Delivering our Vision - East Surrey Hospital · Delivering our vision – How are we doing? October 2017 summary • The Trusts Income & Expenditure 2017/18 Control Total is a £21.3m

Delivering our Vision How are we doing?

October 2017

“We will pursue perfection in the delivery of safe, high quality healthcare which puts the people of our community first”

2

Through integration and partnership we aim to become both a provider and employer of choice

Annual priorities

Reduce avoidable

harm

Improve discharge planning

Staff health, well being and working lives

Create best environment for patients

Improve efficiency of elective care

Values

Safety & quality

One team

Dignity & respect Compassion

Vision We will pursue perfection in the

delivery of safe, high quality healthcare which puts the people of

our community first

Patient

Strategic objectives

Safe Effective Well-led Caring Responsive

3

• There were 8 SIs declared in October 2017.

• Patient safety indicators continue to show expected levels of

performance.

• There were no MRSA bloodstream infections and 3 Trust-apportioned

Clostridium Difficile cases in October 2017.

• Mortality is lower than expected for our patient group when benchmarked

against national comparators.

• Readmission indicators continue to see the Trust perform well.

SAFE - People are protected from abuse and avoidable harm

EFFECTIVE - People’s care, treatment and support achieves good

outcomes, promotes a good quality of life and is based on the best

available evidence.

• Friends & Family Test continues to show good patient feedback for the

Emergency department during a time of both high demand and refurbishment

while Inpatient FFT dropped slightly to 94.5% in October maintaining Amber

performance on the Trust RAG rating.

CARING - service involves and treats people with compassion,

kindness, dignity and respect.

Delivering our vision – How are we doing?

October 2017 summary

Serious

Incidents

8

%

Emergency

readmissions

within 7 days

3.8%

%

HSMR

(July-17)

91.7

%

ED FFT

96.7%

Inpatient FFT

94.5%

Safety Thermometer

99.3%

4

• The 4hr ED standard was not achieved in October 2017 with

performance of 93.2%. National performance for ‘Type 1

Departments’ in October was 87.8%.

• October saw improvements in both the Cancer TWW standards with

both returning to achieving the 93% standard.

• 62 Day GP performance continued to exceed the national standard

with over 90% of patients starting treatment within 62 days.

• 18 Weeks RTT - The Trust did not achieve the RTT Incomplete

pathways standard with performance of 86.8%. Recovery actions

and trajectory are in place.

• The SASH Star Awards were held on 9th November with awards presented to staff in

ten categories. We also recognised staff with long service ranging from 20 to 45 years.

• The 2017 National Staff Survey was launched on 5th October. Response rates are

currently at 53% against a national average of 28%. The survey closes on 1st

December.

• The work to support mental health awareness, (with South London & the Maudsley NHS

Trust), is on-going with positive feedback received for these interventions to date.

• ‘Staff Health’ has been chosen as one of three key priorities for the Trust across the

next twelve months.

• The Trust’s Inclusion Strategy has been developed and is now with stakeholder groups

(i.e. Black, Asian, and minority ethnic network (BAME), Local Negotiating Committee

(LNC), Joint Negotiating Consultative Committee (JNCC)), for review and comment.

RESPONSIVE - services meet people’s needs.

WELL LED - leadership, management and governance of the

organisation assures the delivery of high-quality person-centred care,

supports learning and innovation, and promotes an open and fair culture



ED 95% seen

in 4 hours

93.2%

%

Vacancy Rate

10.9%

%

Staff

turnover

16.2%

%

RTT

Incomplete

86.8%

62 Day GP

90.4%

5

FINANCE AND USE OF RESOURCES



• The Trusts Income & Expenditure 2017/18 Control Total is a £21.3m adjusted surplus.

Current forecasts show a £16m risk against delivery of this control total.

• The Trust achieved a £5.3m [adjusted] surplus at the end of October 2017, which was

£1.8m worse than plan for the YTD position. This is driven by a £0.9m shortfall in

clinical income and a £0.9m shortfall in Sustainability & Transformation Funding (STF).

• The position includes £3.1m STF for successfully delivering the Q1 & Q2 financial plans.

• £2.8m of savings have been achieved YTD.

YTD £m

Adjusted

Surplus

£5.3m

Action: The Board are asked to note and accept this report

Legal: All aspects of care provision is covered by the Health and Social care Act, this paper provides assurance

on safe high quality care (Including mortality).

Regulation: The Care Quality Commission (CQC) regulates patient safety and quality of care and the CQC register and

therefore license care services under the Health and Social Care Act 2009 and associated regulations.

Patient experience/

engagement: This paper includes significant detail on both patient experience and access to services.

Risk & performance

management

This is the main Board assurance report for performance against quality and financial measures and is

linked to risk management through the SRR.

NHS constitution; equality

& diversity;

communication.

This report covers performance against access standards with the NHS Constitution.

YTD £m

Savings

£2.8m

https://bi01/ReportServer?/015 Performance Investigator/D07 Trust Performance Dashboard - Money and Resource

Are we safe?

Section 2

6


Safe – People are protected from abuse and avoidable harm

7

• Positive Safety Thermometer performance continued for the “New Harm” measure with performance of

99.3% in October.

• The Trust declared eight serious incidents in October 2017.

• 2017/24286 - Falls – There was an unwitnessed patient fall resulting in a fractured neck of femur.

• 2017/24554 – Clinical Diagnosis - Delay in recognition of degree of trauma leading to delay in

transfer to trauma centre .

• 2017/24874 - Falls - There was a witnessed patient fall resulting in a fractured neck of femur.

• 2017/24941 – Falls - There was a witnessed patient fall resulting in the patient suffering a

haemorrhagic stroke and they sadly died.

• 2017/25142 – Falls - There was an unwitnessed patient fall resulting in a fractured neck of femur

• 2017/26053 – Infection Control - Patient was positive for Group A streptococcus from a blood culture

taken on 06/10/17. There is a possibility that this is cross infection. Typing and investigation

underway.

• 2017/26488 - Maternity/Neonatal – The incident is the discovery at a routine growth scan of the

intra-uterine death of a baby at 32 weeks gestation. The investigation will review all care given.

• 2017/26722 – Maternity/Neonatal – The incident is the intra-uterine death of a baby during labour.

The investigation will focus on the triage process and admission to unit to determine whether there

was a missed opportunity to manage care.

Serious

Incidents

8

Safety

Thermometer

99.3%

Safety



8

• Daily staffing - The Trust continues to monitor ward nursing numbers and skill mix on a daily basis and is

assured that adequate staffing is in place. The Trust has delivered the planned vs actual staffing profile for

October at organisational level. The overall compliance is similar to previous months.

• Nurse recruitment - Continues both locally and from overseas.

• Retention - The Trust continues to imbed the various work streams outlined in the retention strategy. As part

of the support programme offered to the Trust from NHS Improvement, the Deputy Chief Nurse and the

Deputy Director of Workforce will be attending the next retention masterclass on the 23rd November, where it

is hoped that feedback will be given on the Trust’s retention improvement plan.

• The Trust has now received a copy of the recommendations document following the Health Education

England Kent, Surrey and Sussex commissioned crowdsourcing work on staff retention. This is being

reviewed with a view to incorporating the findings into the organisations’ retention plans.

Ward staffing

RN Fill Rate

Day

95.4%

RN Fill Rate

Night

95.8%



9

• There were no cases of MRSA blood stream infection in October 2017 and 3 cases of Trust-apportioned

Clostridium difficile.

• Twenty cases of Clostridium difficile for 2017/18 have been reviewed by the CCG and 4 cases have

been viewed as a ‘lapse in care.’

• The topic of the most recent RPIW for the SASH+ work stream for diarrhoea was stool sampling.

• ARK study – Brighton has seen an immense reduction in antimicrobial consumption on Q1 of their

CQUIN this year. Aim for SASH to participate in the ARK study in Jan 2018.

• Explore Point of Care testing – Pro-calcitonin (inflammatory marker for acute infection) in ICU/admissions

with the aim to reduce initiation of antibiotics.

• A band 7 pharmacist has started a microbiology rotation.

• The Retention Pathway is under review and a Urology Nurse Specialist ward round pilot has commenced,

the pilot will focus on the management of retention and urinary catheter reviews.

Infection control

MRSA

0

C-Diff

3

Delivering our vision – How are we improving?

Safe – Reduce avoidable harm

10

• In October 2017, Inpatient falls were 5.23 per 1000 bed stay days which remains

below the national average.

• Focused work continues on the 8 falls pilot wards where we have seen a collective

reduction in falls of 26%.

• In October we had 4 Serious Incidents relating to falls which are currently being

investigated, any learning will be shared.

• The Monthly Falls Focus Group has implemented several falls initiatives and have

recently taken delivery of beds that incorporate an alarm to alert staff that a patient

at risk of falls is moving. The Deputy Chief Nurse for Innovation and Improvement

and the Clinical Matrons continue to monitor progress with these interventions.

Reduce falls

• In October, we reported four Grade 2 and two Grade 3 wounds.

• The pressure damage investigation process has been revised and the Root

Cause Analysis (RCA) are being presented to the bi-monthly Serious Incident

Review Group with effect from November 2017.

• The monthly Pressure Damage Board will re-focus as a working group and

disseminate the shared learning, action plans and changes in practise.

• Pressure Damage continues to be discussed daily at ward safety huddles.

• Pressure Damage prevention/management has been re-instated onto the

mandatory training agenda for clinical staff.

• Thursday 16th November is World Pressure Ulcer Prevention Day, we will be

holding education events throughout the Trust to enhance staff and patient

knowledge.

Reduce pressure damage

Total Falls

102

Falls / ‘000

Bed days

5.23

Total

Pressure

Damage

15

Pressure

Damage / ‘000

Bed days

0.77


Safe – Scorecard

11

Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Trend

No of Never Events in month 0 0 0 0 0 0 0 0 0 0 0 0 0

Serious Incidents - No declared in month 4 0 1 4 2 2 1 4 4 6 3 4 8

Serious Incidents - No per 1000 Bed Days 0.21 0.00 0.05 0.21 0.11 0.10 0.05 0.21 0.21 0.31 0.16 0.21 0.41

Patient Safety Incidents causing Severe harm or Death - Number in Month 4 0 3 1 0 0 2 1 3 5 1 4 2

Patient Safety Incidents causing Severe harm or Death - Percentage of all patient safety

incidents0.5% 0.0% 0.5% 0.2% 0.0% 0.0% 0.3% 0.1% 0.6% 0.8% 0.2% 0.7% 0.5%

Safety Thermometer - % of patients with harm free care (new harm) 94.8% 94.4% 96.8% 94.2% 97.9% 98.7% 99.0% 99.3% 98.0% 99.0% 98.8% 98.8% 99.3%

Percentage of patients who have a VTE risk assessment 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 97% 97% 97%

MRSA BSI (incidences in month) 0 0 0 1 0 1 0 0 0 0 0 0 0

CDiff Incidences (in month) 0 1 2 1 5 5 3 4 2 4 6 4 3

MSSA Trust Incidence 1 1 6 3 2 6 8 4 1 1 1 0 1

E-Coli Trust Incidence 3 6 4 5 4 5 7

Average fi l l rate – registered nurses/midwives (%) - Day 97.6% 98.7% 96.9% 97.5% 96.7% 95.6% 95.4% 96.9% 95.9% 94.4% 93.4% 93.5% 95.4%

Average fi l l rate – care staff (%) - Day 91.1% 88.7% 92.4% 91.9% 96.4% 93.0% 96.5% 96.6% 94.7% 94.9% 92.3% 96.3% 94.4%

Average fi l l rate – registered nurses/midwives (%) - Night 98.3% 97.7% 97.0% 97.3% 97.9% 97.4% 96.7% 97.9% 97.0% 97.5% 96.7% 96.0% 95.8%

Average fi l l rate – care staff (%) - Night 93.9% 92.8% 92.3% 95.4% 95.0% 94.9% 96.1% 95.3% 96.6% 96.5% 95.4% 95.1% 94.3%

Falls - Total in month 116 93 131 116 92 101 97 84 96 115 101 76 102

Falls per '000 Bed days 6.06 5.07 6.86 6.00 5.16 5.20 5.15 4.31 5.06 5.91 5.25 4.07 5.23

Pressure Damage (Hospital Aquired) - Total in Month 9 15 13 14 14 17 8 14 17 8 15 20 15

Pressure Damage per '000 Bed days 0.47 0.82 0.68 0.72 0.78 0.87 0.43 0.72 0.90 0.41 0.78 1.07 0.77

Safety

Ward Staffing

Infection Control (Trust Aquired)

Reduce Avoidable Harm

Are we effective?

Section 3

12


Effective – People’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence

13

• Latest HSMR data for the Trust continues to show improvements in relative risk and

remains rated ‘better than expected’ for our patient group when benchmarked against

national comparators.

• July in-month Hospital Standardised Mortality Rate for #NoF was a relative risk of

87.3.

• Latest SHMI data also shows positive performance.

Mortality and readmissions

• Readmission indicators continue to see the Trust perform well.

• Divisional audit programmes remain on track.

• The Trust reported significant progress in meeting NICE guidance around Acutely Ill

Patient.

Other effectiveness

HSMR

(July-17)

91.7

SHMI

(Mar-17)

0.95

7 day

Readmission

3.8%

28 day

Readmission (Sept-17)

8.0%


Effective – Improve discharge planning

14

• Daily calls with Senior Leaders from partner organisations to discuss ‘Delayed Transfer of Care’

(DTOC) patients continue with additional twice weekly calls with Chief Executive Officers.

• Improvements to the Discharge Tracker have been made and it is now automated and accessible by all

ward staff and community teams.

• CCGs have committed to 100k resilience monies to deliver required improvements and to strengthen

the Integrated Discharge Team over the winter period. The Team is working with external experts to fill

vacant posts.

• A post that has been funded to support delivery of the CQUIN ‘Supporting proactive and safe

discharge’ has been appointed to with a start date being agreed.

Discharge Planning

• The Trust continues to embed SAFER flow and a project is underway to move towards using

real-time data in the management of inpatient beds and associated resources.

SAFER Flow


Effective – Scorecard

15


HSMR (56 Monitored diagnoses - 12 Months) 93.4 93.9 95.8 95.9 94.7 94.8 94.4 93.0 93.4 91.7

SHMI 0.96 0.95

Emergency readmissions within 7 days 3.6% 3.4% 4.2% 3.6% 3.5% 3.7% 3.7% 3.8% 3.9% 3.5% 3.6% 3.7% 3.8%

Emergency readmissions within 28 days 7.4% 7.3% 8.4% 7.5% 7.2% 7.7% 7.5% 8.0% 8.0% 7.4% 7.6% 8.0%

Maternity - C Section Rate - Emergency 15.1% 15.9% 16.5% 12.8% 17.9% 17.1% 20.0% 20.0% 19.4% 16.5% 18.5% 15.3% 16.0%

Research - Overall Recruitment % Vs Expected 77% 88% 86% 100% 96% 98% 90% 79% 98% 110%

YCM - Were you kept informed of your estimated data of discharge from hospital? 71 68 67 70 64 68 67

YCM - When you were ready to be discharged, were you satisfied with the plan that was put in

place?84 79 79 82 79 77 83

Average No of Adults Over 7 Days 272 253 280 296 292 277 293 280 290 294 285 279 282

Average No of Adults Over 14 Days 163 152 163 184 178 171 182 171 185 188 180 173 177

Average No of MRD 102 98 96 110 105 108 115 97 95 123 117 109 116

Discharge Planning

Mortality and Readmissions

Other Effectiveness

Are we caring?

Section 4

16


Caring – service involves and treats people with compassion, kindness, dignity and respect

17

Outpatient

FFT

88.8%

• Inpatient FFT – Inpatient FFT dropped slightly to 94.5% in October from 95.7% in September

but maintains Amber performance on the Trust RAG rating. The response rate average for all

inpatient areas is 33%.

• Emergency Department FFT - The FFT score has increased to 96.7% in October from 95.5%

in September. The response rate for October was unusually low at 8.89%. This was due to the

building works in the Emergency Department and an interruption to the usual patient feedback

methods which has now been rectified.

• Maternity FFT – The FFT score for the postnatal ward has decreased significantly to 89.6% in

October from 95.7% in September. The Delivery/birthing centre score for September also

dropped to 80% however this was based on only 5 responses. Work is underway with the

maternity teams to understand the latest patient feedback score with a focus on improving

response rates at the same time as reviewing patient feedback.

• Outpatients FFT - The FFT score for Outpatients has decreased slightly to 88.8% from 89%

in September. The number of responses however has increased to 1335 in October compared

to 1200 received in September.

Friends and family test

ED FFT

96.7%

Inpatient FFT

94.5%

Raising awareness and supporting carers – Continuous opportunities are being used to promote the carers

passport and raise carer awareness among staff. An event is being organised in the restaurant to welcome carers

of patients for ‘tea and a chat’ hosted by our two carer support organisations. On the same day, and in recognition

of ‘carers rights day’, a staff even has also been arranged to reach out to staff who are carers to offer support and

listen to what these staff members need would appreciate in the way of support.

The carers steering group continues to meet regularly and the two carer support organisations visit wards

throughout the week to identify and provide assistance to carers of patients

Carers


Caring – service involves and treats people with compassion, kindness, dignity and respect

18

• Mixed Sex Breaches – The Trust continues to report zero mixed sex breaches in October. The organisation is

currently awaiting feedback from NHS England/NHS Improvement following the week long mixed sex accommodation

audit undertaken at the end of September.

• Complaints – In October complaints received increased to 52 in comparison to 36 the previous month. 100% of

complaints have been acknowledged within 3 working days, as per statutory requirements, consistently for the last 7

months and 100% of complaints were closed within the agreed timeframe in October.

• Accessible Information Standard – The testing phase for producing patient letters in alternate formats is currently

underway.

• Way Finding – Executive approval for the budget has been provided and the project is now being mobilised. Final

artwork is being prepared by the contractor for review and sign off. Following this, samples of proposed signs will be

installed in one area for final agreement and the signage within the scope of the project will then be installed in January

as well as a de-cluttering of old signage. Areas within the project scope are; main corridors, cardiology, therapies and

the two entrances.

Other Patient Experience

Complaints

per 10,000 pt.

contacts

11

Mixed Sex

Breaches

0

• Responsiveness to feedback – Automated actions generated by the Meridian system require key staff to make

appropriate and continuing improvements in their areas. Areas with a low FFT score are monitored and work streams

arise from this feedback. For example work continues in outpatients with oversight from the SASH+ team with Patient

experience involvement.

• Focusing on priorities for improvement at ward/departmental level – Priorities are consistently being raised to key

staff through the alerts system on the reporting platform and by the monthly batch reports provided to the clinical areas

by Meridian. The monthly ‘Patient Experience Committee analyses data from meridian to assess overall performance.

However it is agreed that a better approach to identifying top trends through the system should be provided and this is

going to be implemented in the coming months.

Patient experience platform


Caring – Create best environment for patients

19

• The new GP streaming area opens on the 9th November. The new ambulance bay continues to work well with excellent

compliance from all vehicles.

• The new Kingsfold Ambulatory Care Unit opened in October 2017.

• Work has commenced on design work for the different elements of the Neonatal project. These will be used to inform the tenders

which will be issued in early 2018.

Estate / Building Developments – Major Schemes

A variety of improvement works have been undertaken across the hospital wards and the following table summarises the main

activities:

Ward Improvement Works

Ward Works Status

Tandridge General refurbishment Preparing tender for revised scheme

Delivery Suite Bathrooms Underway

Delivery Suite Sluice and SANDs room In plan

Leigh & Newdigate Sluice Complete

Leigh & Newdigate Over-bed lighting and power Underway

Various Yellow toilet and shower doors Underway

Meadvale MDT room Complete

Outwood Bathrooms November

Outwood External windows Underway

Buckland Over-bed lighting Complete

Abinger MDT Room In plan

Capel Bathrooms In plan

Chaldon Flooring In plan

Abinger & Meadvale Rear Entrance In plan

Holmwood General Refurbishment Complete


Caring – Create best environment for patients

20

In addition to work in ward areas a number of other smaller projects have taken place or are planned, these are shown below:

Estate / Building Developments – Other Improvement Works

Outpatients General refurbishment Complete

Chapel Multi-faith facilities and refurbishment In plan

Diagnostic Imaging Various works Complete

Phlebotomy and Haematology Minor works including new back-door Complete

ED New flooring Underway

PGEC New reception and seating for lecture theatre In plan

Lung Function Refurbishment Complete

Bereavement New office Complete

Security New office Complete

Modular 1 Refurbishment and office moves Underway

Chamomile Courtyard New dementia garden by Pendleton Unit Tender being prepared

Mortuary Visitors’ Room Refurbishment Complete

Chipstead New OPD consulting room, ECG room and assessment

space

Underway

Main Kitchen Ventilation Upgrade Complete

Trust HQ

Toilet Upgrade Complete

Delivering Our Vision – How are we doing?

Caring – Scorecard

21


Emergency Department FFT - % positive responses 96.1% 96.8% 96.0% 96.3% 96.6% 96.9% 96.3% 95.7% 93.8% 95.7% 93.7% 95.5% 96.7%

Inpatient FFT - % positive responses 95.4% 94.8% 95.5% 96.7% 96.2% 95.8% 96.6% 95.6% 95.2% 96.2% 95.2% 95.7% 94.5%

Day Case FFT - % positive responses 95.4% 94.8% 95.5% 96.7% 96.2% 95.8% 96.6% 96.9% 94.4% 94.7% 93.9% 96.1% 95.5%

Outpatient FFT - % positive responses 91.1% 91.2% 88.0% 89.7% 90.7% 90.6% 88.0% 88.7% 88.6% 88.0% 90.5% 89.0% 88.8%

Maternity FFT - Antenatal - % positive responses 98.6% 95.6% 93.9% 98.5% 95.2% 95.9% 100.0% 94.7% 90.6% 87.5% 96.8% 100.0% 100.0%

Maternity FFT - Delivery - % positive responses 97.1% 96.9% 98.7% 97.8% 97.3% 98.8% 96.7% 100.0% 100.0% 83.3% 100.0% 100.0% 80.0%

Maternity FFT - Postnatal Ward - % positive responses 92.8% 86.6% 96.2% 92.3% 89.0% 92.1% 95.8% 91.0% 94.9% 95.2% 97.3% 95.6% 89.6%

Maternity FFT - Postnatal Community Care - % positive responses 96.4% 98.3% 92.5% 100.0% 92.0% 100.0% 97.7% 96.2% 100.0% 96.6% 97.2% 100.0% 100.0%

Mixed Sex Breaches 0 0 0 0 0 0 0 0 0 0 0 0 0

Complaints - Number received in month 48 36 36 56 43 57 41 50 55 37 42 36 52

Complaints - Rate per 10,000 patient contacts 10 7 8 12 10 11 10 10 11 8 9 8 11

Friends and Family Test

Other Caring

Are we responsive?

Section 5

22


Responsive – services meet people’s needs

23

ED 4hr

93.2%

Amb

Handover

over 60min

38

• October continued to be a busy month for emergency care. The ED 4hr standard was not

achieved in October 2017 with performance of 93.2%, however SASH system AEDB

performance was 95.9%.

• Ambulance turnaround performance remains a challenge in October 2017 with 38 breaches of

the 1hr standard. The re-development of the Emergency Department “Front Door” including

physical re-configuration and revised streaming will support improvements in ambulance

handover. From December, all 1hr breaches will be investigated as moderate incidents with an

RCA and reported through the Serious Incident Review Group.

Emergency department

• October saw improvements in both the Cancer TWW standards with both returning to achieving

the 93% standard.

• 62 Day GP performance continued to exceed the national standard with over 90% of patients

starting treatment within 62 days.

• Performance on the screening standard was 75.0% as a result of two breaches on the breast

screening pathway with delay due to patient deferrals.

Cancer treatment

Two Week

Wait

94.0%

62 Day GP

90.4%


Responsive – services meet people’s needs

24

• The Trust did not achieve the 92% RTT Incomplete pathway standard with performance

of 86.8% in September 2017.

• RTT remains a challenge with the impact of emergency pressures, cancer referrals,

tracking system change over as well as specialty specific capacity issues being the root

causes of the under performance.

• At the end of October 2017, 22 patients were waiting over 52 weeks for treatment. Of

these 22 patients, 9 have since either received treatment or been discharged back to

the care of their GP. Treatment plans are in place for the remaining 13 patients.

• No patient harm has been identified from RTT 52 week breaches and root cause

analysis of the pathway is undertaken by clinical divisions.

• The 6 week diagnostic standard was not achieved in October 2017 with performance of

1.19% with capacity issues in Cardiac CT being the key driver. Recovery is expected in

November 2017.

RTT and diagnostics

RTT

Incompletes

86.8%

6 Week

Diagnostic

1.19%


Responsive – Improve efficiency of elective care

25

• Outpatients has seen positive performance with £579k of savings YTD. The DNA rate

reduced in October to 7.7%. The un-booked rate remained static in October, driven by a

variety of factors including staffing levels. Recruitment plans are in place which will

support further improvement in this indicator in the coming months. Review of capacity in

specialties with short waiting times are also underway.

• Theatres saw improved performance in October 2017, although remains behind trajectory

and significantly impacted YTD by Q1 performance.

• Theatre cases per session increased to 3.03 with some specialties continuing to show

improvements compared to prior year. Cancellation rates were 7.2% which is behind

trajectory but an improvement on September – there were zero on-the-day bed

cancellations.

• Endoscopy productivity was adverse to trajectory in October and a number of measures

are being put in place to support improvement and these are yielding benefit in November.

• Across all booking teams there has been an impact on plans from delays in EPR upgrades

and office moves as well as from staff sickness.

Overview of October 2017

OPD (OBO)

DNA Rate

7.7%

OPD (OBO

Un-booked

Rate

10.4%

THR - Cases

Per Session

3.03

THR

Cancellation

Rate

7.2%

Endo -

Patients Per

Session

5.51

Endo - Points

Per Session

7.54


Responsive – Scorecard

26


ED 95% in 4 hours 95.4% 95.1% 89.8% 87.0% 90.9% 95.1% 92.9% 92.6% 92.8% 93.6% 94.4% 94.1% 93.2%

Patients Waiting in ED for over 12 hours following DTA 0 0 0 0 0 0 0 0 0 0 0 0 0

Ambulance Turnaround - Number Over 30 mins 189 224 336 253 194 249 188 253 199 246 306 225 299

Ambulance Turnaround - Number Over 60 mins 11 22 80 66 34 19 27 46 50 33 47 40 38

Cancer - TWR 94.8% 94.3% 94.5% 94.7% 94.4% 95.0% 92.2% 93.0% 93.7% 90.6% 91.1% 91.6% 94.0%

Cancer - TWR Breast Symptomatic 99.0% 95.8% 94.7% 95.4% 93.0% 95.7% 93.0% 93.5% 93.5% 95.7% 90.5% 85.7% 94.1%

Cancer - 62 Day Referral to Treatment Standard 89.8% 89.7% 86.6% 87.9% 86.0% 86.4% 87.9% 86.0% 85.2% 86.9% 85.7% 86.3% 90.4%

Cancer - 62 Day Referral to Treatment Screening 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 71.4% 100.0% 81.8% 75.0% 80.0% 87.5% 75.0%

Cancer - 31 Day Diagnosis to Treatment 96.0% 95.6% 100.0% 97.7% 99.0% 98.7% 100.0% 99.2% 98.6% 99.2% 95.5% 95.2% 97.3%

Cancer - 31 Day Second or Subsequent Treatment (SURGERY) 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 95.5% 100.0% 100.0%

Cancer - 31 Day Second or Subsequent Treatment (DRUG) 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

RTT Incomplete Pathways - % waiting less than 18 weeks 92.1% 92.5% 90.9% 90.5% 90.0% 90.1% 88.7% 87.3% 87.3% 86.9% 86.4% 86.1% 86.6%

RTT Patients over 52 weeks on incomplete pathways 3 4 5 13 15 19 19 53 51 33 23 20 22

Percentage of patients waiting 6 weeks or more for diagnostic 9.5% 8.3% 4.7% 0.4% 0.3% 0.2% 0.4% 0.7% 1.0% 0.9% 0.7% 0.8% 1.19%

No of operations cancelled on the day not treated within 28 days 9 5 2 7 3 9 7 18 21 15 5 11 12

Cancer Access

RTT

Emergency Department

Are we well led

Section 6

27


Well led – leadership, management and governance of the organisation assures the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture

28

Vacancy Rate

10.9%

• Vacancy rates across all staff groups has decreased by 0.7% to 10.9%. For Nursing, vacancy rates

have remained at 19%.

• Turnover has reduced by 0.3% to 16.2% for all staff groups, but increased by 0.5% for nursing to

19%.

• We are reviewing our approach to recruiting nursing and midwifery staff and are undertaking an

assessment of different options for this (e.g. direct sourcing, etc.).

• Our Retention Plan has been submitted to NHSi and we are awaiting feedback. Our objective is to

reduce turnover by 1% across all staff groups in the 12 months from October 2017 to November

2018.

• We have submitted a bid to Health Education England Kent, Surrey and Sussex for funding to

support our succession planning and talent management programmes.

• We have started to design the management training component (‘How to Get Thing’s Done’), of our

overall ‘SASH Leaders’ programme.

Establishment

Turnover

Rate

16.2%

• MAST figures have remained fairly static at 76%.

• All clinical Divisions have a compliance rate of at least 77%, with Cancer & Diagnostics currently at

80%, (against a green RAG rating KPI of 80%).

• We are reviewing areas with low compliance rates (i.e. Estates & Facilities), to consider bespoke

solutions to increase their overall rate.

• Achievement Review completion rates increased to 84%, by the end of October against a target of

90%. We have however subsequently achieved the 90% target.

• The Trust’s HR Business Partners are working with Divisions to ensure all relevant staff have a

completed achievement review for 2017.

Training and Achievement Review

MAST

Compliance

76.1%

Achievement

Review

84%


Well Led – Staff health, well being and working lives

29

• Sickness has increased by 0.3% to 4.1%.

• There has been a reduction in absences for planned surgery and MSK related issues.

• There has been a significant increase in absences for ‘colds, coughs, and flu’, as well as

increases for GI and mental health related conditions.

• Long term sickness is at 1.8%

• Short term sickness is at 2.3%

• The new in-house Employee Relations Team are proactively managing sickness cases

with line managers to ensure these are concluded in a timely manner

Sickness

• The Trust’s Flu vaccination campaign commenced on 9th October and over 2,200 vaccinations have

been administered so far. Our target is that 70% of all frontline staff are vaccinated by 31st

December.

• The collaborative work with South London & the Maudsley, (SLaM), which is to support staff with

managing their mental health is on-going. The mental health impact assessments are now complete

and analysis of the outcomes of these are being reviewed to support ‘next steps’ in this programme.

• SLaM are also delivering Mental Health Awareness sessions for staff and managers which have

been well received.

• We continue to promote ‘Active SASH’ activities across the Trust – we are currently promoting on-

site circuit training for staff (which commences on 5th December).

• We are developing our ‘Step Ahead’ campaign which encourages staff to walk more frequently and

sets out a number of walks they can take in lunch breaks, etc.

Health and Well being strategy

Sickness %

4.1%


Well Led – Scorecard

30


Total Establishment (WTE) 3891 3937 3944 3952 3925 3932 3929 3944 3950 3961 4006 4006 4027

Vacancy Rate (All Staff) 11.2% 11.5% 11.8% 11.0% 9.8% 9.4% 9.5% 9.5% 9.6% 10.4% 11.1% 11.6% 10.9%

Staff Turnover rate 15.6% 15.5% 16.4% 16.4% 16.1% 15.8% 16.0% 15.7% 15.8% 15.9% 16.1% 16.5% 16.2%

% of Staff who have had an Achievement Review YTD 86.4% 95.2% 96.4% 97.0% 97.2% 97.6% 1.3% 11.5% 19.5% 39.7% 53.0% 65.0% 84.0%

%age of staff who have completed MAST training in the last 12 months 80.3% 79.9% 80.0% 80.3% 76.8% 78.0% 77.2% 76.0% 77.0% 75.0% 77.0% 76.6% 76.1%

Overall Sickness Rate 3.9% 4.2% 4.3% 4.1% 3.7% 3.5% 2.8% 3.5% 3.6% 3.8% 4.1% 3.8% 4.1%

Establishment and Training

Staff health, well being and working lives

Do we use resources effectively

Section 7

31



Effective use of resources

32

• The Trust’s Income & Expenditure 2017/18 Control Total is a £21.3m adjusted surplus. Current

forecasts show a £16m risk against delivery of this control total.

• The Trust achieved a £5.3m [adjusted] surplus at the end of October 2017, which was £1.8m worse

than plan for the YTD position. This is driven by a £0.9m shortfall in clinical income and a £0.9m

shortfall in Sustainability & Transformation Funding (STF).

• The position includes £3.1m STF for successfully delivering the Q1 & Q2 financial plans.

• £2.8m of savings have been achieved YTD.

• The 2017/18 savings programme totals £6.2m.

• The Programme includes:

• £2m saving in agency premium,

• £2.4m productivity savings,

• £1.8m non pay savings,

• YTD achievement is £2.8m (including £1.2m use of contingency reserves) against a plan of £2.8m.

Savings Plan

YTD Savings

£m - Actual

£2.8m

YTD £m

Adjusted

Surplus

£5.3m

Income and Expenditure





Effective use of resources

33

• The planned Capital Resource Limit (CRL) for 2017/18 is £18.8m including £1.1m CRL deferred from

2016/17.

• The capital programme will be funded by £9.8m from depreciation, £7m capital investment loans, £0.9

Public Dividend Capital for ED Primary Care Screening and other internally generated funds; the Trust will

repay £1.3m of existing capital investment loans.

• Major projects in the 2017/18 capital programme include, Ambulatory Care Unit £2.9m, Pathology Joint

Venture £2.7m, EPR Digitise £2.0m, Day Surgery Unit £1.7m and Estates Fixed Allocation £1.5m.

• The cash balance at the end of August 2017 was £5.4m.

• The Trust repaid £3.5m revolving working capital in April 2017 and borrowed a further

£1.3m in July leaving an outstanding balance of £13.8m.

• This cash has supported the Trust’s Better Payment Practice Code performance

which is 87% by volume, 86% by value in the first four months of 2017/18.

Capital Plan

Cash Management



Resources – Scorecard

34


Outturn £m Surplus / (Deficit) - Plan 15.2 15.2 15.2 15.2 15.2 15.2 21.3 21.3 21.3 21.3 21.3 21.3 21.3

Outturn £m Surplus / (Deficit) - Forecast 15.2 15.2 0.3 5.0 5.0 5.0 21.3 21.3 21.3 21.3 21.3 21.3 21.3

YTD £m Surplus / (Deficit) - Plan 1.8 6.2 5.0 6.8 10.1 15.2 (1.6) (0.3) 1.1 2.7 3.0 4.3 7.1

YTD £m Surplus / (Deficit) - Actual 0.1 2.8 2.0 3.6 2.0 3.5 (1.0) 0.1 1.2 2.7 3.1 4.4 5.3

Annual Outturn UNDERLYING £m Surplus / (Deficit) - Plan 7.5 7.5 7.5 7.5 7.5 7.5 12.5 12.5 12.5 12.5 12.0 12.5 12.5

Annual Outturn UNDERLYING £m Surplus / (Deficit) - Actual 7.5 7.5 (4.6) (2.8) (2.8) (4.3) 12.5 12.5 12.5 12.5 12.0 12.0 12.0

YTD Savings £m - Actual 3.1 4.4 5.6 6.8 8.0 9.2 0.3 0.7 1.0 1.4 1.8 2.2 2.8

OT Risk £m Surplus / (Deficit) - Assessment (14.9) (14.9) (4.0) (2.5) (2.5) 0.0 (8.0) (8.0) (8.0) (16.3) (16.3) (16.0) (16.0)

Outturn Cash position £m Fav / (Adv) - Forecast 2.1 6.3 2.5 2.5 2.5 5.6 2.7 2.7 2.7 2.7 2.7 2.7 2.7

YTD Cash position £m Fav / (Adv) - Actual 4.8 7.2 5.3 4.4 2.9 5.6 3.8 5.9 2.6 3.9 5.4 5.1 6.0

YTD Liquid ratio - days (16.0) (10.0) (9.0) (7.0) (11.0) (12.0) (14.0) (13.0) (12.0) (11.0) (10.0) (9.0) (8.0)

YTD BPPC (overall) volume £m 77% 79% 80% 82% 83% 83% 94% 93% 92% 88% 86% 82% 74%

YTD BPPC (overall) value £m 77% 79% 80% 80% 82% 82% 97% 94% 91% 87% 87% 83% 78%

Outturn Capital spend Fav / (Adv) - forecast 15.9 12.6 12.4 11.3 11.4 11.4 18.8 18.8 18.8 18.8 18.8 18.8 18.8


Documents

Delivering our Vision - East Surrey Hospital · Delivering our vision – How are we doing? October 2017 summary • The Trusts Income & Expenditure 2017/18 Control Total is a £21.3m