of the actions that have been achieved.
3.5 Appendix 2 details the actions which were partially achieved or not achieved. Four actions were not achieved: Action 73 and 74. Business case and implementation plan for funding to update the
intranet to be reviewed
These actions was not achieved due to financial resources and capacity constraints within IT and communication teams. Action 75. Bi-annual updates on trend analysis of communications to the Trust
Board.
This was not achieved due to a lack of resources in the communication team.
Action 77. Secure approval for acute SOC from HVCCG, STP, NHSI and DHSC and the Treasury. The trust is awaiting to receive confirmation of approval of the SOC from NHS Improvement (NHSI). A meeting with NHSI and NHS England is scheduled for 01 May 2018.
3.6 Two actions were not rated as they were either dependent on the completion of another
action. One action relating to an audit of clinical guidelines and practices was closed as the trust follows national guidance and therefore the audit was not required.
4. BAF 2018/19
4.1 In quarter 4 of the 2017/18 financial year, the board commenced a comprehensive review and refresh of its BAF to offer greater assurance that major risks were being tracked appropriately. The newly formatted BAF will reflect the primary risks to delivery of the trust’s 2018-2020 objectives. A number of actions that have not been achieved in 2017/18 will be carried over to the 2018/19 BAF and further relevant actions will be added. The 2018/19 BAF will be presented to the board for approval in June 2018.
4.2 Robust management of the 2018/19 BAF will continue with lead committees providing
regular assurance to the board on the delivery of BAF actions within their area of responsibility.
4.3 Following approval of the 2018/19 BAF in June, the board will receive a status report in October and March 2018 on any recommended changes made by the lead committees, progress of actions that have reached their due date and a forward look to escalate any actions with future due dates where there is a risk to delivery.
Action achieved Partially achieved Not achieved Actions carried over
55 25 4 30
12
Tab 12 Board assurance framework update
4 of 114 Trust Board Meeting in Public-12/04/18
5. Recommendation
5.1 The board is asked to note the closure of actions from the 2017/18 BAF and the plans in place for the 2018/19 BAF.
Helen Brown Deputy Chief Executive
April 2018 Appendix 1. Actions that have been achieved. Appendix 2. Actions that have been partially achieved or not achieved.
12
Tab 12 Board assurance framework update
5 of 114Trust Board Meeting in Public-12/04/18
ref PR actions / milestones owner 1 owner 2due date
(original)
date
completeupdate as at April 2018 Status
Carried
forward
1 1Review & update KPI's for Board IPR
regarding complaintsCNO Jul-17 Sep-17
Narrative updated on the IPR to show divisional
overview and performance. Charts also
updated, main KPI’s not changed. Updated for
September Board.
Achieved No
3 1Review complaints team management
capacity and roles and responsibilitiesCNO Jul-17 Jul-17 Team roles and responsibilities reviewed Achieved No
4 1Implement recommendations from review
of complaints teamCNO Oct-17 Oct-17
Processes changed to comply with responding
to all complaints within the required 25 working
days. The policy and datix reviewed and
updated to make the above mandatory.
Achieved No
5 1
Joint audit of quality of complaint
responses with Hertfordshire
Healthwatch.
CNO Nov-17 Mar-18This work has been completed by Healthwatch
and a final report received. Achieved No
6 1
Finalise QIP update to reflect all new
actions following receipt of CQC report for
Sept 15
CNO CIO May-17 Jun-17
All new actions and change forms completed
and approved by TEC. Divisional reviews of all
musts and should with a full QIP refresh.
Achieved No
7 1
Updated QIP reporting format via safety
and compliance sub committee to Board
and Oversight committee
CNO Jun-17 Jun-17 New reporting via PM3 in place. Achieved No
8 1
Develop process to track actions from SIs
via divisional performance review
meetings
CMO CNO Jun-17 Jul-17 Scheduled commenced in July 2017 Achieved No
9 1
Audit effectiveness of SI Review group to
provide assurance that all SI action plans
are implemented and embedded. (Report
to Safety & Compliance Committee)
CMO CNO Feb-18 Sep-18
Report established and presented at each SI
Review Group meeting. This provides a RAG
rated overview of all open SI action plans to
indicate their current status and whether
additional action is required in respect of
reviewing and closing the action plans.
Achieved No
10 1Implement Datix tracking mechanism for
moderate harm incidentsCNO CMO Jul-17 Jul-17 Completed Achieved No
11 1
Trajectory to deliver improvements in
clinical guidelines from May baseline (54%)
to be developed.
CMO CNO Jun-18 Jul-17Trajectory developed and signed off by the
Policy Review group in July 2017Achieved No
14 1MCA / Best Interests training programme
and schedule to be finalisedCMO
DD
SurgeryJun-17 Dec 17
MCA / Best interests training in place as part of
core training programme. Achieved No
15 1MCA / Best Interests training programme
delivered (six month progress report)CMO
DD
SurgeryJan-18
Reported via Workforce IPR to PSEC.
Compliance 82% (Feb 18)Achieved No
18 1
New learning from deaths policy finalised
and adopted.
(dependent on national guidance being
finalised)
CMO Dec-17 Dec-17
Trust policy ratified and published.
SJR training for clinicians has started with 2
further dates scheduled.
Trust Mortality dashboard as regular board
agenda item to start Feb 2018
Achieved No
19 1
A learning from deaths action Plan to
address requirements - report via
outcomes & effectiveness committee.
(dependent on national guidance being
finalised)
CMO Jun-17 Jun-17
Action plan in respect of the national guidance
submitted and approved at June 2017 Mortality
Review Group.
Achieved No
20 2
Divisional staff survey action plans in place
to drive continued improvement in
engagement
DWF Jun-17 Jun-17Plans are now in place for all divisions and being
managed via Divisional Performance Reviews. Achieved No
21 2
Review & agree (revised) internal targets
for appraisal and mandatory training -
benchmark with organisations rated
'outstanding' by CQC
DWF Jun-17 Jun-17Completed and as a result targets have been
adjusted.Achieved No
22 2Funding for CPD activity agreed and
programmes being implemented.DWF Sep-17 Sep-17
Transformation commissioned to benchmark
clinical staffing levels. Achieved No
23 2Equality and diversity action plan approved
via patient and staff experience committeeDWF Sep-17 Sep-17
Action plan approved by patient and staff
experience committeeAchieved No
BOARD ASSURANCE FRAMEWORK ACTION TRACKER 2017/18
Closure report
Appendix 1
12
Tab 12 Board assurance framework update
6 of 114 Trust Board Meeting in Public-12/04/18
ref PR actions / milestones owner 1 owner 2due date
(original)
date
completeupdate as at April 2018 Status
Carried
forward
24 2
Plan in place to address high level of
agency use within surgery and in particular
anaesthetics.
DWF Aug-17 Aug-17
Action plan in place in relation to theatre
staffing including apprenticeships, recruitment
events, clinical supervision, induction, ‘rescue’
interviews.
Anaesthetic Consultant business case for
recruitment of an additional 12 consultants
approved by TEC in August 2017.
Achieved No
25 2Progress review against agency plan via Pt
& Staff experience committeeDWF Feb-18 Feb-18
Recruitment plan is in place and being managed
by the divisional management team with
support from the HR BP.
Achieved No
26 2
Strategy / implementation plan developed
to maximise opportunities from
apprenticeship levy for approval via Pt &
Staff experience committee
DWF Oct-17 Oct-17Full work plan in place with steering group to
manage apprenticeships.Achieved No
28 2Agreed programme of management
development in placeDWF Oct-17 Oct-17 Programme in place Achieved No
29 2 Launch of 'shared' bank with STP partners DWF Dec-17 Oct-17 Shared bank has been launched Achieved No
30 3Finalise priority one capital programme
(funded internally) Dir Env May-17 May-17 Capital programme finalised Achieved No
31 3
Develop implementation plan with
milestones for tracking capital programme
via Estates Steering Group
Dir Env Jul-17 Jul-17 Implementation plan finalised Achieved No
32 3Agree priority 2 schemes for inclusion in
ITFF applicationDCEO Jul-17 Jul-17
A list of Priority 2 schemes was put forward for
inclusion within ITFF.Achieved No
33 3Technical Advisor to be confirmed for
management of confined spaces. Dir Env Jul-17 Sep-17
Technical Advisor was confirmed for
management of confined spaces. Achieved No
34 3
Ensure authorised and competent persons
in place for all high risk activities
(substantive appointments made to all
posts / incorporated into existing job roles)
Dir Env Aug-17 Jul-17 All posts filled by Trust staff Achieved No
35 3
First Estates Steering Group held &
monthly forward plan in place (reports to
Safety & Compliance Committee)
Dir Env Jun-17 Jun-17Regular ETG meetings established, with agreed
term of reference and work plan Achieved No
36 3
Estates and facilities dashboard finalised
with bi-monthly reporting against agreed
metrics (first draft to be issued July 17
after June ESG). System to be fully
implemented by Dec 17
Dir Env Dec-17 Dec-17Dashboard established and presented regularly
to the estates steering groupAchieved No
38 3
Update premises assurance model self-
assessment and develop new action plan
to further strengthen assurance.
Dir Env Dec-17 Mar-18
PAM interim review complete. The findings
were presented to safety and compliance
committee on 9 Aug I7. Continuous
improvement action plan in place. This is an
ongoing exercise / part of environment division
BAU governance.
Achieved No
45 4aImplement formal chief nursing
information officer (CNIO) roleCIO CNO May-17 Apr-17 CNIO appointed and in post. Achieved No
46 4a Board development session CIO Jun-17 Jun-17Updated Board on digital strategy at Board
Development Session in June 2017Achieved No
49 4a CIS capital funding secured CIO May-17 May-17 Funding secured Achieved No
50 4aCancer information system
implementation plan approved by TECCIO Jul-17 Jul-17
The business case was approved by TEC and the
project established. OJEU procurement process
is underway per national framework and
associated timeframes Achieved No
51 5aDevelop and deliver ED workforce
plan/business case for TEC review.DD USC CMO Jul-17 Jun-17
Business case for 3 new Acute physicians, 2
ANPs approved by TEC June 2017 . Achieved No
53 5a Submit bid for GP streaming capital DCEO CFO Apr-17 Apr-17Bid submitted but not successful; other funding
routes to be explored.Achieved No
54 5aDevelop bid for phase one 'do minimum'
improvement works for EDDCEO DD USC May-17 May-17
Bid submitted as a variant bid to wave 2
national ED transformation programme. £1m
capital funding confirmed.
Achieved No
55 5a
ED infrastructure improvements. National
funding contingent on delivery by end Oct
17. Plan in place to deliver this.
DCEO CFO Oct-17 Dec-17
Delays in build programme and scheduling have
resulted in slippage to the completion date for
this project. Now completed with expanded
CDU operational from 27th December 2017
Achieved No
56 5b
Develop an RTT delivery work plan to
address gaps in controls and assurance
and embed new processes implemented in
16/17 (including actions from audit
recommendations)
Dir Perf COO Jun-17 Jul-17
All actions from the audit recommendations are
complete.
A paper taken to CoE on 25/1/18 prior to
review by the Audit Committee. Performance
of RTT continues to be reviewed by TEC
Achieved No
12
Tab 12 Board assurance framework update
7 of 114Trust Board Meeting in Public-12/04/18
ref PR actions / milestones owner 1 owner 2due date
(original)
date
completeupdate as at April 2018 Status
Carried
forward
57 5b
Delivery of improved performance against
Breast Symptomatic 2 week wait standard,
develop a joint action plan with HVCCG
Dir Perf COO Jun-17 Jun-17
Draft plan developed for review by Beds and
Herts Cancer Action Group. WHHT sign off by
the TEC in June 2017.
Achieved No
59 7a
Commission external report of cost of back
office function metrics to support more
targeted interventions
CFO May-17 May-17Review commissioned and initial report
provided. Achieved No
61 7a & 7b ITFF application submitted. CFO Jul-17 Jul-17
ITFF application submitted July 2017. Next
steps likely to be an NHSI review of business
cases.
Achieved No
63 7aCommission external review of staffing
levelsCFO Jun-17 Jun-17
GK Transformation commissioned to benchmark
clinical staffing levels. Achieved No
65 7a
Commission third party expertise to
strengthen contractual risk assessment,
mediation and arbitration processes. CFO Jun-17 Jun-17
PWC reviewed 16/17 contract dispute and
drafted mediation statement.
Recommendations to strengthen arrangements
this year made as part of this process. New
mediation cases emerging however.
Achieved No
66 7a
Action plan / implement recommendations
to strengthen contractual risk assessment,
mediation and arbitration processes.
CFO Jul-17 Jul-17PWC recommendations implemented by
contracts team. Achieved No
69 8
Proposed approach to re-boot visible
leadership programme be presented to
TEC for approval.
Dir
CommsMay-17 May-17 Proposed approach agreed at TEC in May-17. Achieved No
79 9
Scope potential opportunities and agree
work plan for partnership work with Royal
Free
DCEO Jul-17 Nov-17 Work plan approved at November Board. Achieved No
80 10
Implement new STP governance
arrangements with strengthened PMO to
support delivery.
CEO STP CEO Jul-17 Aug-17
New STP governance arrangements agreed in
principle. Additional programme support
recruited into PMO to support workstreams.
Recruitment to clinical lead role / clinical
advisory group in progress.
Achieved No
81 10
Ensure visible leadership contribution
from WHHT to STP work streams - agree
WHHT nominees.
CEO STP CEO May-17 May-17Active input from WHHT in STP work streams.
Achieved No
82a 10Develop joint HVCCG and WHHT QIPP
board and increase clinical engagement.CEO HVCCG Jul-17 Jul-17
Joint QIPP Board established. Increased clinical
engagement in place. Achieved No
83 10Complete pilot scheme to discharge to
assess pathway one (discharge home).DIR IC Jul-17 Jul-17
Pilot ended in November 2017 and a six month
evaluation was completed. Patients who would
have gone through this service in month are
being referred to Herts County Council
commissioned Specialist Care at Home service
instead
Achieved No
84 10
Implement discharge to assess pathway
two (further assessment and / or
rehabilitation prior to decision re long
term care) – plan to be developed by July
2017. Implementation milestones TBC
DIR IC Jul-17 Jul-17
Beds are now operational with the Integrated
Discharge team managing the flow into the beds
from WHHT
Achieved No
85 10
Implement discharge to assess pathway
three (patients expected to need a long
term placement). Transition hub to be
developed / implemented by July 2017.
DIR IC Jul-17 Aug-17
Draft SLA is still with HCT for their final
comment and agreement. As now outstanding
this has Director to Director escalation to
resolve. However, invoices are being sent in,
scrutinised and mostly paid in accordance with
the Letter Of Intent from August 2017.
Achieved No
86 7a
In response to a deterioration in financial
plan, develop financial recovery plan and
covering letter to be signed by CEO and
Chair. Secure Board agreement for the
plan.
CFO Oct-17 Oct-17
Recovery plan sent on 16 October 2017.
Progress with the plan will form part of the
trust’s next Quarterly Review meeting with
NHSI.
Achieved No
12
Tab 12 Board assurance framework update
8 of 114 Trust Board Meeting in Public-12/04/18
ref PR actions / milestones owner 1 owner 2due date
(original)
due date
(revised)Status
Reason for
delay/failure to
deliver as
expected
UpdateCarried
forward
2 1Set trajectory for complaints performance
at Trust and divisional level and embedCNO Jul-17 Jun-18
Partially
achieved
Management
capacity /
operational
pressures
Some improvement in performance
over the year, although not fully
embedded at over 60% against a
trajectory of 85% for year end.
Yes
12 1 90% clinical guidelines in date CMO CNO Mar-18 Sep-18Partially
achieved
Management
capacity /
operational
pressures
As at 07/11/17 the percentage of
clinical guidelines registered with the
Assurance Team and in date is 72%.
Yes
13 1 Audit a sample of guidelines and practice CMO CNO Dec-17 Feb-18 Not rated N/A
As the Trust follows national guidelines,
this action is recommended for closure
as no longer required.
No
16 1Develop metrics for reporting nursing and
medical staff coverDWF CMO Jun-17 Mar-18
Partially
achieved
Management
capacity /
operational
pressures
A form of e-rostering was required to
be in place in order to allow a reporting
metrics to be established, which
required significant time and resource.
However, a medi-rota is now
established to take this action forward.
This requires embedding before it will
provide the required level of reporting
metrics.
Yes
27 2
Relaunch of bullying and harassment
advisors to challenge inappropriate
behaviour
DWF Oct-17 Jun-18Partially
achieved
Milestone too
ambitious
Work is continuing to address this
action. This will be completed as one of
the main activities from the Respect Me
campaign planned for June 2018
Yes
37 3All actions from 2016/17 PAM review
completed.Dir Env Aug-17 Feb-18
Partially
achieved
Milestone too
ambitious
Improvements made across 4 areas
previously deemed inadequate. One
remaining area on car parking. Action
on 2018/19 BAF to reflect the one
outstanding area on car parking. SOC
approved, and minor interim works
currently being costed to improve areas
during interim period.
Yes
39 3Updated 6 facet survey and summary
report Dir Env Sep-17 Feb-18
Partially
achievedExternal
The trust has received the outcome of a
6 facet survey, however it is not happy
with the quality of the report and is
working with the company to address
this.
Yes
40 3 ARCHIBUS full functionality implemented Dir Env Sep-17 Feb-18Partially
achievedExternal
Full functionality cannot be delivered
until 6 facet survey and asset survey
finalised and uploaded.
Yes
41 3Development Control Plans produced for
WGH, SACH and HHGHDir Env Mar-18 Sep-18
Partially
achievedExternal
Programme underway with clinical
teams to determine 'As Is’ and 'To Be'
models for each site. DCP programme
delayed 6 months.
Yes
42 3
Develop action plan to address highest risk
areas - identify priorities for 2018/19
capital programme based on 2017 ^ Facet
& Life Cycle exercise
Dir Env Feb-18 Feb-18Partially
achievedExternal
Initial risk based capital programme
developed for 18/19 based on existing
data re estate performance. Update to
be undertaken once 6 facet survey and
asset survey finalised.
Yes
43 3 Asset Database fully populated. Dir Env Sep-17 Jun-18Partially
achievedExternal
The trust has received the outcome of a
6 facet survey / asset survey, however it
is not happy with the quality of the
report and is working with the company
to address this.
Yes
44 3PPM programme completed - assurance
update report to Safety & complianceDir Env Mar-18 Jun-18
Partially
achievedExternal
System level statutory PPM's
implemented at SACH/HH and WGH
based on existing data - programme will
need to be reviewed and updated once
the 6 facet survey and asset survey has
been completed.
Yes
47 4aFormal Board approval of updated digital
strategy CIO Sep-17 May-18
Partially
achieved
Management
capacity/
operational
pressures
Digital Strategy Framework approved at
FIC in November 2017, with briefing to
Trust Board in December 2017.
Digital Strategy refresh completed and
taken to TEC and FIC in March 2018. To
go to Trust Board for approval in May
2018
Yes
48 4aCompletion of ICT infrastructure
improvement programme CIO Jul-17 Jun-18
Partially
achieved
Management
capacity/
operational
pressures
Plans are in place with robust
programme management and monthly
Exec level review. 90% EUD rollout
completed by the end Sep 2017. The
timeline was moved to reflect delays
due to the trust's response to cyber
risks and high priority incidents.
Yes
BOARD ASSURANCE FRAMEWORK ACTION TRACKER 2017/18
Closure report
Appendix 2
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Tab 12 Board assurance framework update
9 of 114Trust Board Meeting in Public-12/04/18
ref PR actions / milestones owner 1 owner 2due date
(original)
due date
(revised)Status
Reason for
delay/failure to
deliver as
expected
UpdateCarried
forward
52 5a
Recruitment timeline for new posts - target
for appointments to be made by Oct-17
and staff in post by Jan-18.
DD USC CMO Jan-18 Jun-18Partially
achieved
Management
capacity/
operational
pressures
2 new consultants in post. 4 new ANPs
and nurse consultant in post. Additional
locum posts recruited over winter
2017/18. Business case for substantive
changes to establishment and
recruitment to be reviewed at Trust
Board in April 2018.
yes
58 7aDevelop 2 year CIP plan with clear
implementation milestones.CFO CIO Oct-17 Mar-18
Partially
achieved
Management
capacity /
operational
pressures
2 year CIP plan developed. Action plan
in place to produce detailed delivery
programme. Work ongoing.
yes
60 7a
Develop action plans relating to back office
functions to be agreed with relevant
directorates following receipt of report.
CFO Oct-17 Dec-17Partially
achieved
Milestone too
ambitious
Report received and action plan
incorporated into CIPs. Business case
on human resources and financial back
office to be presented to TEC in April
2018
Yes
62 7a
Improve SLR and cost benchmarking and
agree pilot projects for deep dive CFO Jul-17 Nov-17Partially
achieved
Milestone too
ambitious
Working group meeting regularly and
monthly SLR reporting established.
Deep dive areas in progress and findings
incorporated into CIPs.More deep dives
to be undertaken
Yes
64 7a
Report and implementation milestones on
independent review of staffing
establishment levels to respond to
efficiency challenge and NHSI challenge to
trust's high staff costs.
CFO Nov-17 Jan-18Partially
achievedExternal
Report on nursing staff establishment
review scheduled for April 2018. The
trust is still in discussion with NHSI
regarding medical staff review.
Yes
67 7b
Actions to be implemented as agreed from
internal audit of costing, tendering and
control estates capital projectsDir Env Oct-17 Apr-18
Partially
achieved
Milestone too
ambitious
Local actions implemented. Trust
Capital Delivery SOP currently being
written for implementation April 18.
Yes
68 7b
Recruit capital programme manager &
retender call off contract for project
support.
Dir Env Sep-17 May-18Partially
achieved
milestone too
ambitious
Capital Program Manager in post,
procurement in process to establish call
off contract for project support. Target
completion / go live date for call off
contract May 18.
Yes
70 8Finalise stakeholder strategy and action
plan for approval by PSE and Trust Board.
Dir
CommsJul-17 Jun-18
Partially
achieved
Milestone too
ambitious
Draft strategy reviewed by patient and
staff experience committee and
discussion at board development
session. Agreed further work required
around metrics used to measure
progress.
Yes
71 8Stakeholder strategy implementation
milestones
Dir
CommsTBC Not rated N/A
Dependent upon completion of the
action aboveYes
72 8
Comprehensive communications plans for
four major strategic issues (STP, SOC,
Hemel SOC, RFH partnership)
Dir
CommsJun-17 Mar-18
Partially
achieved
Management
capacity /
operational
pressures
Director of Comms is part of STP
comms network which has its own
communications plan. Hemel SOC
clinical engagement workshops held in
September 2017. RFH group model
presented at clinical event in July 2017
and March 18. Timelines reset for SOC
due to internal CQC comms.
Yes
73 8Business case for funding to update the
intranet to be reviewed and updated.
Dir
CommsCIO Oct-17 No date Not achieved
lack of / delay in
capital funding
There has been a delay due to financial
resource issuesYes
74 8Implementation plan for update of the
intranet following confirmation of funding
Dir
CommsCIO
TBC
No date Not achieved N/ADependent upon completion of the
business case and capital funding. Yes
75 8Bi-annual updates on trend analysis of
communications to Trust Board
Dir
CommsOct-17 Jan-18 Not achieved
management
capacity/operation
al pressures
Delayed due to communication team
resource issues. Yes
77 9
Secure approval for acute SOC from
HVCCG, STP, NHSI, DH &Treasury DCEO Oct-17 Mar-18 Not achieved External
SOC submitted to NHS I in September
2017. Delays to review process for
major schemes at a national level.
Senior review meeting scheduled for 1st
May with NHS I and NHS E.
Yes
78 9
Mobilise additional internal programme
team capacity & programme management
structures
DCEO Oct-17 Mar-18 Partially
achievedExternal
Programme Director for Acute
redevelopment and additional service
planner appointed. Remaining posts
approved in principle have been frozen
pending outcome of SOC review
process. Governance structure being
mobilised. First programme Board
meeting held in February 2018.
Yes
82b 10
Develop and implement joint progress
tracker for QIPP programme Board (to be
reviewed via SDB TEC on a regular basis)
CEO HVCCG Oct-17 Feb-18Partially
achievedExternal
Tracker established and reviewed at
joint QIPP programme board. Process
continues to evolve to ensure HVCCG
and Trust views on progress and issues
are fully aligned.
Yes
Partially
achieved
Milestone too
ambitious
Some benefits already being worked up
on basis of initial reports, with the
majority of targeted interventions
expected to have an impact from
2018/19.
Yes87
Action plans to be agreed with relevant
directorates following receipt of a report into
an independent review of clinical divisions
financial metrics,
CFO Nov-17 Mar-187a
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Tab 12 Board assurance framework update
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1
Agenda item: 13/58
Report to: Trust Board
Title of Report: Assurance report from Finance and Investment Committee
Date of meeting: 12 April 2018
Recommendation: For information and assurance
Chairperson: John Brougham, Non-Executive Director
Purpose
The report summarises the assurances received, approvals, recommendations and decisions made by the Finance and Investment Committee at its meeting on 29 March 2018.
Background The Committee meets monthly and provides assurance on:
Scheduled reports from all Trust operational committees with a finance and information technology brief according to an established work programme.
Financial Performance
i. I&E deficit
Following last month’s FIC and Board recommendations, and subsequent review meeting with NHSI, a change to the Trust’s year end deficit forecast was approved from £35m to £43.2m. It was recognised at the meeting that there was still a material risk to the forecast, dependent upon the final agreement still to be settled with HVCCG on full year revenue.
For assurance that the revised forecast would be achieved, the Committee reviewed the deficit outcome in February compared to forecast, the latest forecast view for March, and the expected outcome from the ongoing discussions with HVCCG on the full year revenue settlement.
The Committee concluded that, excluding the HVCCG discussions, the latest expected outturn was broadly in line with the revised forecast, but there was not sufficient confidence that the outcome of the HVCCG discussions would be successful.
The Committee was therefore not assured that the £43.2m deficit forecast would be met, and recommends that a report on the latest view of the full year deficit is presented to Part 2 of the April Board.
ii. Productivity improvement plans
The Committee reviewed the emerging agenda of the Herts Procurement Shared Service to modernise procurement and supply across the STP. The plan is consistent with the direction of the 2016
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Carter Review on operational productivity, and the aim is to adopt procurement technologies, including electronic ordering and invoicing, based on an interoperable network to enable optimum management of price and demand, and overall improved contract management. Product harmonisation will be a key contributor to deliver Carter estimated total annual savings of between £3m and £5m for acute Trusts similar in size to West Herts.
The expectation is that the plans will develop into a series of discrete business cases across the Trusts in the STP, which will be seeking approval in the first half of 2018/19.
The Committee was supportive of the planned developments and will receive regular updates on progress prior to receiving business cases for review.
iii. Capital Spend/Funding
The Committee was pleased to hear that, finally, the Trust’s application for Capital Spend in the year was approved by NHSI in March, and that of the authorised sum of £13.7m, only £1.4m was for this year, with £6.1m to be spent in 2018/19 and £6.2m in 2019/20.
Together with other funding approved in March of £1.6m, for A&E Primary Care Streaming and Cyber resilience, the authorised capital spend in 2017/18 has increased by £3.0m in March to £9.7m.
Year to date spend at the end of February was £5.9m, which creates a challenge to spend the full £3.8m in March.
The Committee was assured that the spend would continue to be made in line with the priority classifications agreed early in the year, and recommends that the Board approves the DH capital loan of £13.7m, which will be drawn down over a 3 year period.
Financial Plan 2018/19
The Committee reviewed the latest status of the operational and financial plan for 2018/19, which now includes national planning guidance and financial control totals issued after last month’s Committee.
A number of key planning assumptions have yet to be finalised, in particular the reduction in the Trust’s revenues from QIPPs which have yet to be agreed with HVCCG.
The draft plan currently assumes that underlying revenues reduce by £6m year, primarily driven by QIPP reductions. Costs are planned to reduce next year, driven by cost improvements of £14m, 4% of revenues, and the plan is to drive significant operational improvements in patient waiting times for both A&E and elective care.
The draft plan deficit, pre STF funding, currently stands at £40m, £5m better than the equivalent latest forecast for 2017/18. NHSI have set a pre-STF control total of £20m for 2018/19, £20m lower than the Trust’s latest draft, which equates to an additional 6% of CIPs, making an unprecedented 10% in total. After reviewing the
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operational and financial plan the Committee was not assured that the control total could be met.
The Committee fully endorses the need for a very challenging plan, but not one that is set at a level which is not realistically achievable.
The Committee gave its support to the draft plan capital spend of £17m, £12m of which will be funded by a combination of internally generated funds and the £6m of authorised spend carried forward from the current year, with the remaining £5m subject to NHSI approval of the Watford Theatres upgrade Final Business Case which is expected to be submitted by the second quarter of 2018/19.
The Committee also gave its support for the Trust applying for a £20m working capital loan, in addition to the loans to cover capital spend and the final agreed deficit. The loan would make a significant improvement to the liquidity of the Trust, and would enable more up to date payment of suppliers.
The Committee recommends the latest draft plan is presented to part 2 of the April Board.
Corporate risk register (CRR)
The Committee reviewed the 6 IM&T and 5 finance currently on the CRR.
The Committee was assured that the risks and ratings should remain as presented, apart from one ICT & Information risk and one Finance risk which the Committee asked to be revisited prior to presentation to the April Board.
Service Line Reporting
The Committee reviewed a paper on the current progress of SLR reporting in the Trust. This included seeking assurance that the 2017/18 annual national Reference Cost Return due to be submitted in August 2018, would comply with the principles and standards set by NHSI, and is backed by appropriate costing and information capture systems, adequate costing team resource, and procedures in place for a self-assessment quality check prior to submission. The reference costs inform the setting of payment by results (PbR) tariffs in future years and enable benchmarking between Trusts through the reference cost index (RCI).
The Committee noted, and was pleased to hear, that the Trust had volunteered to be an early implementer to complete a national patient level costing return along with the Reference Cost Return, with the same compliance requirements as the Reference Cost return.
Following review the Committee was assured that appropriate compliance with both returns was in place.
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Information and Communications Technology (ICT)
The Committee reviewed the status of those areas of the ICT Transformation Programme, which remain incomplete and many months overdue. These areas include the wide area network, end user device rollout, migration of applications to offsite data centres, and fixed telephony deployment. The actions required by our supplier to complete will be discussed at senior executive level in April, with a report back to next month’s Committee.
Until a completion plan is agreed, with commitments from the supplier, the Committee is not assured that completion will be rapidly implemented.
The Committee was pleased to note that the Trust had been successful in securing £480k funding from NHSE’s Cyber Security Funding Programme. This will be used to replace XP devices and other equipment outside the scope of the Transformation Programme.
The Committee discussed the draft Digital Vision presentation and will feedback recommendations for changes prior to submission to the May Board.
Review of Policies
The Committee received verbal assurance that all IM&T and Finance policies were up to date.
Emergency Medicine Workforce Business Case
The Committee received a report on a Business Case to increase the substantive clinical workforce in ED, to improve capacity, patient experience, quality and performance measures.
The Committee recommended a number of changes be made to the paper before it is presented to Part 2 of the April Board to clarify the associated benefits and risks.
Department of Health & Social Care Bank Pilot Scheme
The Committee reviewed a paper on the tendering consequences of the Herts and Beds consortium, of which the Trust is part, being successful in their application to be one of 12 pilots looking at different shared staff bank arrangements, which are sponsored and funded by DHSC. The aim of the pilots is identify changes to bank arrangements for the benefit of both staff and Trusts, and they will run from April 2018 to January 2019.
The Trust’s current contract with its bank provider expires in March 2019, which would mean running the retendering process
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concurrently with the pilot. To enable the results of the pilot to be incorporated in the next round of tendering the TEC recommends extending the current contract by one year to March 2020.
The Committee was assured that this is the optimum course of action for the Trust and endorses the recommendation.
Risks to refer to risk register
See corporate risk register above.
Issues to escalate The Committee recommends the following:
to Part 1 of the April Board for approval:
i. the Department of Health & Social Care capital loan of £13.7m
to Part 2 of the April Board for assurance:
ii. the latest view of achieving the £43.2m deficit forecast.
iii. The latest draft operational and financial plan for 2018/19
to Part 2 of the April Board for review
iv. a paper on the planned resource increase in the Emergency Medicine workforce.
Attendance record
Attended
John Brougham, Non-Executive Director (Chair)
Don Richards, Chief Financial Officer
Mike van der Watt, Medical Director
Phil Townsend, Non-Executive Director
Sally Tucker, Chief Operating Officer
Sean Gilchrist, Director of ICT
Stephen Dunham, Assistant Director of Finance & Commercial Development
Tom Drabble, Patients’ representative
Apologies
Helen Brown, Deputy Chief Executive
Jeremy Livingstone, Divisional Director, Surgery, Anaesthetics & Cancer
Katie Fisher, Chief Executive
Lesley Headland, Chair of Staffside
Lisa Emery, Chief Information Officer
Paddy Hennessy, Director of Environment
Prof. Steve Barnett, WHHT Chair
Clerk
Clare Ransom, Executive Assistant
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Agenda item: 14/58
Report to: Trust Board
Title of Report: Assurance report from Clinical Outcomes and Effectiveness Committee
Date of meeting: 11 April 2018
Recommendation: For information and assurance
Chairperson: Jonathan Rennison, Chair
Purpose
The report summarises the assurances received, approvals, recommendations and decisions made by the Clinical Outcomes and Effectiveness Committee at its meeting on 30 November 2017
Background The Committee meets bi-monthly and provides assurance to the Board on:
Safe and effective patient care
Prevention, early intervention, recovery and rehabilitation
Ensure that the Trusts responsibility for infection control is effectively fulfilled
Promoting a culture of learning and continuous improvement.
Measure change using clinical outcome measures to monitor the impact of the services provided by the Trust.
Business undertaken
Integrated Performance Report (IPR) The Committee received and reviewed the IPR and was assured that appropriate actions were being taken to maintain and improve performance across a range of measures. In particular, the Committee was informed that there were 6 cases of Clostridium difficile infection (CDI) reported in February. The trust currently has a year to date total of 28 against the full-year target of 23. The rybotyping for each of the 6 cases in February were all individually different. The committee noted that the staffing fill rate remained below target at 91% but with an increase of 0.4% from last month. There are low fill rates in paediatrics, and this area is being reviewed as part of the establishment review covering skill mix and redesign. The complaint response position had deteriorated in month from 76% in January to 44% in February against a target of 85%.
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Neonatal peer review 2017 The committee received an update report on the neonatal peer review outcome. Overall the key findings included; evidence of strong clinical leadership, a cohesive team with good collaboration, proactive identification of risks, a successful own education programme, strong links with the network and support for nursing staff to access neonatal specialist nurse training.
There were no immediate risks identified, with two serious concerns noted:-
Restricted space around cots in the IC and HDU areas - it is suggested that a refurbishment of the area is undertaken and a business case for capital funding will be submitted early in 2019.
Entering activity onto the neonatal electronic admissions database to ensure additional workload for staff is captured – a 3-month audit has been undertaken, and the team are now analysing the data.
Two areas of improvement included:-
The number of qualified in speciality (QIS) trained nurses and
the service is to develop a nursing workforce strategy to
achieve compliance towards registered QIS numbers.
A lack of dedicated speech and language therapy service; the
management team and HVCCG are looking at a scoping
exercise to identify the need within the neonatal service
Resources support safe care for full-term babies The committee reviewed an update on the action plans implementing the recommendations from the reducing term admissions report. The committee received an update on actions currently on track for completion within the set timescales and those actions already completed. The committee were also updated on two outstanding actions still in progress. The committee was assured on the progress being made and the mitigations in place to reduce the risk of term admissions to NICU. Learning from deaths 6-monthly report The Committee received an update on the progress that had been made against the actions the trust was taking to implement the recommendations set out in the National Guidance on Learning from Deaths. The committee reviewed the two outstanding actions:-
Ensure that learning from deaths is core to the Trust's quality improvement work – the committee was advised that this was
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not yet embedded but continued focus by the trust mortality review group.
Offer a bereavement service for families and carers of people who die while in our care- A bereavement leaflet updated and training programme for PALs and patient affairs in place.
COE Committee risk register to include risks at 15 There are currently no corporate risks aligned to the clinical
outcomes and effectiveness committee. The previous aligned risk
had been closed and re-opened as two individual risk due to the
restructuring of the medicine and emergency medicine divisions.
BAF Action Tracker 2017-18 The Committee reviewed the board assurance framework and was assured that all actions were appropriate and on track. Action 56 to develop an RTT delivery work plan had been completed. Quality Account six monthly review against 2017/18 priorities
The committee received an update on the proposed trust quality
priorities for 2018/19, once finalised will be published as the Quality
account.
The three themes for the 18/19 quality priorities are:-
Sharing a commitment to quality of care and service
Fostering a team working culture
Building an organisation that drives quality
The committee reviewed the priorities and measures of success.
These have been aligned with the corporate objectives for the next
two years and will be signed off by the trust board.
Risks to refer to the risk register
None
Attendance In attendance for specific Items
Jonathan Rennison, Non-Executive Director Ginny Edwards, Non-Executive Director Tracey Carter, Chief Nurse & DIPC Mike van der Watt, Medical Director Martin Keeble, Chief Pharmacist Anna Wood, Associate Medical Director of Clinical Standards and audit Jane Shentall, Director of Performance Leigh Franklin, Assistant trust secretary (minutes) Tracey Payne, Interim Head of Midwifery Elvira Baker, Matron Neonatal services Dr Naaz Merhant, Neonatal consultant Dr Jinadatha, Neonatal Consultant
14
Tab 14 Assurance report from the Clinical Outcomes and Effectiveness committee
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Agenda Item: 15/58
Report to: Trust Board
Title of Report:
Patient and Staff Experience Committee Assurance Report to Trust Board
Date of meeting:
12 April 2018
Recommendation:
For information and assurance
Chairperson: Ginny Edwards, Non-Executive Director
Purpose
The report summarises the assurances received, approvals, recommendations and decisions made by the Patient and Staff Experience Committee at its meeting on Thursday 22 February 2018..
Background The Committee meets bi-monthly and provides assurance on:
Patient and staff experience measures, i.e. outcomes of surveys and audits
Staff engagement
Progress against the patient experience and workforce strategies
Organisational development
Workforce performance (IPR), including training, appraisals, revalidation, recruitment and retention
Equality and diversity
Health and wellbeing
Lessons learnt through comparison of best practice between services
Key Business Undertaken
Training compliance: The committee received a paper regarding steps being taken by the Training team to ensure that mandatory training data is correct. What is being proposed is a ‘bulk upload’ of training data requirements which will ensure that correct data regarding training competencies are in place for all positions within the Trust. The paper adviced that it is likely that in the short term this will impact negatively upon training compliance figures. This work will happen over the next two months with a plan in place to ensure that additional training is put into place to meet any shortfalls in compliance. The Committee recommends this work to the Board.
The Gender Pay Gap Report: The Committee received a paper on the
Publication of WHHT Gender Pay Gap. Whilst the Committee were clearly
concerned by the gaps in pay between our male and female employees and
particularly in relation to CEAs, it was assured by the further analysis which
showed a more positive picture. It was particularly pleasing to see that
women were forming a growing portion of our consultant workforce and
many other gaps between our male and female employees seem to be
narrowing. The Committee recommended the findings of this paper to the
Board.
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Tab 15 Assurance report from the Patient and staff experience committee
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National Staff Survey Results 2017 and next steps: The committee
received a paper presenting the results of the 2017 National Staff survey.
Whilst the Trust saw a small decline in the overall results as compared to
last year’s results it was pleasing to see a significant improvement as
compared to comparator trusts. The full results will be published on 6th
March alongside the publication of national results.
Review of Draft NHS Workforce Strategy: The Committee received a
paper providing an update on the consultation process regarding the
proposed NHS National Workforce strategy. The Committee welcomed the
proposal and were supportive of a number of observations regarding the
proposed strategy, as well as the fact that the trust would be fully involved in
feeding back upon the proposed strategy.
Review of PSEC Terms of Reference and Workplan 2018-19: The committee approved the proposed workplan and Terms of Reference with some minor amendments.
Review of Consultant and SAS Doctor Job Planning 2017/18 The Committee received a paper on the review of consultant and speciality and associate specialist (SAS) doctor job planning. The Committee noted that as at 11 January 2018, 79% of job plans had
been fully signed off. A further 9.5% of plans were not signed off because
they had necessarily been republished mid-year due to ongoing team
reconfiguration. Job plans for 2018/19 were published on 12 January 2018
with a final sign off deadline of 31 March 2018. The Committee welcomed
this update.
Outline of workforce role development Band 4,5 and 6 Nurse activity The Committee received a report to note initiation of an STP workforce
planning project, focussing upon the Band 4, 5 and 6 nursing workforce.
The project will determine whether deployment of current band 5 roles
makes best use of training and skill sets, and whether some duties can best
be undertaken by other qualified and unqualified staff.
Further updating will be provided to the committee once the project has determined options and recommendations for implementation.
Enabling BME Nurse and Midwife Progression into Senior Leadership Positions: The Committee received a paper advising that the Chief Nursing Officer for the NHS Jane Cummings had commissioned an enquiry into gaps in the experiences and opportunities across the NHS between white and BME staff. Senior leaders within the NHS are encouraged to review how they can impact on enabling a culture of diversity and inclusion, to encourage all talent to thrive within health and social care setting. The trust will be fully participating in this work and this will include regular reports to PSEC to ensure good progress with reports to the Board. The Committee recommends this work to the Board.
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The committee were asked to note the following: Update on OHS Service Provision The Committee received a paper for noting which provided details of a
proposal to work with the Royal National Orthopaedic Hospital NHS Trust,
the Royal Free Hospital, Barnet, Enfield and Haringey Mental Health Trust
and North Middlesex Hospital to work together on a new Occupational
Health Service. Update on progress around this work will be provided to
PSEC on an ongoing basis.
Approval to run a Mutually Agreed Resignation Scheme (MARS) The Committee received a paper for noting which provided details of a
proposal that the Trust introduces a Mutually Agreed Resignation Scheme
(MARS) to assist with proposed service reconfigurations during 2018-19.
This paper has also gone to Financial and Investment Committee for
assurance purposes.
Other items reviewed by the Committee:
Patient & Staff Experience Risks/BAF
Patient Experience Performance Report
Review of monthly workforce report
Update on CQC Report Workforce Issues
CQUIN NHS staff health and wellbeing; Indicator 1b Healthy food for NHS staff, visitors and patients
Risks to refer to risk register
.None
Key decisions taken
None
Issues to escalate
The Committee recommended the work being undertaken to improve the accuracy of training data to the Board.
The Committee recommended the Trust’s report into the gender pay gap to the Board for its approval.
The Committee recommended that the Trust be fully involved with
the work being undertaken into enabling BME nurse and midwife
progression into senior leadership positions
Challenges and exceptions
None
Future exceptional items
None
Attendance record
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Ginny Edwards, Non-Executive Director Tracey Carter, Chief Nurse & Director of Infection Prevention and Control Paul da Gama, Director of Human Resources Paul Cartwright, Non-Executive Director Jonathan Renison, Non-Executive Director Sally Tucker, Chief Operating Officer
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Agenda item: 16/58
Report to: Trust Board
Title of Report: Charitable Funds Committee Assurance Report to Board
Date of meeting: 12 April 2018
Recommendation: For discussion
Chairperson: Jonathan Rennison, Non-Executive Director Purpose
The report summarises the assurances received, approvals, recommendations and decisions made by the Charitable Funds Committee at its meeting on 15 March 2018.
Background The Committee meets quarterly and provides assurance to the Board:
that robust processes are in place to manage charitable funds and to ensure they are implemented;
that donated funds are utilised in a way that takes into account any stipulations set out by donors and ensure best value is obtained from the funds donated;
that further donations are being encouraged;
that systems comply with regulation and governance of NHS Charities.
Business undertaken
Options report on the future of the charity The committee reviewed and discussed the report on the future status of the charity provided by Kingston Smith. A series of interviews were conducted with representatives of West Herts Hospitals and other NHS trust charities and other charities working in Hertfordshire. From that work 10 options against 13 criteria were outlined in a matrix. The top scoring option recommended was to become an independent charity through merging with the Royal Free Charity. There were two other options which scored similarly highly; to outsource infrastructure services or to move towards independence without merging with another charity. The committee reviewed all the options and agreed that the next step would be to meet with the Royal free charity to gain a better understanding of how this might work. Progress on compliance with general data protection regulations The committee received assurance that the charity is fulfilling its responsibilities in preparing for GDPR and to ensure the trust is complaint by 25 May 2018. Terms of reference and work plan 2018/19 It was agreed that further review of the terms of reference would be required and a meeting would be arranged, circulate to the committee members for review before being taken to the board at its May meeting for final approval.
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Overview of funds The committee received a report on the charity’s financial position and financial performance as at the end of January 2018. The report included the balance sheet, a statement of financial activity, an investment trend report and a cash flow forecast. The committee was assured that investments were performing well and were being well managed. The committee also received an update on new income, grants and donations. On Site Fundraising The committee received a request to approve a way forward with on-site fundraising for charities or retail where the benefit is unclear. It was agreed that there should be a policy in place to deal with any applications, it was suggested contact with another NHS charity who may already have a similar policy in place.
Escalation to the Corporate Trustee
Update on the options appraisal on the future of the charity
Progress on compliance with GDPR
Terms of reference
Attendance record Jonathan Rennison, Non-Executive Director Ginny Edwards, Non-Executive Director Helen Brown, Deputy Chief Executive Tracey Carter, Chief Nurse Don Richards, Chief Financial Officer Louise Halfpenny, Director of Communications Paul da Gama, Director of Human Resources Jean Hickman, Trust Secretary Leigh Franklin, Assistant Trust Secretary (notes)
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Page 1 of 2
TRUST BOARD MEETING IN PUBLIC
AGENDA Agenda item: 20/58
03 May 2018 at 9.30am – 12.00noon
Lecture Room, Postgraduate Centre, St Albans Hospital
Apologies should be conveyed to the Trust Secretary, Jean Hickman on jean.hickman@whht.nhs.uk or call 01923 436 283
Item ref
Title Objective Previously presented
Lead Paper or verbal
01/59 Opening and welcome
To note N/A Chair Verbal
02/59 Patient experience presentation
To receive N/A Chief Nurse Presentation
OPENING
03/59 Apologies for absence
To note N/A Chair Verbal
04/59 Conflict of interests To note N/A Chair Paper
05/59 Minutes of the meeting held on 12 April 2018
For approval
N/A Chair Paper
06/59 Board action log from 12 April 2018 and previous meetings and decision log
To note N/A Chair Paper
07/59 Chair’s report
For information
N/A Chair Paper
08/59 Chief Executive’s report For information
N/A Chief Executive
Paper
PERFORMANCE
09/59 Integrated performance report – month 12
For information
and assurance
Trust Executive Committee
Chief Operating Officer
Paper
DELIVER A LONG TERM STRATEGY (BAF RISK 9)
14/59 Strategy update For information
and assurance
Trust Executive Committee
Deputy Chief Executive
Paper
GOVERNANCE
15/59 Terms of reference and work plans for board and committees
For approval
Trust Executive Committee
Deputy Chief Executive
Paper
16/59 Bi-monthly report on the corporate risk register
For information
Safety and Compliance Committee
Medical Director Paper
20
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Page 2 of 2
17/59 Slavery and human trafficking statement 2017
For approval
Safety and Compliance Committee
Deputy Chief Executive
Paper
COMMITTEE REPORTS
18/59 Assurance report from Finance and Investment Committee
For information
and assurance
Finance and Investment Committee
Committee Chair/ Chief Financial
Officer
Paper
19/59 Assurance report from Clinical Outcomes and Effectiveness Committee
For information
and assurance
Clinical outcomes and effectiveness
committee
Committee Chair/Chief Nurse
Verbal
20/59 Assurance report from the Audit committee
For information
and assurance
Audit Committee Committee Chair/Chief
Financial Officer
Paper
CORPORATE TRUSTEE
16/59 Update on charity general data protection regulations
For information
and assurance
Charitable Funds
Committee
Director of Communications
Paper
ANY OTHER BUSINESS
21/59 Any other business previously notified to the chair
N/A N/A Chair Verbal
QUESTION TIME
22/59 Questions from Hertfordshire Healthwatch
To receive
N/A
Chair Verbal
23/59 Questions from our patients and members of the public
To receive N/A Chair Verbal
ADMINISTRATION
24/59 Draft agenda for next meeting
To approve N/A Chair Paper
25/59 Date of the next board meeting in public: 07 June 2018, Trust Executive Meeting Room, Watford Hospital
To note N/A Chair Verbal
20
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Recommended