Meeting of the Board of Directors AGENDA – MEETING IN PUBLIC

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Meeting of the Board of Directors

10.00am to 12.30pm on Thursday 28 January 2016

Boardroom, Washington Suite, Worthing Hospital, Lyndhurst Road, Worthing, BN11 2DH

AGENDA – MEETING IN PUBLIC

1. 10.00 Welcome and Apologies for Absence Chair

2. 10.00 Declarations of Interests All

3. 10.00 Minutes of Board Meeting held on 26 November 2015 To approve

Enclosure Chair

4. 10.05 Matters Arising from the Minutes

To note Enclosure Chair

5. 10.10 Chief Executive’s Report

To receive and agree any necessary action Enclosure MG

PATIENT SAFETY/EXPERIENCE ITEMS

6. 10.25 Quality Report To receive and agree any necessary action

Enclosure AP/GF

7. 10.45 Organ Donation Annual Report

To receive and agree any necessary actions Enclosure GF

OPERATIONAL ITEMS

8. 10.55 Performance Report To receive and agree any necessary actions

Enclosure JF

9. 11.10 Organisational Development and Workforce Performance

Report To receive and agree and necessary actions

Enclosure DF

10. 11.20 Annual Equality and Diversity Performance Report

To receive and agree and necessary actions Enclosure DF

11. 11.30 Financial Performance Report

To receive and agree any necessary actions Enclosure KG

STRATEGIC ITEMS

12. 11.40 Patient First Programme Update To receive and agree any necessary actions

Enclosure MG

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GOVERNANCE/RISK MANAGEMENT/CONTROL

13. 11.50 Quarterly Operational Plan Objectives and Board Assurance Framework Update To receive and agree any necessary actions

Enclosure MJ/AG

14. 12:00 Quarterly Submission to Monitor

To approve Enclosure AG

OTHER ITEMS

15. 12.10 Other Business Chair

16. 12.15 Resolution into Board Committee To pass the following resolution: “That the Board now meets in private due to the confidential nature of the business to be transacted.”

Verbal Chair

17. 12.15 Date of Next Meeting

The next meeting in public of the Board of Directors is scheduled to take place at 10.00am on 3 March 2016 in the Bateman Room, Chichester Medical Education Centre, St Richard’s Hospital, Spitalfield Lane, Chichester, PO19 6SE

Chair

18. 12.15 Close of Meeting Chair

19. 12.15

to 12.30

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

Chair

Andy Gray Company Secretary Tel: 01903 285288 / Mobile: 07785332416

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MINUTES OF A MEETING OF THE BOARD OF DIRECTORS IN PUBLIC HELD AT 10:00 ON 26 NOVEMBER 2015 IN BOARDROOM A, WASHINGTON SUITE, WORTHING HOSPITAL, LYNDHUSRT ROAD, WORTHING, BN11 2DH

Present: Mike Viggers Chair

Bill Brown Non-Executive Director

Joanna Crane Non-Executive Director

Jon Furmston Non-Executive Director

Lizzie Peers Non-Executive Director

Mike Rymer Non-Executive Director

Marianne Griffiths Chief Executive

Jane Farrell Chief Operating Officer and Deputy Chief Executive

Denise Farmer Director of Organisational Development and Leadership

George Findlay Medical Director

Karen Geoghegan Director of Finance

Amanda Parker Director of Nursing and Patient Safety

In Attendance: Andy Gray Company Secretary

Mike Jennings Commercial Director

Carol Fenn Board Administrator (Minutes)

1. WELCOME

1.1 The Chair welcomed everyone to the meeting.

2. DECLARATIONS OF INTERESTS

2.1 There were no interests to declare.

3. MINUTES

3.1

The Board received the minutes of the meeting held on 29 October 2015, copies of which had previously been circulated.

3.2 IT WAS RESOLVED THAT the minutes be approved for signature by the Chair.

4. MATTERS ARISING

4.1

A schedule of Matters Arising from the previous meeting held on 29 October 2015, copies of which had previously been circulated, was considered and noted.

5. CHIEF EXECUTIVE

5.1

Marianne Griffiths presented her report, copies of which had previously been circulated. The following were highlighted:

Endoscopy Services at Worthing Hospital – the £7m endoscopy works at Worthing Hospital had been completed. The investment would help the Trust manage the increasing demand for endoscopy services;

Chichester Emergency Floor – the emergency floor at St Richard’s Hospital had been refurbished to provide a single point of access for acute medical and surgical admissions;

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Nursing Recruitment o the success of the domestic nurse recruitment campaign; o the initiatives to mitigate the delayed arrival of nurses from the Philippines,

which included: plans for the nurses to join the Trust in an unregistered capacity initially

once they passed the first two English language tests; and further Skype interviews with nurses from Europe;

o the plans to support the orientation and integration of nurses joining the Trust from overseas;

CQC Inspection – the ongoing preparations for the CQC inspection scheduled to take place from 8 to 11 December 2015;

Eye Care at Southland’s Hospital – the public events held to display plans for the new state-of-the-art eye care facilities at Southland’s Hospital;

Staff Conference – the second Staff Conference scheduled to take place on 27 November 2015; and

Medicine for Members – the two “Medicine for Members” events held to raise awareness and offer assurance of the treatment of sepsis within the Trust.

6. QUALITY

6.1

George Findlay and Amanda Parker presented the Quality Report for Month 7, copies of which had previously been circulated. The following were highlighted:

Effectiveness o the crude non-elective mortality rate rose from 2.70% in September to

2.97% in October (October 2014: 2.83%). This represented a normal trend for the winter period. The 12-month mortality also rose slightly to 3.23%;

o the Dr Foster Hospital Standardised Mortality Ratio (“HSMR”) for the 12 months to July had fallen to 93.2 (100 being the level predicted by the Dr Forster model using the April 2015 benchmark);

o there remained a slight difference between the mortality rates at Worthing Hospital and St Richard’s Hospital. This might be due to a difference in casemix (for example, the older/frailer population at Worthing), for which, the Dr Foster tool did not adjust; and

o the significant improvement in stroke care with Worthing Hospital and St Richard’s Hospital being ranked seventh and 35th place respectively in the latest Sentinel Stroke National Audit Programme results (previously, neither hospital featured in the top 100);

Safety o there were:

five Serious Incidents Requiring Investigation; 42 falls resulting in harm (against a benchmark of 43); no cases of MRSA bacteraemia; seven cases of hospital attributable C-difficile. Four related to lapses in

care (environment and commodes); 19 cases of Grade 2 hospital acquired pressure ulcers; three cases of Grade 3 hospital acquired pressure ulcers; and four exception reports relating to prescribing incidents, compliance with

WHO checklist, two lapses in catheter care plans and a “Never Event” following knee replacement surgery, the details of which were outlined in full to the Board together with the initial action taken;

Patient Experience o there were 72 complaints, which represented a significant increase on

previous months. The most significant theme was the communication of ophthalmology appointments;

o Friends and Family Test scores remained good against national benchmarks; and

o there were three exception reports relating to cancellations, the MUST assessment and the breach of mixed sex accommodation arrangements previously reported.

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6.2

6.3

In response to an inquiry from Jon Furmston, George Findlay advised that the slightly higher fractured neck of femur rate at Worthing Hospital compared to St Richard’s Hospital was not a cause for concern. Both hospitals’ rates were lower than the national average. The difference might be attributable to casemix (for example, the older/frailer population at Worthing), for which, the Dr Foster tool did not adjust. There was a mechanism by which issues/anomalies in relation to the tool could be fed back to Dr Foster. Marianne Griffiths added that the Medicine Division was exploring the difference in mortality rates and would report back to the Board in January.

GF

6.4

6.5

6.6

6.7

6.8

In response to a question from Lizzie Peers, George Findlay advised that three to four “True North” metrics were being developed. The metrics would be presented at the Board Review Day in January. In relation to an inquiry from Lizzie Peers, Amanda Parker advised that the Trust had responded quickly to the increase in ophthalmology complaints during October. An ophthalmology call centre had been established and communications improved. Following a comment from Mike Rymer, Jane Farrell advised that the number of cancellations on the day of surgery remained high due to bed pressures. She also highlighted the work being undertaken as part of the Elective Transformation Programme to eliminate pre-assessment backlogs and optimise theatre schedules. In relation to an inquiry from Joanna Crane, Jane Farrell advised that the increase in clinics cancelled with less than six weeks’ notice for annual/study leave was being investigated to identify any themes and determine if these were the same as those attributable for the deterioration in Month 5. The Board noted the findings of the CQC Review of Health Services for Children Looked After and Safeguarding in West Sussex (Appendix 1). It was agreed that the recommendations should be monitored to completion and reported on in future Quality Reports.

AP

7. NURSING STAFFING AND CAPACITY

7.1

Amanda Parker presented the Nursing Staffing and Capacity Levels Report, copies of which had previously been circulated. The following were highlighted:

the requirement to review nurse staffing and capacity levels every six months to determine if they met safety requirements;

the guidelines developed by NICE on the assessment methodology and escalation processes;

the findings of the latest review: o staffing on adult inpatient, midwifery, children and neonatal care wards met

safe staffing requirements; and o one adult inpatient ward (Barrow) was flagged as Amber as its staffing

levels for September did not reflect the opening of additional escalation beds during that month;

the Trust’s rigorous monitoring and escalation processes, which included: o the display of live information by shift on screens in wards; o the reporting of incidents through Datix; and o the review of information at monthly triangulation and Board meetings.

8. PERFORMANCE

8.1

Jane Farrell presented the Performance Report for Month 7, copies of which had previously been circulated.

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The following were highlighted:

Activity o A&E attendances were up 4.4% on the same month last year; o emergency admissions were up 9.9% on the same month last year. There

was an increase in the age profile of patients compared to the same month last year (up 10.9% for 65-84 years and up 13.5% for 85 years and over);

o delayed transfers of care totalled 3.41%; and o occupancy of funded bed stock was 95.4%;

A&E o the Trust was fully compliant in October with 95.47% of patients waiting less

than four hours from arrival at A&E to admission, transfer or discharge (against a national target of 95%); and

o the Trust continued to benchmark well locally and nationally. Compliance across the southern region was 89.5%, with Surrey and Sussex trusts (excluding the Trust) generating aggregate compliance of 90.6%. National compliance was 90.1%;

Cancer o the provisional position for October indicated that the Trust was compliant in

six out of seven cancer metrics as projected in the Month 6 report; and o the Trust was provisionally below the 62-day Referral to Treatment (“RTT”)

target of 85%, with 84.6% of patients being seen within 62 days. Inclusive of the provisional October position, Quarter 2 was fully compliant at 85.7%;

RTT o during October, the Trust completed 11,435 RTT patient pathways (2.5%

above the planned recovery volume for the month); o cumulatively the Trust was 3.7% ahead of recovery plan commitments in

the year-to-date. Urgent/cancer referrals were up 9.6% on the same month last year; and

o despite improved performance in recent months, referral demand remained a critical risk to the delivery of the RTT recovery programme. To mitigate this, the Trust was working with secondary and primary care clinicians to develop schemes to reduce referrals to secondary care;

Diagnostic test waiting times o the restricted diagnostic capacity provided by external organisations and

excessive demand for diagnostics remained a challenge. To mitigate this, extensive recovery actions had been implemented across five diagnostic procedure types; and

o during October, 248 of 5,837 patients waited over six weeks (a reduction of 33.9% from the peak volume of 375 observed in September).

8.2

8.3

Following an inquiry from the Chair, Jane Farrell advised that workforce and financial constraints remained key challenges for the Trust and its partners. Efforts to mitigate and manage the risk included:

the Seasonal Resilience Group (“SRG”) had established a system wide winter resilience plan;

the SRG was challenging commissioners to release additional financial resources; and

the Trust together with other acute providers had written to the Health and Adult Social Care Committee (“HASC”) to raise awareness of the risk level.

The Chair asked Jane Farrell to circulate a copy of the letter sent to HASC to the Board.

JF

9. ORGANISATIONAL DEVELOPMENT AND WORKFORCE PERFORMANCE

9.1

Denise Farmer presented the Organisational Development and Workforce Performance Report for Month 7, copies of which had previously been circulated.

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The following were highlighted:

Workforce o the progress being made in relation to recruitment and retention. For

example, the number of nurses joining the Trust exceeded the number of leavers in October; and

o the continued work to eliminate non-framework agency usage;

Equality and Diversity o the annual report due to be presented to the Board in January; and o the community engagement event scheduled to take place on 8 December

2015 at Bognor Regis;

Long Service Awards – the long service awards held for over 100 members of staff who had completed 25, 30 and 40 years’ service in the NHS.

9.2

9.3

9.4

In response to an inquiry from Joanna Crane, Denise Farmer advised that the reduction in bank staff usage and increase in agency staff usage during Month 7 might be attributable to half-term. Overall fill rates had improved. Following a further question from Joanna Crane, it was agreed that additional information on compliance with the Working Time Directive, particularly in relation to bank staff, would be provided in the next report. In relation to an inquiry from Lizzie Peers, Denise Farmer advised that the increase in short term sickness would be explored to identify any themes. Denise emphasised the importance of protecting and promoting the health and wellbeing of staff.

DF

10. FINANCE

10.1

Karen Geoghegan presented the Financial Performance Report for Month 7, copies of which had previously been circulated. The following were highlighted:

the Trust reported a year-to-date deficit of £2.0m against a planned surplus of £1.7m due to underperformance in income from activities and increased pay expenditure;

the Trust reported an overall Financial Sustainability Risk Rating (“FSRR”) of 3. The Capital Servicing Capacity Ratio improved delivering an FSRR of 3. The Income and Expenditure (“I&E”) Margin and Variance in I&E Margin as a Percentage of Income both delivered an FSRR of 2. The Liquidity Ratio deteriorated but delivered an FSRR of 3;

cash remained behind plan in the year-to-date due to the I&E variance. There was an increase in accrued income, which related to contractual overperformance and CQUIN payments. However, this was offset by slippage against the capital programme and increased creditors;

income was £1.7m behind plan in October. Income for PbR excluded items and seasonal resilience continued to offset activity underperformance. Private patient and non-patient care contracts continued to underperform;

operational costs were £2.1m adverse to plan in October. Pay overspend was driven by ongoing agency costs to cover vacancies. The increase in pay expenditure related in part to the provision of additional medical bed capacity. Non-pay overspend continued to be driven by PbR excluded items;

agency expenditure increased to £2.3m in October and continued to exceed the same period in 2013/14 and 2014/15, particularly in medical and nursing;

there was slippage of £4.1m against the capital programme in the year-to-date, notably in Endoscopy, Estates and Information Technology. This was being actively managed and the programme was forecast to be on plan by the year-end; and

the Efficiency Programme delivered cumulative savings of £9.2m against a plan of £9.7m.

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10.2

10.3

Karen Geoghegan advised that the Trust’s overall FSRR would deteriorate to a 2 next month if the financial position did not improve. Marianne Griffiths emphasised that the Trust was doing everything it could to reduce agency spend and optimise run rates.

11. PATIENT FIRST PROGRAMME

11.1

Marianne Griffiths presented the Patient First Programme Update Report, copies of which had previously been circulated. The following were highlighted:

the success of the first phase of implementation of the Patient First Improvement System (“PFIS”) training on four wards; and

the activity planned for December, which included continued implementation of PFIS training, continued establishment of the Kaizen Office, and the development of “True North” metrics and a “Lean” training plan.

11.2

11.3

George Findlay emphasised the success of PFIS training on four wards. Sisters and other members of staff were developing new ways of working to organise and manage wards more proactively. Members of staff, who had some scepticism initially, were now powerful advocates. It was agreed that an update would be provided as part of the Board Review Day in the new year.

AG

12. OTHER BUSINESS

12.1

George Findlay gave an update on the extensive planning underway to mitigate disruption from the junior doctors’ strike scheduled to take place in December.

13. NEXT MEETING

13.1

The next meeting would take place at 10.00am on Thursday, 28 January 2016 in Boardroom A, Washington Suite, Worthing Hospital, Lyndhurst Road, Worthing, BN11 2DH.

………………………………………………….

Mike Viggers, Chair

Date:

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QUESTIONS FROM MEMBERS OF THE PUBLIC ATTENDING THE MEETING

Member Topic Response

Malcolm Brett

Finance – sale of Harness Block

Karen Geoghegan confirmed that the proceeds from the sale of the Harness Block were held with other Trust deposits and would be reinvested in Southland’s Hospital.

Estates – reception at Southland’s Hospital

Karen Geoghegan agreed to look into the provision of staff/volunteer cover and the facilities at the main reception at Southland’s Hospital.

John Bull Quality – “time to theatre”

George Findlay confirmed that 36 hours was the best practice target set nationally for “time to theatre”. In many cases, the Trust performed ahead of this target.

Beda Oliver Recruitment –Upper GI Surgeon

George Findlay confirmed that the Trust was recruiting for an Upper GI Surgeon.

Quality – “True North” metrics

The Chair explained that a piece of work was underway to identify three to four key objectives (“True North” metrics).

Heather Duffield

Patient First Programme – training

Denise Farmer advised that staff had an opportunity to develop their skills through the Patient First Programme.

Nurse training/ apprenticeships

Denise Farmer confirmed that the routes into nursing included an apprenticeship. The Trust was keen to identify other routes to widen access to nursing for young people.

Recruitment – international

Denise Farmer advised that nurses from overseas were required to pass English language tests to evidence their English language competency.

Discharge delays

Jane Farrell advised that the slight rise in patients fit for discharge but still within the hospital was due to a combination of factors, including the constraints of the local social care market.

MATTERS ARISING Board in Public

Meeting Minute Ref

Action Person Responsible

Deadline Status

29 October 2015

6.2 Circulate report on the visit to John Radcliffe, Oxford (re caesarean section management). GF

January 2016

Action completed – report circulated to the Board on 21 January 2016.

8.3 Consider and report on opportunities to speed up Medical consultant recruitment processes. DF

Action completed – see page 2 of the Organisational Development and Workforce Performance Report.

26 November 2015

6.3 Explore and report on the differences in mortality rates at Worthing Hospital and St Richard’s Hospital.

GF Verbal update to be given at meeting.

6.8 Monitor the CQC’s recommendations (re children safeguarding) to completion and report on them in future Quality Reports.

AP Action completed – recommendations being monitored and reported on.

8.3 Circulate the letter sent by the Trust and other acute providers to HASC.

JF Action completed – letter circulated.

9.3

Provide additional information on compliance with the Working Time Directive (particularly re bank staff) in

the next Organisational Development and Workforce Performance Report.

DF

Action completed – see page 3 of the

Organisational Development and Workforce Performance Report.

11.3 Provide update on PFIS training on wards to the Board.

GF Action completed – update provided at the Board Review Day.

To: Trust Board

Date: 28 January 2016

From: Marianne Griffiths, Chief Executive Agenda Item: 5

FOR INFORMATION

CHIEF EXECUTIVE’S BOARD PAPER

1. Patient First

Congratulations to Helen Lee “for going above and beyond to put the patient first” Our Chief Audiologist at Worthing and Southlands has been crowned Audiologist of the Year by the British Academy of Audiology (BAA). Helen Lee, who has been helping patients with hearing problems for more than 30 years, won the prestigious prize after a colleague put her forward. The BAA’s Audiologist of the Year accolade is awarded to an audiologist that stands out from the crowd – someone who has gone above and beyond to put the patient first. Carol Churchill, Audiology Manager, nominated Helen for the exemplary care she gave to a young girl whose quality of life was being severely affected by tinnitus, which creates a buzzing in the ears. Carol wrote in the nomination: “In her own time, Helen prepared a personalised care plan, researched current best practice, liaised with tinnitus specialists, prepared visuals and made a chart to aid this little girl’s rehabilitation.” She added: “Helen is one of the most compassionate, caring, hard-working, patient-centred audiologists I have ever met and she is truly worthy of the award.” As a result of Helen’s innovative approach the young girl is now sleeping at night, coping better at school and at home and is much happier and able to manage the symptoms of tinnitus. In September 2015 Worthing and Southlands Audiology Department became the first department in the Trust to be recommended for a prestigious accreditation that recognises high standards of care and important quality improvement work. The Department passed a rigorous assessment and inspection process in the IQIPS (Improving Quality in Physiological Services) programme, which is run by the Royal College of Physicians and leads to accreditation from the United Kingdom Accreditation Service (UKAS). The inspectors’ feedback was overwhelmingly positive, with the department commended in a number of areas including clinical practice, the caring and professional manner of staff and for being generally well run. They also told staff it was the cleanest department they had ever visited. Care Quality Commission (CQC) visit in December It with an enormous sense of pride that I recount the week the CQC visited our hospitals. During their four days with us, they wrote copious notes, were present from early morning until early evening and spoke to hundreds of patients and staff. The notes, their observations and the evidence they gathered will determine our rating in their final inspection report. I must mention that more than anything, they have an incredibly positive impression of our people, our passion and the esteem in which we are held by our patients and public alike.

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I am beyond proud of the way our staff conducted themselves over what was an intense and exhausting week. It gave me great pleasure to immediately share the compliments the inspectors paid our staff and volunteers. They said they were struck throughout their visit by the passion staff showed in all aspects of delivering patient care, by the way in which our caring values shine from everything we do and by the support colleagues provide for each other in all circumstances. I was told that they have never experienced a welcome like the one they received at Western Sussex. I am not only grateful to our staff for the professional way they handled the pressure leading up to, and during the inspection, and the enthusiasm shown by the numbers attending the focus groups, I am enormously grateful to our patients for submitting their experiences of our care prior to the inspection. The list of colleagues who were instrumental in making the inspection go so smoothly is far too long for me to name individuals, but special mention must be made of the CQC Support Team and the Trust’s Ambassadors. The support team prepared more than 1,000 documents for the CQC in advance of their visit and continued to handle more requests for information during the visit. Our wonderful ambassadors set the tone on the ground by providing a concierge service to the inspectors of which any five-star hotel would be proud – nothing too much trouble, everything done efficiently and always with a smile. I will single out our housekeeping and facilities and estates teams for delivering the high standards of cleanliness and environment across the trust that so impressed the inspectors too. The inspection process was formally concluded after the standard, unannounced visit the inspectors made just before Christmas. We now await the report which is due in the next few months. Foundation Trust Governor elections Nine of our Public Governors and one Staff Governor have come to the end of the first three year term and we have two vacancies for a Public and a Staff Governor. Planning the process is now underway and there will be comprehensive information on our website shortly. In the meantime, anyone interested in becoming a Governor is welcome register their interest by emailing [email protected] Membership Engagement Survey – Are we reaching you? The Trust’s Membership Committee, chaired by Vicki King, Lead Governor, has instigated a Membership Engagement Survey to measure the impact of our communications activities with members and specifically how informed and engaged they feel. Members are a key part of the organisation and their feedback helps shape services and make improvements to all aspects of patient care. The survey is available on the Trust’s website www.westernsussexhospitals.nhs.uk/membersurvey and will help ensure we communicate as effectively as possible with our members. Congratulations to Leah Colclough Pharmacist Leah Colclough is also an Army Reservist serving with 256 (City of London) Field Hospital, based in Dyke Road, Brighton passed out of the Royal Military Academy Sandhurst, heralded as the national centre for leadership, following a four-week intensive course transforming her into an officer. Leah, who serves with the capital’s only military field hospital has attended a Commissioning Course for Professionally Qualified Officers (PQO) which has been specifically designed for doctors, dentists, pharmacists, nurses and lawyers.

mailto:[email protected]

http://www.westernsussexhospitals.nhs.uk/membersurvey

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Celebrating 30 years of thank yous! Janet Webber, from the Friends of Worthing Hospitals, has been the key Christmas present buyer and wrapper for patients’ presents for more than 30 years. On Christmas Eve, we surprised Janet on Broadwater Ward and presented her with a bouquet of flowers and box of chocolates from the Trust in recognition of her many years’ service to patients.

2. Junior Doctors’ strike action – Tuesday 12 January 2016

Around 100 F1, F2 doctors and SAS doctors from the Trust joined colleagues nationwide in 24hrs of industrial action. In order to protect patient safety it was necessary to postpone around 300 (15%) outpatient appointments, around 30 planned day-case procedures (25%) and less than 10 inpatient operations (50%). Our call centre and administrative teams contacted all patients affected to advise them of the postponement. Our operational site teams manned two control rooms at Worthing and St Richard’s and were there to assist with any queries or issues arising from within our hospitals or partner organisations. I would like to thank all staff and volunteers across the organisation for pulling together to minimise, as much as was possible, any adverse effects on patient care.

3. Nursing recruitment and staff retention Our 18 nurses from Spain and Portugal who arrived in December are settling in well and this month we are welcoming 8 nurses from the Philippines. All the nurses will undertake a one-month induction programme which introduces them to working within the Trust and the UK. We would like to hear from anyone who has a spare room which they might be willing to rent to our new nurses while they look for more permanent arrangements. Please call Sue Villis, Accommodation Manager, on 01903 285115. The Trust’s ‘one stop shop’ local recruitment events are continuing at regular intervals and we’ve already held out first this one this year; Band 5 Nurses are invited to meet the Trust’s senior nursing team, tour our hospitals, and be interviewed and tested all on the same day. Those successful leave with a firm job offer on the table, subject to pre-employment checks. The total number of nurses recruited last year from these events is 85. Open and Selection Days are continuing for Band 5 Qualified Nurses and the forthcoming dates are: • Homefield, Worthing, Tuesday 2nd February 2016 • CMEC, St Richard’s, Wednesday 24th February 2016 • CMEC, St Richard’s, Friday 11th March 2016 • Homefield, Worthing, Wednesday 6th April 2016

4. Welcome to new colleagues Dr Katie Manning (GMC: 6122915) – Consultant in Emergency Medicine (Chichester) – start date March 2016 Mr Surajit Das (GMC: 6073925) – Fixed Term Consultant in Obstetrics and Gynaecology (Worthing) – start date 17 February 2016 Mr Almasuddin Qazi (GMC: 5193710) – Fixed Term Consultant in General Surgery (Worthing) – start date 14 December 2015 Mr Lawrence Dodd (GMC: 6029178) – Fixed Term Consultant in Orthopaedics (Chichester) – start date 3 February 2016 Mr Aneel Ansari (GMC: 4718378) – Consultant in Orthopaedics (Worthing) – start date 21 December 2015

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Mr Sathish Madhavarajan (GMC: 6070582/GDC: 193160) – Consultant in Oral and Maxillofacial Surgery (Chichester) – start date 18 April 2016 Updated start date: Dr Peter Basford – Consultant in Gastroenterology (Chichester) – start date 7 March 2016

5. Chief Operating Officer Jane Farrell, Chief Operating Officer and Deputy Chief Executive, will be leaving us at the end of March to take up the post of Chief Operating Officer at King’s College Hospital NHS Foundation Trust in London. Jane has made a huge contribution to the development of the trust over the past seven years, helping take us through merger, achieve Foundation Trust status and deliver some major improvements in care for people right across the communities we serve. Her appointment to a key role in one of the country’s largest hospitals is a great tribute to Jane’s professional and personal qualities, but it also reflects well on Western Sussex as an organisation staffed by people of that calibre. The recruitment process has begun and we hope to have someone in place as soon as possible.

6. Summary of our Employee of the Months

In October we had joint winners: Carl Schwar, Waste Porter at St Richard’s. This nomination was submitted by David Jones, Director of Facilities and Estates, following the assistance Carl gave to the wife of a patient who collapsed in a corridor whilst her husband was here for a blood test. The A&E Doctor who attended the call spoke to the Portering Supervisor and said that he was impressed with the action Carl took. He said that Carl had put the lady in the recovery position and constantly spoke to her up until the time the crash team arrived.

Suzanne Prior, Oncology Secretary, Worthing Hospital This nomination was submitted by Claire Dikken, Lead Nurse for Cancer and Tim Hutson, Lead Manager for Cancer and End of Life Care. They described, in detail, the professionalism and dedication Suzanne showed during recent difficult times when the team has been short due to staff sickness. What shone through in their nomination was Suzanne’s commitment to the team and the compassion shown to patients and relatives, which all ensures safe and timely care.

November’s winner was Sister Debby Wolf, Barrow Ward, Worthing. The nomination was submitted by Dr Peter Davies, GPST2 SHO, who wanted Debby to be recognised for managing the recent significant changes on her ward. He called Debby ‘inspirational’ and submitted an impassioned nomination and said despite supervising 38 medical beds, Debby always has time to discuss patients with colleagues and families and “is dedicated in maintaining her in depth, holistic knowledge of the patients’ needs on the ward”.

December’s winners were Sarah Griffin and the Antenatal team at St Richard’s for exceptional

leadership which resolved a difficult situation with speed and efficiency. Their nomination was submitted by Gail Addison, Senior Midwifery Manager, who described her return to the Women and Children’s unit from community midwifery duties on December 7th.

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“On entering the west block I was redirected to enter the unit through day surgery, on arrival into the antenatal clinic I was met by complete devastation – sewage was dripping from the ceiling, the parentcraft room was flooded and the computer was very nearly floating! The entrance to the department was flooded and the staff were dressed in scrubs with plastic aprons over their heads to protect themselves from the dripping waste. The notes room was also flooded with water dripping onto the work surfaces and this, don't forget, was two days before the arrival of the CQC!!

“The staff, led by Sarah, were amazing. Within 24 hours the rooms were de-humidified, a new carpet was laid, the office and parentcraft room were in working order and a new computer was ordered. All staff were fantastic and this demonstrated true team work form the antenatal clinic staff, including the receptionists and support workers, Emma, Sally, Denise and Jade. Estates were truly fantastic thanks to Ralph, Mike, George and Elliott. The night domestic team worked their socks off - Judy, Yuri, Andre and Jeff. Two volunteers redirected patients, staff and visitors - Naomi and Francesca - and the DSU porters and Security moved buckets full of water.

7. Events PZAZZ, is a new singing group which has just started at St Richard’s Hospital. It is open to members of staff and the local community and the group will sing pop, rock and songs from musicals, con conducted by the young, and extremely talented, musical director Marc Yarrow, of Brighton GMC fame. PZAZZ meets each Wednesday in the Training Room from 7.30-9.00pm. The first taster session is free, thereafter it costs £4 per session. For more information please contact [email protected]

On Thursday 4th February between 10am -12.30 pm in Worthing’s Medical Education Centre, there is a fantastic opportunity to come along to meet members of our Occupational Therapy (OT) team and find out more about their work. There will be presentations by OTs and an opportunity to see some of the practical work they do and to ask questions. A tutor from the University of Brighton will also attend to talk about the BSc and MSc OT courses they offer. If you, or someone you know is interested in a career in OT or is currently applying for an OT course then please come along to find out more. To book a place please email Lisa Harford via [email protected]

On 4 May between 6-8pm at St Richard’s Hospital, our IBD Nurse Specialist Carla Hookway is hosting another of her informal friendly awareness and information sessions on Crohn’s and Colitis Disease. Anyone is welcome to attend. Please register via [email protected]




Title

Quality Report – Month 9

Responsible Executive Director

Dr George Findlay, Medical Director Amanda Parker, Director of Nursing and Patient Safety

Status

Disclosable

Summary of Proposal

N/A

Implications for Quality of Care

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

Link to Strategic Objectives/Board Assurance Framework

This report pulls together key national, regional and local quality indicators relating to quality and safety providing assurance for the board and (if necessary) highlighting issues.

Financial Implications

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

Human Resource Implications

Describes KPIs linked to workforce.

Recommendation The Board is asked to NOTE the report. Communication and Consultation

N/A

Appendices

Appendix 1: Quality Scorecard Appendix 2: Ward Staffing Scorecard

To: Trust Board

Date of Meeting: 28 January 2016

Agenda Item: 6

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

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

Western Sussex Hospitals Foundation Trust (WSHFT).

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

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

appendices.

2 2015/16 REFRESH

2.1 As part of the refresh of the Quality Strategy outlining key quality objectives for the next three years, this

report will be refreshed and redesigned. The Trust Quality Board has reviewed and approved a new

format with a view to making a recommendation to the Trust Board. A discussion took place at the last

Trust Board and this will be progressed in line with development of the Trust’s quality improvement

agenda.

2.2 As described in April, to provide assurance in the interim period, the format and metrics used for

2014/15 have been used. Targets for this interim period have been applied according to the following

hierarchy: 1. Where national targets are available these are applied; 2. Where specific local targets or

thresholds have been previously agreed these have been applied; 3. Where the 2014/15 targets were

based on 2013/14 levels, these have been refreshed to use the 2014/15 levels as a benchmark. (Any

exceptions to this are noted below).

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

3 KEY QUALITY OBJECTIVES

3.1 Dashboard Definitions

3.1.1 The full Clinical Quality Dashboard is presented as Appendix I. Figures are in-month figures (e.g. the

number of falls reported in October) unless otherwise stated. The dashboard shows 13 months to allow

trends to be identified, although some data items are reported retrospectively. Year to date

actuals/targets are based on financial years unless otherwise stated (e.g. standardised mortality ratios

are recorded as 12 month positions). A subset of the key measures from the report is presented at 3.3.

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

Effectiveness, Safety and Experience).

3.1.3 Only the current financial year and year to date values are RAG rated, with the exception of those

metrics reported in arrears with no data in the current financial year where the most recent data-point of

last year is RAG rated.

3.2 Domain scores

3.2.1 The domain score is an overall indication of the performance in relation to each of the three areas. The

score is calculated as follows: Each RAG rated indicator for a month is scored as follows: reds score 1,

ambers score 2, greens score 3. These scores are then totalled and divided by the total number of

indicators with RAG ratings to give a score for the domain as a whole between 1 and 3. This final score

can then itself be RAG rated with >2.5 giving an overall green, 1.5 to 2.5 amber and <1.5 an overall red

score for the domain as a whole. For example if a domain had two greens and a red the calculation

would be as follows:

3 (green) + 3 (green) + 1 (red) = 7

7 / 3 (i.e. the total number of metrics) = 2.33 i.e. amber overall.

3.2.2 Year to date domain scores are calculated based on the year to date RAG ratings for each metric.

Previous months are retrospectively updated to take account of any measures reported in arrears.

3.2.3 As with any aggregate indicator, it remains essential that the board retains sight of the individual

elements as well as the domain score as a whole.


3.3 Overview of Key Quality Objectives

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

Indicator Oct 2015

Nov 2015

Dec 2015

2015/16 to date

2015/16 Target /

limit

Effectiveness Domain Score 2.73 2.47 2.71 2.60 2.5

Safety Domain Score 2.44 2.89 2.53 2.39 2.5

Experience Domain Score 2.07 2.40 2.13 2.20 2.5

E01 Trust crude mortality rate (non-elective) 2.97% 3.56% 3.35% 3.05 3.27%

E02 Hospital Standardised Mortality Ratio for top

56 diagnoses (Dr Foster, based on rolling 12

months)

90.3

(12m to

Sep)

<92

S05 Number of Serious Incidents Requiring

Investigation (number reported in month)

5 5 6 56 60

S14 Numbers of hospital attributable MRSA 0 0 0 0 0

S28 Numbers of hospital C. diff where a lapse in

the quality of care was noted

4 1 3 15 18 (national

target = 39)

X01 The Friends and Family Test: Percentage

Recommending Inpatients

95.4% 95.5% 96.0% 95.0%

X02 The Friends and Family Test: Percentage

Recommending A&E

90.2% 92.1% 92.1% 91.3%

X15 Mixed Sex Accommodation breaches

(number of breaches)

0 0 0 1 0

X20 Number of complaints 72 43 45 453 570

3 EFFECTIVENESS

3.1 Crude Trust Mortality

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

non-elective activity. The Trust uses the previous year as a benchmark.

3.1.2 Crude non-elective mortality fell from 3.56% in November to 3.35% in December, lower than the

equivalent month in 2014 (December 2014 = 3.64%). The year to date level remains lower than the

same months in 2014. The 12 month mortality also rose slightly to 3.27%.


3.2 Hospital Standardised Mortality Ratio (HSMR)

3.2.1 There is a delay in data being available in Dr Foster tools to allow for coding and processing by the

Health and Social Care Information Centre and Dr Foster. The most recent data available is September

2015.

3.2.2 The Trust’s HSMR for the twelve months to September 2015 is 90.3 (where 100 is the level predicted by

the Dr Foster model using the April 2015 benchmark). HSMR has shown a steady reduction this

financial year.

3.2.3 The twelve month HSMR to July 2015 split by site is lower for St Richards (88.0) than for Worthing

(92.3), however both are lower than 100.

3.2.4 This data is now rebased using the latest available benchmark (April 2015), this accounts for the

observable increase at April 2015.

3.2.5 A further report is available to clinical leaders in the Trust showing the clinical diagnostic areas with high

actual versus expected mortality and any mortality CuSum alerts.

3.3 Summary Hospital-Level Mortality Indicator (SHMI)

3.3.1 The latest data made available by the Health and Social Care Information Centre is for the period April

2014 to March 2015. The Trust value is 1.03 (where 1.00 is the national average), with the Trust banded

as ‘as expected’.

3.4 Exception Reports Relating to Effectiveness

3.4.1 None to report


4 SAFETY

4.1 Central Alert System (CAS) Safety Alerts

4.1.1 There are no outstanding alerts for the Trust relating to December 2015 or earlier.

4.2 Serious Incidents Requiring Investigation (SIRIs)

There were 6 incidents which occurred in December that have initially been graded as serious incidents

requiring investigation. A detailed SIRI report is provided to the Committee section of the Trust Board.

The Board should note there is a slight variation in the month by month numbers between the SIRI

report and the scorecard as the scorecard assigns incidents to the month in which they occur whereas

the latter assigns them to the month in which the SIRI was raised.

Recent actions undertaken/planned following SIRIs include the use of anti-embolism stockings with grips

and slipper socks to reduce likelihood of falling, undertaking a review of the pathway for patients wearing

a collar (in relation to pressure damage) and development and implementation of the Procedural Safety

Checklist for Gynaecology Outpatient Procedures adapted from the WHO checklist for use in

Colposcopy, Hysteroscopy and all minor procedure clinics.

4.3 Infection control

4.3.1 There were zero cases of Methicillin-resistant Staphylococcus Aureus (MRSA) bacteraemia during

October.

4.3.2 There were 3 cases of hospital attributable Clostridium difficile during December; 1 at the Worthing site

and 2 at St Richards.

4.3.3 The 3 cases in December equate to a rate of 10.70 cases of C diff per 100,000 bed days compared the

national average for 2014/15 of 15.1 cases per 100,000 bed days (interquartile range 10.3 to 17.6)

(source: https://www.gov.uk/government/statistics/clostridium-difficile-infection-annual-data).

4.3.4 Of the 3 cases in December, root cause analysis identified all three cases related to lapses in care,

relating to environmental issues and issues relating to commodes and prompt isolation.

4.3.5 The year to date figures for both the overall hospital attributable C diff and C diff relating to lapses in

care are now marginally above trajectory.


https://www.gov.uk/government/statistics/clostridium-difficile-infection-annual-data

4.4 Falls

4.4.1 In December there were 39 falls resulting in harm against a benchmark of 43.

4.4.2 There were no falls resulting in severe harm or death in December.

4.4.3 Of the 39 falls in December, in 11 instances the patient had previously fallen during the inpatient stay.

4.4.4 The trust continues to review whether falls identified as part of the safety thermometer audit were

avoidable (see indicator S24). The consistent themes identified in these cases were the level of staffing

and the lack of consistent intentional rounding.

4.5 Tissue Viability

4.5.1 As described previously, changes in the way the Trust reports pressure ulcers means that more grade 2

and grade 3 ulcers will be reported in 2015/16 than previous years.

4.5.2 Based upon the new reporting arrangements, during December the Trust reported 16 cases of grade 2

hospital acquired pressure ulcers.

4.5.3 In addition to this there were 3 hospital acquired grade 3 pressure ulcers. These related to deterioration

of existing skin damage. There were no grade 4 pressure ulcers.

4.5.4 The incidence of pressure ulcers (including those developing within 72 hours after admission) per 1000

bed days in December was 0.66.

4.5.5 Root cause analysis (RCA) of all of these cases identified in seven instances the harm was deemed

avoidable due to omissions in documentation of skin assessments and the frequency of repositioning.

The following actions are being undertaken as a result of this:

• All wards are undertaking monthly SSKIN bundle audits.

• Emergency Floor Worthing has planned a number of pop up sessions with Tissue Viability Nurse

to reinforce the importance of Skin assessment and the correct use of the intentional rounding form.

• Photography guidelines and cameras now in place, with teaching sessions planned for key staff

groups.

• Purpose T pilot is extending to include a further ward.


4.5.6 All grade 3 pressure ulcers have a root cause analysis investigation and are subject to an executive

review.

4.5.7 There were 81 patients admitted to the Trust from the Community with pressure damage.

4.6 NHS Patient Safety Thermometer

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

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

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

available to each ward showing Trust-wide and ward-level data for each individual harm as well as the

harm-free care score. These numbers are also shared via the new ward screens.

4.6.2 The harm-free care score for the Trust in December was 96.0% (indicator S02), better than the target of

93.8% (target based on national average for 2014/15).

4.6.3 The Safety Thermometer includes harms suffered by the patient in healthcare settings prior to

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

(indicator S03) was 98.6%. A new target of 99% of patients suffering no new harms following admission

for 2015/16 has been set within the Trust Quality Account. This will prove a stretching target as it is

considerably higher than the national average of 97.7%.

4.6.4 National data relating to the NHS safety thermometer is available here:

http://www.safetythermometer.nhs.uk/

4.6.5 As part of the Trust’s 2015/16 CQUIN programme, WSHFT are rolling out the use of the Medication

Safety Thermometer – a separate, but complementary data collection focused on appropriate

prescription and administration of medicines – across all key wards during 2015/16. At the time of writing

the Medical Safety Thermometer is used on 45 wards across the Trust.


http://www.safetythermometer.nhs.uk/

4.7 Exception Reports Relating to Safety:

4.7.1 Exception Report: Indicator S09 – Moderate and severe prescribing incidents: There was one moderate

incident relating to medication or prescribing in December. At the time of writing this incident is still under

review.

5 PATIENT EXPERIENCE

5.1 PALS and Complaints

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

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

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

Trust Board.

5.1.2 During December 2015 the Trust received 45 complaints. This is similar to the number reported in

November and a significant decrease from the high figure reported in October.

5.2 Friends and Family Test (FFT)

5.2.1 Patients who access hospital services are asked whether they would recommend WSHFT to their

friends or family if they needed similar treatment. Patients who access inpatient, outpatient, day-case,

A&E and maternity are all offered the opportunity to respond to the question (plus a number of other

areas outside the scope of the official friends and family data collection).

5.2.2 Immediate feedback is provided to wards and departments on a continuous basis to ensure staff can

address problems or get positive feedback as quickly as possible. In addition to this a dashboard is

available giving wards access to their individual scores and a poster printed with ward performance to

display to the public. Ward recommend rates are also shown on the new screens installed on wards.

5.2.3 Friends and Family Test Response Rates: As described previously the criteria for inclusion in Friends

and Family changed significantly for 2015/16 to include paediatric patients, day-cases and short-stay

non-electives. As such the response rate fell considerably at the beginning of the year. Work is

underway in the new areas to increase the response rates.


5.2.4 Friends and Family Test Recommend Rates: In line with national guidance the Friend and Family test is

now reported as a ‘percentage recommending’ score (calculated as the percentage of respondents

indicating they were either ‘highly likely’ or ‘likely’ to recommend the service divided by the total

respondents including ‘don’t knows’). National performance is published on the NHS England website:

http://www.england.nhs.uk/statistics/statistical-work-areas/friends-and-family-test/friends-and-family-test-data/

5.2.5 The table below shows the latest local scores against national benchmarks:

Percentage recommending WSHFT in Oct (year to date in brackets)

National median (April 2014 to March 2015)*

Inpatient care 96.0% (95.0%) 94.1%

A&E 92.1% (91.3%) 86.8%

Maternity: Delivery care 98.6% (96.4%) 95.4%

Outpatient care 92.4% (89.9%) No benchmark

Maternity: Antenatal care 100% (96.6%) 94.6%

Maternity: Postnatal ward 98.6% (96.2%) 92.2%

Maternity: Postnatal community

care

100% (98.2%) 96.6%

* Some caution should be undertaken using this benchmark due to the changes to the eligible patients noted

above.

5.3 Feedback from Hospital Experience Questionnaires

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

divisions and wards. Information, including satisfaction levels for patient admitted both in and out of

hours, is also shown on the new ward information system. 400 inpatients gave their views on the Trust

using the RTPE system in December.

5.4 Exception Reports Relating to Experience

5.4.1 Exception Report: Indicator X12 – Patients cancelled on the day of surgery for non-clinical reasons:

There were 43 patients cancelled on the day of surgery during December. This was a direct result of

pressure on availability of beds. The year to date performance remains on target.


http://www.england.nhs.uk/statistics/statistical-work-areas/friends-and-family-test/friends-and-family-test-data/

5.4.2 Exception Report: Indicator X14 and X15 – MUST Assessment in 24 hours and 7 days: As reported

previously, the Trust has implemented this assessment on the electronic Patientrack system. This gives

a more robust and stringent monitoring system, capturing data continuously on all appropriate patients

rather than relying on once a month audit. Initial data from Patientrack shows reduced compliance for

December, particularly for the 24 hour measure. In some cases this will be the result of MUST scores

being recorded on paper first and then transferred to Patientrack subsequently. Work is underway with

ward in ensuring both the accurate capture of this data and compliance with this key patient safety and

experience indicator.

6 CARE QUALITY COMMISSION (CQC)

6.1 CQC Inspection

6.1.1 The CQC have undertook inspection of the Trust on 8th to 11th December. Limited verbal feedback was

given to the Chairman and CEO at the end of the inspection. The draft report is awaited and expected

to be received in the next few months.

6.2 CQC Intelligent Monitoring Reports

6.2.1 The CQC have announced that they will not be producing any further Intelligent Monitoring Reports and

will rely on trust inspections.


7 NATIONAL AND LOCAL REPORTS

7.1.1 None to report

8 COMMISSIONING FOR QUALITY AND INNOVATION (CQUIN)

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

agreed quality metrics.

8.2 Agreement has been reached in relation to 2015/16 CQUIN measures. National measures include care

for patients suffering acute kidney injury and sepsis, reducing urgent care admissions and continuation

of the national dementia screening measures. The local CQUIN programme for 2015/16 relates to seven

day services, care for patients with diagnosed dementia (in addition to the national screening project),

supporting patients during end of life care, increasing training in mental capacity assessment, and roll

out of the medication safety thermometer and ward accreditation. The Trust has provided information to

commissioners to demonstrate performance against these goals for quarter 3.

9 RECOMMENDATION

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


Operational Planning and Performance: Quality

6a. Quality Scorecard - Jan 16.xlsm.Quality Scorecard Page 1 of 6 Printed 25/01/2016 15:19

DECEMBER 2015Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov DEC

YTD Actual

YTD Target

Target Trend

EFFECTIVENESSEffectiveness domain score 2.44 2.56 2.52 2.64 2.60 2.56 2.75 2.47 2.71 2.60

Trust-wide mortality

E01 Trust crude mortality rate (non-elective) 4.24% 4.22% 3.44% 3.23% 2.82% 2.99% 2.66% 3.15% 2.70% 2.97% 3.56% 3.35% 3.05% 3.04% 3.27%

E02 Crude mortality rate (non-elective): 12 month rolling 3.21% 3.25% 3.27% 3.30% 3.28% 3.28% 3.26% 3.23% 3.22% 3.23% 3.30% 3.27% 3.27% 3.27% 3.27%

E03 Trust Hospital Standardised Mortality Ratio (HSMR) 92.3 92.1 91.2 95.3 93.9 93.8 93.5 91.2 90.3 90.3 92 92

E04 Summary Hospital-level Mortality Indicator (SHMI) (rolling 12M) 1 1

Improve mortality in specific conditions

E07 Crude non-elective mortality for Renal failure 17.4% 19.4% 34.8% 13.8% 13.3% 30.0% 21.4% 14.8% 13.8% 9.8% 18.5% 28.2% 18.1% 19.9% 19.9%

Reduce mortality following hip fracture

E09 SMR for hip fracture (all diagnoses/procedures) 96.7 89.5 75.8 76.5 83.3 85.8 84.2 79.5 78.9 78.9 100 100

E09a Worthing SMR for hip fracture (all diagnoses/procedures) 122.5 115.6 105.7 109.0 115.7 116.4 109.6 100.1 99.0 99.0 100 100

E09b St Richard's SMR for hip fracture (all diagnoses/procedures) 64.7 58.8 40.1 38.8 43.8 46.9 51.0 51.9 52.7 52.7 100 100

E10 30 day mortaliy rate following hip fracture 10.8% 8.0% 2.9% 2.5% 6.1% 8.3% 7.5% 5.8% 6.0% 6.0% 8.2% 8.2%

Reduce the rate of readmission following discharge from the Trust

E11 Emergency readmissions within 30 days % 12.9% 13.3% 12.3% 12.7% 13.7% 13.7% 13.1% 12.6% 12.7% 13.5% 14.5% 13.8% 13.6% 13% 13%

To improve maternity care by encouraging natural chilbirth

E13 C-Section Rate 30.1% 26.3% 24.1% 29.4% 24.2% 27.6% 26.0% 24.9% 30.3% 27.8% 31.3% 24.6% 27.3% 26% 26%

E14 % Mothers requiring forceps for delivery 10.4% 14.2% 13.4% 10.5% 11.1% 10.8% 11.3% 15.7% 10.2% 12.0% 9.5% 10.6% 11.3% <15% <15%

E15 % Deliveries complicated by post-partum haemorrhage 0.5% 1.0% 0.9% 0.4% 0.2% 0.4% 0.0% 0.2% 1.1% 0.0% 0.7% 0.9% 0.4% 1% 1%

E16 Maternal deaths 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0

E17 Admission of term babies to neonatal care 3.3% 2.4% 2.7% 1.8% 2.5% 3.1% 2.3% 1.0% 2.6% 3.6% 3.5% 3.2% 2.6% <10% <10%

Caring for the elderly patient

E18 % Emergency admissions staying over 72h screened for dementia 96.0% 90.3% 93.4% 93.4% 94.9% 97.6% 92.1% 91.3% 92.4% 93.0% 93.9% 93.6% 93.6% 90% 90%

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

94.2% 90.9% 87.1% 85.7% 96.5% 95.3% 91.7% 93.1% 91.2% 86.3% 91.5% 95.5% 91.9% 90% 90%

E20 % Patients with identified dementia referred to specialist services 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 96.3% 100.0% 100.0% 99.6% 90% 90%

E25 Number of admissions for patients with dementia flag 233 181 185 222 186 186 212 205 174 168 233 241 1827 tbc tbc

E39 Ward moves for patients flagged with dementia 190 124 105 132 107 118 137 107 119 127 202 213 1262 tbc tbc

E42 Night-time ward moves for patients flagged with dementia 75 35 44 37 42 39 34 39 35 30 45 52 353 tbc tbc

E43Documentation Audit: % patients with dementia with Knowing Me document

67.5% 74.8% 97.8% 95.4% 97.8% 99.4% 97.4% 99.7% 98.6% 98.2% 99.0% 100.0% 98.4% 75% 75%

QUALITY SCORECARD

1.03




YTD Actual

YTD Target

Target TrendQUALITY SCORECARD

Stroke care

E26 % CT scans undertaken within 12 hours 91.1% 97.4% 93.3% 89.3% 92.5% 91.8% 94.0% 88.8% 89.6% 91.0% 95% 95%

E27 % Stroke thrombolysis within 60 minutes of hospital arrival 77.8% 58.3% 77.8% 54.5% 83.3% 100.0% 85.7% 70.0% 75.0% 72.0% 95% 95%

E28 % Swallow screen for stroke patients within 4 hours of admission 73.8% 81.3% 82.4% 78.4% 75.5% 86.2% 85.0% 81.5% 77.8% 81.2% 95% 95%

E29 % of stroke patients admitted to stroke unit within 4 hours of admission 68.4% 76.3% 80.7% 84.7% 80.0% 74.3% 83.0% 74.7% 78.8% 78.8% 90% 90%

E30 % high risk TIA patients seen within 24 hours 60.0% 81.3% 80.0% 71.4% 61.1% 76.5% 62.5% 77.8% 66.7% 65.0% 65.2% 60% 60%

Ensure active engagement with research

E21 Patients recruited to interventional studies within CRN portfolio 24 15 9 15 7 17 14 14 15 25 11 18 136 n/a n/a

E22 Patients recruited to observational studies within CRN portfolio 65 115 100 44 39 31 38 27 26 55 25 17 302 n/a n/a

E23 Local Clinical Research Network (LCRN) Score 185 190 145 119 74 116 108 97 101 180 80 107 982 979 1305

Data Quality

E24 NHS IC Data validity summary (YTD) 99.9 99.9 99.9 99.9 99.9 99.9 99.9 99.9 99.9 99.9 99.9 99.9 96.1 96.1

E37 % inpatients with electronic discharge summaries produced 84.0% 85.0% 84.0% 85.1% 83.0% 85.0% 84.0% 85.5% 84.3% 85.0% 80.8% 81.7% 85.3% tbc tbc




YTD Actual

YTD Target


SAFETYSafety domain score (Patient Aggregate Safety Score - PASS) 2.50 2.50 2.89 2.44 2.33 2.33 2.44 2.89 2.53 2.39

Safer staffing

S36 Safer Staffing: Average fill rate - registered nurses/ midwives (day shifts) 95.5% 94.2% 95.5% 97.0% 96.8% 96.6% 96.8% 95.9% 94.1% 97.2% 96.8% 95.9% 96.4% tbc tbc

S37Safer Staffing: Average fill rate - registered nurses/ midwives (night shifts)

96.9% 96.3% 95.6% 97.5% 97.6% 97.3% 98.2% 97.3% 97.0% 98.5% 97.7% 97.2% 97.6% tbc tbc

S38 Safer Staffing: Average fill rate - care staff (day shifts) 90.5% 89.5% 91.7% 93.8% 93.0% 93.9% 91.0% 91.5% 88.9% 90.1% 87.8% 88.3% 90.9% tbc tbc

S39 Safer Staffing: Average fill rate - care staff (night shifts) 93.3% 92.0% 92.9% 94.7% 93.3% 95.0% 93.3% 93.6% 90.1% 93.0% 87.8% 90.7% 92.4% tbc tbc

NHS safety thermometer

S02 Safety Thermometer: % of patients harm-free 93.8% 94.5% 96.6% 96.3% 95.3% 97.3% 96.3% 95.6% 94.9% 95.8% 95.2% 96.0% 95.8% 93.82% 93.82%

S03 Safety Thermometer: % of patients with no new harms 98.1% 98.5% 99.0% 98.6% 98.0% 99.0% 98.2% 97.6% 98.4% 98.5% 98.2% 98.6% 98.3% 99% 99%

S29% of patients with catheters and UTIs where best practice protocol was not followed.

0.23% 0.11% 0.22% 0.44% 0.11% 0.00% 0.00% 0.00% 0.00% 0.23% 0.00% 0.00% 0.10% 0.2% 0.2%

Monitoring of clinical incidents

S04 Total incidents 789 726 755 723 758 742 818 875 852 922 819 910 74196092-8241

8122 - 10988

S05 Total moderate, severe or death incidents 11 16 8 12 12 5 19 16 10 9 11 15 109 115 153

S06 Total serious incidents (SIRIs) 6 7 2 7 7 2 8 11 5 5 5 6 56 45 60

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

Improve safety of prescribing

S08 Total incidents involving drug/prescribing errors 98 67 103 74 85 95 107 106 88 103 107 95 860792-1071

1056 - 1428

S09 Moderate/severe incidents involving drug/prescribing errors 0 0 2 0 0 0 1 0 1 0 0 1 3 4 5

Reduce incidence of healthcare acquired infections

S14 Number of hospital attributable MRSA cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

S15 Number of hospital C.diff cases 3 1 2 0 5 2 3 3 5 7 2 3 30 29 39

S28 Number of C. diff cases where a lapse in the quality of care was noted 3 0 1 0 2 1 1 0 3 4 1 12 14 18

S16 Number of reportable MSSA bacteraemia cases 8 6 6 4 6 8 6 5 10 6 11 9 65 n/a n/a

S17 Number of reportable E.coli cases 27 25 37 21 23 25 34 23 35 26 22 24 233 n/a n/a




YTD Actual

YTD Target


Improve theatre safety for patients

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

S19 NEVER events 0 0 0 0 0 0 0 1 0 1 0 0 2 0 0

S30 SSIs: Total hip replacement (YTD is rolling 12 months) tbc tbc

S33 SSIs: Total knee replacement (YTD is rolling 12 months) tbc tbc

S34 SSIs: Large bowel surgery (YTD is rolling 12 months) tbc tbc

S35 SSIs: Breast surgery (YTD is rolling 12 months) tbc tbc

Reduce number of falls in hospital

S21 Falls resulting in harm 42 32 45 42 34 28 35 39 45 42 34 39 338 385 513

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

S23 Falls assessment within 24hrs of admission 92.5% 92.0% 90.5% 92.0% 96.5% 85.0% 91.8% 88.3% 95.5% 83.5% 87.4% 88.0% 89.8% 80% 80%

S24 Avoidable falls identified on the Safety Thermometer 1.35% 1.16% 0.77% 1.09% 0.55% 0.57% 0.69% 0.97% 0.94% 0.69% 0.58% 0.17% 0.69% 0.76% 0.76%

Pressure ulcers

S25 Grade 2 pressure ulcers 7 8 9 12 10 10 13 15 15 19 16 16 126 tbc tbc

S26 Grade 3 & 4 pressure ulcers 2 0 0 0 0 1 1 5 2 3 4 3 19 tbc tbc

Other safety metrics

S11 VTE Assessment Compliance 95.9% 96.0% 95.2% 94.6% 94.0% 94.4% 93.7% 94.1% 92.2% 93.9% 92.7% 91.0% 93.4% 95% 95%

3.4%

4.7%

4.0%

15.4%




YTD Actual

YTD Target


EXPERIENCEExperience domain score 2.67 2.60 2.60 2.00 2.13 2.23 2.07 2.40 2.13 2.20

Friends and Family Test

X38 Trust Friends and Family Recommend %: Inpatient 94.3% 93.4% 94.6% 94.0% 94.4% 95.3% 95.5% 94.6% 94.0% 95.4% 95.5% 96.0% 95.0% tbc tbc

X39 Trust Friends and Family Recommend %: A&E 93.0% 91.7% 93.3% 91.7% 91.1% 91.1% 92.5% 90.6% 90.6% 90.2% 92.1% 92.1% 91.3% tbc tbc

X40Maternity Friends and Family Recommend %: Antenatal care (36 weeks)

95.3% 98.4% 96.6% 100.0% 94.1% 100.0% 100.0% 92.0% 88.9% 100.0% 100.0% 100.0% 96.6% tbc tbc

X41 Maternity Friends and Family Recommend %: Delivery care 97.0% 97.3% 97.9% 98.2% 95.0% 96.5% 93.0% 91.4% 95.3% 96.4% 100.0% 98.6% 96.4% tbc tbc

X42 Maternity Friends and Family Recommend %: Postnatal ward 92.7% 94.4% 95.4% 96.7% 95.0% 96.5% 93.0% 91.4% 95.3% 96.4% 100.0% 98.6% 96.2% tbc tbc

X43 Maternity Friends and Family Recommend %: Postnatal community care 76.5% 98.1% 93.9% 100.0% 100.0% 100.0% 100.0% 100.0% 80.0% 100.0% 100.0% 100.0% 98.2% tbc tbc

X44 Trust Friends and Family Recommend %: Outpatient 91.2% 88.7% 84.7% 87.9% 87.9% 91.6% 90.0% 89.9% 92.4% 89.9% tbc tbc

Friends and Family Test response rates

X24 Trust Friends and Family Response Rate: Inpatient 42.8% 39.8% 56.7% 47.3% 20.8% 19.0% 28.9% 25.2% 24.0% 23.9% 28.9% 25.6% 25.7% 30% 30%

X25 Trust Friends and Family Response Rate: A&E 27.1% 25.4% 30.1% 26.1% 17.2% 18.4% 20.9% 16.6% 18.9% 18.8% 16.2% 13.3% 18.3% 25% 25%

X33 Maternity Friends and Family Response Rate: Delivery care 30.0% 27.7% 36.3% 12.2% 13.8% 19.3% 9.0% 8.2% 9.6% 6.0% 13.1% 16.4% 11.9% tbc tbc

Reduction in patients suffering a bad experience dealing with the Trust

X08 Percentage of re-booked outpatient appointments 7.7% 8.7% 9.4% 8.4% 7.8% 7.5% 7.8% 7.9% 7.0% 7.3% 7.0% 7.8% 7.6% 8.6% 8.6%

X09 Clinics cancelled with less than 6 weeks notice for annual/study leave 84 30 24 17 19 26 33 35 14 30 15 25 214 255 340

X11 PALS contacts relating to appointment problems (% of total appts) 0.09% 0.08% 0.09% 0.09% 0.08% 0.08% 0.07% 0.09% 0.08% 0.08% 0.10% 0.09% 0.08% 0.09% 0.09%

X12 Reduce patients cancelled on the day of surgery for non-clinical reasons 75 32 18 18 11 30 20 17 40 45 22 43 246 299 399

X13 Breaches of mixed sex accommodation arrangements 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0

Nutritional Assessment

X14 Compliance with MUST tool after 24 hours 78.5% 75.5% 79.5% 81.3% 82.5% 72.5% 80.5% 75.8% 44.1% 49.9% 46.5% 66.6% 80% 80%

X15 Compliance with MUST tool after 7 days 94.0% 95.0% 94.0% 93.2% 97.8% 92.0% 94.0% 90.3% 87.4% 91.8% 89.7% 92.0% 95% 95%




YTD Actual

YTD Target


Cleanliness / PLACE Survey

X16 Internal PLACE compliance : St Richard's Hospital 98% 96% 99% 92% 98% 97% 84% 90% 96% 91% 95% 98% 93% 85% 85%

X17 Internal PLACE compliance : Worthing Hospital 91% 97% 98% 98% 97% 94% 97% 95% 94% 94% 98% 92% 95% 85% 85%

Improve our customer service and become a more caring organisation

X18 Number of complaints 51 41 54 43 48 44 58 56 44 72 43 45 453 428 570

X19 Complaints where staff attitude or behaviour is an issue 5 6 10 6 2 3 11 6 4 3 3 2 40 50 67

X20 Complaints where staff communication is an issue 8 3 2 7 2 3 9 7 5 8 2 9 52 37 49

X21 Complaints about nursing 1 5 4 4 4 2 5 2 2 2 5 4 30 35 46


6b. Safer Staffing Scorecard - M9.xlsx SaferStaffingWardNurseScorecard 1 of 6 25/01/2016 15:19

December 2015Shift Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

YTDActual

Trend

Day 95.5% 94.2% 95.5% 97.0% 96.8% 96.6% 96.8% 95.9% 94.1% 97.2% 96.8% 95.9% 96.4%Night 96.9% 96.3% 95.6% 97.5% 97.6% 97.3% 98.2% 97.3% 97.0% 98.5% 97.7% 97.2% 97.6%Day 93.2% 92.1% 94.5% 95.7% 96.1% 97.0% 97.4% 98.4% 96.7% 97.7% 97.7% 96.5% 97.0%

Night 96.8% 95.5% 91.1% 97.5% 97.6% 96.7% 97.6% 98.4% 93.3% 97.6% 99.2% 96.0% 97.1%

Day 94.8% 93.2% 92.5% 95.7% 97.2% 95.9% 93.9% 94.6% 95.7% 98.3% n/a n/a 95.9%

Night 96.1% 97.1% 93.0% 96.8% 97.8% 94.6% 94.7% 95.6% 94.1% 98.2% n/a n/a 96.0%

Day 97.8% 94.8% 97.8% 97.8% 96.8% 98.5% 99.3% 93.9% 95.6% 96.4% 96.3% 94.3% 96.5%

Night 93.5% 94.6% 90.3% 98.3% 93.5% 98.3% 98.4% 87.1% 88.3% 93.5% 95.0% 88.7% 93.5%

Day 92.7% 95.6% 97.2% 97.7% 96.6% 96.5% 97.2% 93.8% 92.4% 92.1% 87.1% 86.5% 93.3%

Night 93.5% 100.0% 98.4% 100.0% 98.4% 96.7% 100.0% 100.0% 98.3% 96.8% 100.0% 96.8% 98.5%

Day 92.1% 89.4% 95.5% 97.1% 95.5% 100.0% 100.0% 100.0% 100.0% 100.0% n/a n/a 98.9%

Night 96.8% 96.4% 90.3% 98.3% 98.4% 100.0% 100.0% 100.0% 100.0% 100.0% n/a n/a 99.5%

Day 98.4% 94.6% 97.4% 98.0% 99.0% 97.3% 98.1% 98.7% 97.0% 99.4% 97.7% 97.4% 98.1%

Night 98.9% 96.4% 98.9% 100.0% 98.9% 97.8% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.6%

Day 100.0% 100.0% 100.0% 98.9% 98.9% 100.0% 97.8% 100.0% 97.4% 100.0% 100.0% 100.0% 99.2%

Night 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 98.9% 100.0% 98.5% 98.8% 98.7% 100.0% 99.5%

Day 99.0% 95.7% 98.6% 99.0% 96.6% 97.0% 97.6% 100.0% 100.0% 100.0% n/a n/a 98.6%

Night 98.4% 94.6% 96.8% 96.7% 95.2% 98.3% 96.8% 100.0% 100.0% 100.0% n/a n/a 98.1%

Day 95.9% 100.0% 97.6% 99.2% 96.0% 100.0% 100.0% 98.9% 95.8% 94.0% 96.6% 99.2% 97.6%

Night 100.0% 95.5% 99.2% 99.2% 99.2% 97.8% 98.9% 100.0% 98.9% 99.1% 98.2% 96.8% 98.6%

Day 89.5% 92.0% 95.6% 97.1% 97.2% 99.6% 98.4% 96.0% 95.8% 97.2% 99.2% 94.8% 97.2%

Night 90.3% 91.1% 91.9% 95.0% 98.4% 100.0% 100.0% 95.2% 91.7% 98.4% 100.0% 91.9% 96.7%

Day 94.4% 85.7% 90.7% 94.7% 94.8% 93.1% 91.5% 92.9% 88.5% 93.7% 94.3% 92.6% 92.9%

Night 94.6% 86.9% 87.1% 94.4% 94.6% 93.3% 97.8% 91.4% 94.4% 98.9% 100.0% 95.7% 95.6%

Day 97.6% 97.8% 98.4% 97.9% 98.0% 97.5% 94.8% 96.4% 98.3% 99.6% 94.6% 97.6% 97.2%

Night 100.0% 98.2% 100.0% 95.0% 96.8% 98.3% 88.7% 91.9% 95.0% 98.4% 90.0% 96.8% 94.5%

Day 95.7% 91.3% 93.0% 95.1% 93.4% 96.0% 99.1% 90.4% 92.0% 98.3% 95.0% 93.5% 94.8%

Night 98.4% 96.4% 96.8% 96.7% 98.4% 100.0% 100.0% 95.2% 100.0% 100.0% 100.0% 100.0% 98.9%

WSHFT

Acute Medical Unit(Chichester)

Bluefin

Bosham

Botolphs

Birdham

Acute Cardiac Unit

Ashling

Barrow

Beacon

Beeding

Becket

Boxgrove

Broadwater

SAFER STAFFING SCORECARD - Registered Nurses and Midwives




YTDActual

Trend

Day 95.5% 94.2% 95.5% 97.0% 96.8% 96.6% 96.8% 95.9% 94.1% 97.2% 96.8% 95.9% 96.4%Night 96.9% 96.3% 95.6% 97.5% 97.6% 97.3% 98.2% 97.3% 97.0% 98.5% 97.7% 97.2% 97.6%

WSHFT


Day 94.2% 93.1% 94.2% 92.1% 93.7% 94.1% 94.7% 92.3% 83.2% 91.8% 96.5% 98.6% 93.0%

Night 95.2% 94.6% 95.2% 91.7% 96.8% 95.0% 100.0% 98.4% 96.7% 100.0% 100.0% 100.0% 97.6%

Day 99.0% 93.6% 96.6% 100.0% 99.0% 96.0% 96.7% 95.2% 85.1% 98.1% 97.0% 95.7% 95.9%

Night 96.8% 96.4% 95.2% 100.0% 98.4% 98.3% 100.0% 100.0% 98.3% 100.0% 100.0% 98.4% 99.3%

Day 94.8% 96.2% 96.5% 96.9% 99.6% 97.3% 97.0% 91.2% 94.6% 96.6% 96.4% 93.5% 95.9%

Night 97.4% 98.5% 97.3% 94.5% 100.0% 97.3% 100.0% 96.0% 98.6% 100.0% 98.6% 97.4% 98.1%

Day 95.5% 96.0% 99.7% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 95.0% 94.6% 98.8%

Night 97.6% 98.2% 99.2% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.2% 97.6% 99.6%

Day n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 95.8% 96.2% 96.0%

Night n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 94.6% 95.6% 95.1%

Day 99.5% 97.9% 96.7% 98.1% 99.1% 99.5% 100.0% 98.6% 97.6% 97.7% 98.5% 98.1% 98.6%

Night 100.0% 98.2% 95.2% 96.7% 100.0% 98.3% 100.0% 96.8% 95.0% 95.2% 96.7% 95.2% 97.1%

Day 98.1% 93.1% 99.0% 96.0% 99.0% 98.0% 97.1% 95.2% 93.1% 97.1% 96.5% 97.6% 96.6%

Night 98.4% 94.6% 100.0% 98.3% 98.4% 100.0% 100.0% 98.4% 100.0% 100.0% 100.0% 98.4% 99.3%

Day 96.4% 93.3% 96.0% 96.7% 97.6% 95.0% 98.0% 96.4% 90.4% 96.8% 97.1% 96.8% 96.1%

Night 98.4% 94.6% 95.2% 96.7% 98.4% 96.7% 100.0% 98.4% 98.3% 98.4% 100.0% 100.0% 98.5%

Day 96.8% 97.8% 98.8% 97.9% 98.8% 98.3% 90.7% 92.3% 89.2% 96.0% 98.8% 98.0% 95.5%

Night 100.0% 98.2% 100.0% 98.3% 98.4% 100.0% 100.0% 98.4% 100.0% 100.0% 98.3% 100.0% 99.3%

Day 96.0% 96.9% 94.0% 98.3% 94.0% 96.3% 96.4% 94.8% 92.5% 95.6% 97.5% 97.2% 95.8%

Night 93.5% 94.6% 93.5% 96.7% 97.6% 89.2% 96.0% 96.0% 95.8% 99.2% 98.3% 96.8% 96.2%

Day 96.8% 94.4% 94.5% 97.6% 97.7% 99.5% 96.3% 95.9% 94.8% 97.7% 96.2% 93.5% 96.6%

Night 96.8% 96.4% 95.2% 98.3% 98.4% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 98.4% 99.5%

Day 95.4% 98.0% 96.3% 98.6% 99.5% 93.3% 96.3% 93.5% 92.4% 97.2% 96.2% 93.1% 95.6%

Night 96.8% 98.2% 95.2% 100.0% 100.0% 100.0% 100.0% 98.4% 100.0% 98.4% 98.3% 98.4% 99.3%

Day 96.8% 94.4% 95.4% 97.6% 96.8% 97.1% 98.2% 95.9% 91.9% 97.7% 94.8% 91.7% 95.7%

Night 100.0% 92.9% 96.8% 100.0% 98.4% 98.3% 100.0% 100.0% 100.0% 100.0% 100.0% 96.8% 99.3%

Day 94.8% 92.4% 95.2% 96.3% 96.4% 97.5% 96.4% 94.0% 80.0% 95.6% 97.1% 94.0% 94.1%

Night 98.4% 94.6% 96.8% 96.7% 98.4% 100.0% 100.0% 96.8% 96.7% 98.4% 100.0% 100.0% 98.5%

Eartham

Eastbrook

Clapham

Coombes

Burlington

Brooklands

Courtlands

Ditchling

Durrington

Buckingham

Castle

Chilgrove

Chiltington

Chichester Emergency Floor




YTDActual

Trend

Day 95.5% 94.2% 95.5% 97.0% 96.8% 96.6% 96.8% 95.9% 94.1% 97.2% 96.8% 95.9% 96.4%Night 96.9% 96.3% 95.6% 97.5% 97.6% 97.3% 98.2% 97.3% 97.0% 98.5% 97.7% 97.2% 97.6%

WSHFT


Day 90.9% 90.0% 92.1% 95.4% 94.0% 90.6% 94.2% 92.3% 89.2% 95.8% 96.9% 94.0% 93.6%

Night 94.7% 95.1% 94.1% 97.0% 97.1% 94.2% 98.2% 95.0% 98.2% 98.2% 97.3% 96.8% 96.9%

Day 100.0% 100.0% 100.0% 99.2% 100.0% 99.2% 100.0% 100.0% 99.2% 100.0% 100.0% 99.2% 99.6%

Night 100.0% 100.0% 100.0% 100.0% 100.0% 98.3% 100.0% 100.0% 98.3% 100.0% 98.3% 100.0% 99.5%

Day 97.2% 96.9% 94.5% 97.1% 98.6% 97.6% 97.2% 93.5% 95.2% 99.1% 99.0% 95.4% 97.0%

Night 100.0% 96.4% 98.4% 100.0% 100.0% 98.3% 100.0% 100.0% 98.3% 100.0% 100.0% 100.0% 99.6%

Day 91.5% 94.6% 90.7% 97.9% 96.0% 95.8% 97.2% 98.8% 97.1% 96.8% 97.1% 97.6% 97.1%

Night 91.9% 96.4% 85.5% 100.0% 93.5% 96.7% 96.8% 98.4% 93.3% 95.2% 96.7% 96.8% 96.4%

Day 93.5% 94.6% 92.9% 96.7% 92.6% 95.7% 95.8% 98.4% 94.3% 96.1% 96.3% 97.4% 95.9%

Night 96.8% 95.2% 88.2% 96.7% 87.1% 95.6% 94.6% 97.8% 90.0% 96.8% 95.6% 96.8% 94.5%

Day 100.0% 96.4% 100.0% 99.3% 98.7% 100.0% 98.7% 100.0% 100.0% 100.0% 100.0% 100.0% 99.6%

Night 100.0% 96.4% 100.0% 100.0% 96.8% 100.0% 98.4% 100.0% 100.0% 100.0% 100.0% 100.0% 99.5%

Day 100.0% 96.5% 99.2% 99.2% 99.2% 100.0% 100.0% 100.0% 100.0% 93.5% 99.2% 99.2% 98.8%

Night 100.0% 100.0% 100.0% 98.3% 100.0% 100.0% 100.0% 96.8% 100.0% 96.0% 92.4% 97.6% 97.8%

Day 94.3% 94.0% 97.1% 93.7% 91.0% 97.4% 96.8% 96.4% 95.9% 97.5% 98.9% 98.9% 96.3%

Night 90.3% 98.2% 96.8% 85.0% 91.9% 98.3% 95.2% 93.5% 90.0% 93.5% 96.7% 98.4% 93.6%

Day 98.0% 92.4% 96.0% 96.3% 98.8% 94.6% 99.6% 98.0% 100.0% 98.4% 98.3% 98.4% 98.0%

Night 95.2% 96.4% 100.0% 100.0% 100.0% 96.7% 98.4% 96.8% 98.3% 96.8% 96.7% 95.2% 97.6%

Day 100.0% 98.6% 100.0% 100.0% 100.0% 97.8% 98.9% 100.0% 100.0% 100.0% 100.0% 98.9% 99.5%

Night 100.0% 98.6% 100.0% 98.8% 100.0% 100.0% 98.8% 100.0% 100.0% 100.0% 100.0% 100.0% 99.7%

Day 94.6% 94.0% 97.3% 99.4% 99.5% 100.0% 98.4% 98.4% 98.9% 99.5% 98.3% 99.5% 99.1%

Night 96.8% 98.2% 100.0% 96.7% 100.0% 100.0% 100.0% 98.4% 98.3% 100.0% 96.7% 100.0% 98.9%

Day 95.8% 94.4% 93.3% 94.0% 97.1% 96.1% 96.7% 96.6% 95.7% 96.7% 96.1% 96.3% 96.1%

Night 96.8% 96.4% 96.8% 96.7% 96.8% 98.9% 95.7% 96.8% 96.7% 97.8% 95.6% 96.8% 96.8%

Day 97.2% 95.1% 94.8% 96.7% 96.0% 95.4% 97.6% 98.8% 96.7% 96.4% 96.7% 95.2% 96.6%

Night 96.8% 98.2% 90.3% 98.3% 95.2% 96.7% 95.2% 98.4% 93.3% 96.8% 93.3% 90.3% 95.3%Wittering

Ford

Graffham

Lavant

Neonatal Unit

Petworth

Enhanced Surgical Care Unit

Erringham

Fishbourne

Selsey

Emergency Floor

Howard Children's Unit

Middleton


6b. Safer Staffing Scorecard - M9.xlsx SaferStaffingWardCareScorecard 4 of 6 25/01/2016 15:19


YTDActual

Trend

Day 90.5% 89.5% 91.7% 93.8% 93.0% 93.9% 91.0% 91.5% 88.9% 90.1% 87.8% 88.3% 91.0%Night 93.3% 92.0% 92.9% 94.7% 93.3% 95.0% 93.3% 93.6% 90.1% 93.0% 91.3% 90.7% 92.8%Day 86.5% 89.3% 82.6% 86.7% 92.3% 97.3% 92.3% 85.8% 93.3% 87.7% 90.7% 90.3% 90.7%

Night 90.3% 89.3% 67.7% 70.0% 77.4% 96.7% 80.6% 64.5% 70.0% 71.0% 83.3% 87.1% 77.8%

Day 93.3% 91.1% 89.8% 95.0% 92.5% 95.0% 94.9% 94.6% 92.3% 91.4% n/a n/a 93.7%

Night 91.8% 93.9% 86.3% 95.8% 83.4% 90.1% 90.5% 89.0% 77.5% 83.6% n/a n/a 87.1%

Day 89.9% 82.1% 91.2% 97.6% 95.2% 96.2% 100.0% 95.4% 96.7% 94.0% 95.7% 91.7% 95.8%

Night 88.7% 78.6% 85.5% 98.3% 90.3% 98.3% 100.0% 88.7% 88.3% 88.7% 90.0% 82.3% 91.6%

Day 87.4% 93.4% 91.3% 95.2% 98.0% 94.5% 97.4% 93.3% 85.6% 80.1% 62.8% 55.6% 84.7%

Night 96.8% 100.0% 96.8% 96.7% 98.4% 98.3% 98.4% 100.0% 93.3% 95.2% 95.0% 80.6% 95.1%

Day 84.1% 86.0% 80.7% 84.9% 91.3% 100.0% 100.0% 100.0% 100.0% 100.0% n/a n/a 96.6%

Night 91.9% 100.0% 95.2% 90.0% 98.4% 100.0% 100.0% 100.0% 100.0% 100.0% n/a n/a 98.4%

Day 86.4% 85.6% 81.9% 87.2% 93.8% 87.8% 86.0% 90.3% 78.5% 81.9% 76.0% 75.3% 84.1%

Night 88.7% 96.4% 88.7% 93.3% 96.8% 95.0% 91.9% 98.4% 90.0% 90.3% 96.7% 90.3% 93.6%

Day 100.0% 100.0% 100.0% 100.0% 97.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.6%

Night 100.0% 96.7% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Day 88.2% 89.2% 90.8% 90.4% 91.8% 89.4% 93.3% 100.0% 100.0% 99.0% n/a n/a 94.9%

Night 85.5% 83.9% 87.1% 93.3% 91.9% 91.7% 95.2% 100.0% 100.0% 98.4% n/a n/a 95.8%

Day 96.8% 82.1% 100.0% 100.0% 100.0% 100.0% 100.0% 93.5% 96.7% 100.0% 76.7% 83.9% 94.5%

Night 96.8% 89.3% 96.8% 88.9% 86.2% 100.0% 96.6% 86.7% 86.7% 86.7% 93.1% 87.1% 90.2%

Day 76.8% 84.3% 83.9% 82.0% 88.4% 99.3% 85.2% 67.1% 87.3% 91.6% 79.3% 94.2% 86.0%

Night 87.1% 82.1% 87.1% 90.0% 87.1% 98.3% 87.1% 64.5% 86.7% 96.8% 76.7% 95.2% 86.9%

Day 92.2% 87.7% 95.9% 95.0% 89.6% 88.2% 86.3% 91.1% 86.6% 89.3% 83.1% 88.6% 88.7%

Night 98.4% 87.5% 95.2% 88.3% 95.2% 91.7% 93.5% 98.4% 96.7% 96.8% 91.7% 93.5% 94.0%

Day 90.3% 83.2% 89.9% 98.6% 90.8% 89.0% 92.2% 91.2% 85.2% 90.8% 93.8% 91.7% 91.5%

Night 90.3% 76.8% 83.9% 98.3% 83.9% 88.3% 85.5% 87.1% 63.3% 80.6% 85.0% 82.3% 83.8%

Day 96.0% 91.7% 89.0% 91.6% 97.7% 94.0% 89.5% 87.4% 85.5% 86.1% 91.1% 95.9% 91.0%

Night 98.4% 98.2% 88.7% 95.0% 98.4% 98.3% 96.8% 95.2% 93.3% 88.7% 96.7% 91.9% 94.9%Broadwater

WSHFT

Acute Cardiac Unit

Acute Medical Unit(Chichester)

Boxgrove

Ashling

Beacon

Beeding

Bluefin

Bosham

Botolphs

Becket

Birdham

Barrow

SAFER STAFFING SCORECARD - Care Staff




YTDActual

Trend

Day 90.5% 89.5% 91.7% 93.8% 93.0% 93.9% 91.0% 91.5% 88.9% 90.1% 87.8% 88.3% 91.0%Night 93.3% 92.0% 92.9% 94.7% 93.3% 95.0% 93.3% 93.6% 90.1% 93.0% 91.3% 90.7% 92.8%

WSHFT


Day 82.3% 91.9% 86.6% 91.8% 89.7% 97.5% 84.7% 79.4% 79.1% 81.7% 89.3% 99.4% 88.0%

Night 95.2% 98.2% 88.7% 98.3% 96.8% 98.3% 98.4% 98.4% 86.7% 85.5% 96.7% 100.0% 95.5%

Day 88.4% 88.6% 90.3% 86.7% 85.2% 93.3% 96.1% 85.8% 84.0% 87.1% 88.0% 91.6% 88.7%

Night 98.4% 96.4% 98.4% 91.7% 88.7% 100.0% 100.0% 96.8% 91.7% 96.8% 91.7% 100.0% 95.3%

Day 93.4% 95.6% 92.7% 87.0% 93.3% 96.6% 88.7% 92.7% 85.6% 96.0% 89.0% 88.7% 90.9%

Night 98.4% 100.0% 98.4% 100.0% 100.0% 95.0% 95.2% 100.0% 95.0% 98.4% 96.7% 96.8% 97.5%

Day 70.2% 77.7% 96.0% 100.0% 100.0% 100.0% 100.0% 99.2% 100.0% 100.0% 80.0% 78.2% 95.3%

Night 77.4% 67.9% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 93.3% 93.5% 98.5%

Day n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 92.3% 93.3% 92.8%

Night n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 75.9% 87.8% 81.9%

Day 95.2% 92.9% 95.2% 92.5% 95.2% 94.2% 89.5% 85.5% 87.5% 83.9% 85.0% 92.7% 89.5%

Night 95.2% 96.4% 96.8% 95.0% 93.5% 98.3% 90.3% 91.9% 88.3% 87.1% 85.0% 93.5% 91.5%

Day 90.3% 88.1% 94.9% 96.8% 90.3% 88.8% 87.6% 91.3% 89.9% 85.6% 91.5% 82.5% 89.4%

Night 96.8% 91.1% 96.8% 93.3% 95.2% 90.0% 96.8% 98.4% 95.0% 100.0% 98.3% 91.9% 95.5%

Day 93.5% 96.4% 92.3% 90.0% 83.2% 94.7% 89.7% 93.5% 90.7% 89.7% 90.0% 77.4% 88.7%

Night 100.0% 96.4% 96.8% 88.3% 91.9% 93.3% 98.4% 96.8% 95.0% 98.4% 98.3% 90.3% 94.5%

Day 91.6% 78.6% 92.9% 93.3% 88.4% 96.7% 80.0% 80.6% 77.3% 70.3% 77.3% 78.1% 82.4%

Night 95.2% 85.7% 98.4% 91.7% 88.7% 96.7% 91.9% 96.8% 91.7% 98.4% 98.3% 90.3% 93.8%

Day 89.5% 78.6% 87.9% 92.5% 97.6% 98.3% 98.4% 89.5% 85.0% 92.7% 78.3% 72.6% 89.5%

Night 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%

Day 91.4% 91.7% 97.3% 93.3% 93.0% 87.2% 85.5% 95.2% 92.2% 84.9% 75.0% 78.0% 87.2%

Night 95.2% 100.0% 96.8% 90.0% 96.8% 91.7% 93.5% 98.4% 95.0% 93.5% 83.3% 87.1% 92.2%

Day 90.9% 81.0% 89.8% 88.3% 96.2% 91.1% 75.8% 86.6% 75.0% 79.0% 64.4% 63.4% 80.0%

Night 100.0% 91.1% 100.0% 93.3% 100.0% 98.3% 93.5% 98.4% 88.3% 95.2% 95.0% 85.5% 94.2%

Day 96.6% 89.4% 98.6% 97.9% 93.8% 91.5% 87.1% 86.9% 78.2% 70.5% 90.1% 88.4% 87.1%

Night 96.8% 100.0% 98.4% 95.0% 98.4% 95.0% 90.3% 100.0% 95.0% 91.9% 98.3% 96.8% 95.6%

Day 98.1% 89.3% 97.4% 99.3% 96.8% 97.3% 88.4% 97.4% 86.0% 96.8% 85.3% 93.5% 93.5%

Night 98.4% 92.9% 98.4% 100.0% 98.4% 96.7% 91.9% 98.4% 88.3% 98.4% 93.3% 91.9% 95.3%

Chilgrove

Chiltington

Clapham

Eastbrook

Brooklands

Buckingham

Burlington

Coombes

Courtlands

Ditchling

Durrington

Eartham

Castle

Chichester Emergency Floor




YTDActual

Trend

Day 90.5% 89.5% 91.7% 93.8% 93.0% 93.9% 91.0% 91.5% 88.9% 90.1% 87.8% 88.3% 91.0%Night 93.3% 92.0% 92.9% 94.7% 93.3% 95.0% 93.3% 93.6% 90.1% 93.0% 91.3% 90.7% 92.8%

WSHFT


Day 95.6% 97.7% 94.0% 93.9% 94.7% 94.8% 93.4% 94.1% 87.0% 91.8% 94.7% 93.8% 93.2%

Night 98.1% 96.4% 94.8% 96.0% 93.5% 94.0% 95.5% 97.4% 94.7% 94.8% 98.0% 91.6% 95.1%

Day 93.5% 98.2% 93.5% 100.0% 100.0% 100.0% 100.0% 100.0% 98.3% 100.0% 95.0% 91.9% 98.4%

Night 88.9% 87.5% 88.9% 100.0% 100.0% 87.5% 100.0% 100.0% 87.5% 100.0% 100.0% 62.5% 93.6%

Day 91.4% 91.1% 91.9% 93.3% 93.5% 89.4% 89.8% 94.1% 91.1% 88.7% 94.4% 90.9% 91.7%

Night 96.8% 94.6% 95.2% 96.7% 100.0% 98.3% 98.4% 96.8% 98.3% 98.4% 100.0% 100.0% 98.5%

Day 88.2% 89.3% 91.9% 97.8% 87.1% 92.8% 82.3% 90.3% 91.7% 94.6% 91.1% 93.0% 91.2%

Night 79.0% 83.9% 85.5% 100.0% 83.9% 91.7% 75.8% 88.7% 85.0% 91.9% 86.7% 91.9% 88.4%

Day 92.3% 90.7% 90.3% 98.0% 94.8% 97.3% 85.8% 95.5% 90.0% 87.7% 86.7% 94.8% 92.3%

Night 90.3% 96.4% 88.7% 95.0% 96.8% 98.3% 88.7% 93.5% 88.3% 83.9% 80.0% 95.2% 91.1%

Day 90.3% 89.3% 96.8% 98.3% 95.2% 93.3% 87.1% 93.5% 100.0% 100.0% 100.0% 100.0% 96.4%

Night 100.0% 85.7% 96.8% 100.0% 96.8% 96.7% 87.1% 96.8% 100.0% 100.0% 100.0% 100.0% 97.5%

Day 100.0% 96.3% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 96.8% 100.0% 100.0% 99.6%

Night 100.0% 100.0% 100.0% 100.0% 100.0% 86.7% 87.1% 80.0% 93.3% 80.6% 75.0% 58.1% 84.5%

Day 94.4% 88.4% 96.8% 94.6% 96.4% 94.6% 94.4% 90.7% 95.0% 94.8% 91.3% 92.3% 93.8%

Night 91.9% 92.9% 90.3% 90.0% 91.9% 90.0% 85.5% 82.3% 86.7% 90.3% 80.0% 77.4% 86.0%

Day 83.9% 97.1% 91.0% 92.7% 92.9% 90.0% 96.8% 89.7% 90.0% 93.5% 95.3% 94.2% 92.8%

Night 85.5% 94.6% 91.9% 93.3% 93.5% 90.0% 96.8% 88.7% 88.3% 90.3% 93.3% 91.9% 91.8%

Day 100.0% 100.0% 100.0% 100.0% 100.0% 93.3% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.2%

Night 100.0% 100.0% 100.0% 100.0% 96.6% 97.0% 96.8% 100.0% 100.0% 100.0% 100.0% 100.0% 98.8%

Day 87.1% 89.3% 96.8% 100.0% 93.2% 99.3% 97.4% 92.9% 90.7% 93.5% 86.0% 91.6% 93.9%

Night 88.7% 87.5% 95.2% 100.0% 88.7% 98.3% 98.4% 90.3% 83.3% 90.3% 80.0% 87.1% 90.7%

Day 96.3% 93.0% 92.6% 96.7% 93.7% 94.6% 90.0% 94.8% 90.8% 97.4% 89.7% 87.9% 92.8%

Night 98.4% 87.5% 88.7% 96.7% 87.1% 95.0% 90.3% 90.3% 83.3% 96.8% 85.0% 85.5% 90.0%

Day 77.4% 82.1% 83.2% 98.7% 90.3% 88.7% 92.3% 92.3% 90.7% 95.5% 97.3% 98.1% 93.7%

Night 72.6% 82.1% 87.1% 96.7% 88.7% 90.0% 88.7% 93.5% 85.0% 95.2% 96.7% 100.0% 92.7%

Fishbourne

Wittering

Ford

Graffham

Lavant

Neonatal Unit

Petworth

Selsey

Middleton

Howard Children's Unit

Enhanced Surgical Care Unit

Erringham

Emergency Floor

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

To: Trust Board

Date of Meeting: 28 January 2016 Agenda Item: 7

Title

Organ Donation Annual Report 2014/15


George Findlay, Medical Director

Prepared by

Dr R D Albertyn, Trust Clinical Lead Organ Donation

Status

Disclosable

Summary of Proposal

This report provides a summary of the work undertaken under the auspices of the Trust Organ donation Committee for 2014/15.


Links to Quality of Care Objectives.


Improved clinical care


N/A


N/A

Recommendation

The Board is asked to receive the Annual report and Business Plan and ask any questions of the Medical Director and the Trust Clinical Lead Organ Donation.

Consultation

Shared with key stakeholders.

Appendices

N/A


1

Western Sussex Hospitals Trust

Organ Donation

Annual Report 2014 – 2015

Business Plan 2015 - 2016

Dr R D Albertyn (Trust Clinical Lead Organ Donation)

Dr D Melville (Deputy Clinical Lead)

Mrs T Thomas (Trust Specialist Nurse Organ Donation)

Mrs A H Fisher (Trust Non – clinical Lead Organ Donation)

2

Contents

Glossary & Definitions 3

1. Executive Summary 7

2. Report from the Organ Donation Committee (ODC) 10

3. Policy Frame work 12

4. Hospital Organ Donation Team Structure 14

5. Organ Donation Rates / PDA Benchmarking 2014/15 16

6. Performance against 2014/15 Objectives 29

7. Strategic Responses to Issues from 2014/15 34

8. Objectives for 2015/16 and Monitoring Arrangements 35

9. Risks to Delivery of Objectives and Mitigating Actions 37

10. Any Other Information 38

Appendices:

A. NHSBT Trust DBD/DCD Data 39

B. FINANCE 40

C. Harefield DCD Heart Donation Protocol 42

D. Organ Donation Study Day 2014 feedback 43

3

Glossary

CLOD – Clinical Lead Organ Donation

SNOD – Specialist Nurse Organ Donation

NCLOD – Non-clinical Lead Organ Donation

NHSBT – NHS Blood and Transplant

DBD – Donation after Brain Death

DCD – Donation after Circulatory Death

ODC – Organ Donation Committee

PDA – Potential Donor Audit (national audit of activity by NHSBT)

ICU/ITU – Intensive Care Unit

ED/A&E – emergency department

SRH – St Richards Hospital

WH – Worthing Hospital

4

Definitions

5

6

On 1 April 2013 significant changes were made to the PDA. The main changes that should be borne in mind, especially when making comparisons across time periods, are as follows:

· Upper age limit increased from 75 to 80 years.

· Cardiothoracic ICUs included.

· Changes to imminent death definition to be clear that death was anticipated within four hours.

· Contraindications brought in line with current practice.

· Terminology changes, eg 'potential donor' changed to 'eligible donor', for consistency with World Health

Organisation definitions.

7

1. Executive Summary

2014/15 was another highly active year for organ donation across the Western Sussex

Hospitals NHS Trust supported by a strong, progressive organ donation committee. There

was 100% attendance by the SNOD, CLOD and Non – CLOD.

The Trust is now taking part in an exciting new pilot scheme regarding the heart retrieval

form DCD donors

Organ donation activity

It is important to note that numbers are small so even a loss of 1 potential donor results in a

large percentage change.

DBD Donors, patients transplanted and organs per donor, 1 April 2014 - 31 March 2015 (1 April 2013 - 31 March 2014 for comparison)

Donor type Number of donors

Δ%

from

2012/13

Number of Patients transplanted

Average number of organs donated per donor

Trust UK

DBD 4(2) +100% 11 (6) 3.0 (4.0) 3.8 (4.0)

Comments:

Increase in number of donors

100% attainment in all KPIs within the DBD donation episodes (see below)

Average number of organs donated per donor have dropped emphasising the

need to utilize the Donor Management Protocol universally (consider that the

increased average age of the Trust’s DBD Donors may influence the number of

organs donated)

DCD Donors, patients transplanted and organs per donor, 1 April 2014 - 31 March 2015 (1 April 2013 - 31 March 2014 for comparison)


Δ%

from

2011/12



Trust UK

DCD 5 (9) -44% 8(15) 2.4 (2.1) 2.7 (2.6)

Comments:

Reduction in DCD donors due to following factors: reduction in no. off eligible

donors as well as sub-optimal referral rates. However, the referral rate KPI has

risen from 60% (13/14) to 68% (14/15)

The number of organs per donor has increased

8

More work around and constant re-enforcement of the need to refer ALL

ventilated withdrawal of treatment patients. This directive should feature

prominently within the Trust’s Organ Donation Policy

Organs transplanted by type, 1 April 2014 - 31 March 2015 (1 April 2013 - 31 March 2014 for comparison)

Donor type Number of organs transplanted by type

Kidney Pancreas Liver Heart Lung

DBD 6 (3) 0 (1) 4 (2) 0 (1) 2 (2)

DCD 8 (13) 0 (0) 1 (3) 0 (0)

Totals 14 (16) 0 5 (5) 0 (0) 2 (2)

Comment:

Numbers of organs donated this year (21) is only marginally less than the number from

last year (23). This illustrates that the number of organs available from DBD donors is

significantly greater than that from DCD donors. Additionally the condition of the organs

(and thus ‘transplantability’) is far superior in all organs with the exception of kidneys

where organ survival is similar.

The 14 kidneys donated from WSHT patients will save the NHS £480 000/year or

£4 800 000 over the next 10 yrs (assuming an average transplanted kidney lifespan of 10 yrs).

Finance (2014/15)

B/Fwd (13/14) £ 21 893

Income: £ 32 384

Expenditure: £ 19 439 Balance: £ 34 838

9

Finance earmarked for 2015/16 projects – film project - £20 000

Additional activities

St Richards Family room re – design and re-furbish:

- Funding agreed and secured

- Final design agreed (eventually) and works commenced in March 2015.

Formal opening of “The Gift” commemorative artwork on both sites.

Memorial service at Chichester Cathedral

Successful Organ Donation Study Day

Attended NHSBT National Congress

Recruited significant numbers of Organ Donation Volunteers

The Committee was involved in a wide range of promotional activities in multiple

areas throughout the year – including training within and without the Trust, National

Transplant Week displays and community presentations – to WI and Chichester &

Worthing GPs

Looking forward

The committee is committed to improving organ donation rates with an ongoing trust

wide education and awareness strategy aimed at key stakeholders.

Significant work remains to maintain and improve several key performance indicators

esp. DCD referral and Donor Management.

Integration and utilization of volunteers in organ donation to work within the Trust and

community promoting organ donation in line with NHSBT’s national 2020 strategy.

Selection, Commissioning and commencement of a film project – suite of short films

interviewing donor families/recipients and waiting list patients for wide use in promotion

and training settings. A further suite of films detailing best practice and conduct of DCD

&DBD donation to be used in e-learning locally/regionally/nationally

Explanatory plaques for ‘The Gift’

10

2. Report from the Organ Donation Committee (ODC) Organ Donation Committee quarterly meetings are conducted within lines of the Terms of Reference and the Annual Planning cycle. 100% attendance by SNOD, CLOD and Non- CLOD. In addition to usual committee business and in support of the advancement of organ donation activity within the trust the committee has, more specifically, undertaken: ODT quarterly meetings are conducted within the guidelines also Terms of Reference and the Annual Planning Cycle. 100% attendance by SNOD, CLOD and NON-CLOD In addition to usual committee business and in support of the advancement of Organ Donation activity within the Trust the committee has more specifically, undertaken a wide range of activities: - Actively involved with cementing relationship across the Trust to enable and encourage awareness of Organ Donation & Transplant protocols. Developing an on-going framework of co-operation, trust and respect between Trust Board members, Clinical Staff, and supporting staff throughout the Trust sites. We support and respect the views of Donors and Donor Families, support those who are waiting on the transplant list and those who have been able to receive the “Gift of Life”. Our CLOD and SNOD both underwent the first of Annual Appraisals in 2015 conducted by Regional CLOD and NHSBT regional office. Lack of SNOD with negative influence on awareness and trust educational activity was highlighted. No other issues. We are participating in a National Research Project – Donor Families – Bereavement, this is at a preliminary stage. During this period CLOD & NON-CLOD attended 2 National Organ Donation Congress meetings at Warwick University with durations of 3 days each. Also CLOD, NON-CLOD & New SNOD attended 2 regional collaboratives. NON-CLOD is also chair of Regional Steering Group on Education & Training. Extensive cross site Teaching & Training sessions have taken place at SRH & Worthing ITUs, Theatres, and A&E units also including Senior Matrons) conducted with CLOD & SNOD. SRH FAMILY & FRIENDS ROOM – Critical Care Unit Funding was secured, Plans approved, Logistics and timescale agreed, Estimated formal opening September 2015. Purpose of project is to provide a place where families and friends of those on the Critical Care Unit are shown respect and dignity. THE GIFT – Unveiling The Gift Artwork situated in main entrance of both St. Richards and Worthing Hospital was formally unveiled by CEO & Chair of WSHT and invited members, including Donor Families, Chaplin, and staff from A&E. Also ITU and those members who have been instrumental in this project. This was followed by a delivery of baskets of fruit to various departments. DONOR FAMILY MEMORIAL Our Chaplin Rachel Bennett was instrumental in organizing the memorial service at Chichester Cathedral the service was attended by 150 people including Donor families, and

11

Friends, members of WSHT staff and staff from NHSBT, followed by an afternoon tea supported by ODT committee. ORGAN DONATION & TRANSPLANT WEEK – national event. Large in-house Organ Donation displays both in St. Richards and Worthing Hospital during the year and also during Transplant Week. These events were supported and staffed by committee members and members of Estates and Comms department. WI – (Women’s Institute) Presentations Various East and West Sussex WI’s requested a presentation from ODT committee to support their national resolution on “Awareness of Organ Donation”. CLOD & NON CLOD gave presentations during WI meetings, which were well received, followed by requests from WI members to be part of WSHT Organ Donation awareness campaign. GP presentations (February + March 2015) – CLOD (accompanied by)Non – CLOD) presented to the Chichester & Worthing GPs – ‘an introduction to Organ Donation’. Very well received. STUDY DAY – Hilton Hotel This was the 3rd year this event had taken place, staff from A&E and Critical Care units both St. Richard and Worthing were invited. Our guests included Transplant Surgeons, Doctors, and staff from Tissues and Eyes services. The day comprised of 3 break- out sessions followed by feedback again a very positive response. WI volunteers attended and helped with registration and issuing of certification. Organ Donation Volunteers – formal trust induction completed. This very successful project is ongoing and Non – CLOD guidance with plans for assistance with Organ Donation committee (and wider) activities. E-LEARNING & FILM PROJECT Discussions regarding costs, sub-committee formed to ascertain alternative solution for formal ODT training. Estimated budget £15 - 20,000.00. 2020T – NHSBT The new 2020 strategy has been released; Chair is reviewing policies and guidelines to use within WSHT and within the local community. PARTNERSHIPS With local commercial companies, Asda has invited us to use their meetings rooms at no costs. In closing this part of the report I wish to thank in particular our CLOD Dr Ryck Albertyn, for his constant attention to referrals and Tracey Thomas our new SNOD who has brought a wealth of experience in ODT and her kind and willing nature when dealing with difficult circumstances. SNOD Activity 2014/15

New in post June 2014 – supernumerary till training complete in late January early February.

Instrumental in introducing highlighting potential organ donors in ITU morning safety huddle across both sites.

Increased SNOD presence across both sites in ITU and ED, which has resulted in increased referrals. This will be reflected in next year’s data.

12

Networking across both sites to raise the profile of Organ and tissue donation, setting up meetings and planning teaching sessions for the coming year

Meeting with CE and Dep Dir of Nursing, Patients Story written for June Trust Brief, Organ Donation

stand at Staff conference September and November, input into End of Life Care Document following

meeting with Palliative Care matron, teaching session with ED doctors on both sites. Attended

medical sisters meeting introducing tissue donation services to raise awareness of this type of

donation. Implemented a flow chart on the wards showing how to refer a patient for tissue donation.

Planning Study Day November 2015, Teaching on the ITU Band 5 study days and regular emails to

Manager and Band 7s on ITU with info of any missed referrals is for next year!

3. Policy Framework

There has been a Trust wide Organ Donation policy in place at Western Sussex Hospital

Trust written in February 2009 and is currently under review – to include an ‘organ donation

from A&E’ section. The policy was written by the CLOD prior to the embedding of the SNOD,

and has gone through the ratification process.

There are also a number of national documents, publications and consultation papers which

have been referred to in order to correctly shape any organ donation policy frame work for

Western Sussex Hospital Trust:

WSHT Organ Donation Policy (review underway)

Department of Health (DOH). Organs for Transplant Taskforce Report

(ODTF) 2008 + Final report December 2011

Academy of Medical Royal Colleges (AMRC). A Code of Practice for the

Diagnosis and Confirmation of Death + Form for the Diagnosis of Death

using Neurological Criteria (November 2014)

Mental Capacity Act (2005)

Human Tissue Act (2006)

DOH. Legal Issues relevant to Non Heart-beating Organ Donation (2009)

Donation after Circulatory Death. (UKDEC) Final ( December 2011)

NHSBT. Donor Contraindications to Organ Donation (2010)

DOH. End of Life Care Strategy. (2008)

General Medical Council (GMC). Treatment and Care Towards the end of

life: Good Practice in Decision Making. Guidance document for doctors.

(2010)

SaBTO – Guidance on Microbiological Safety of Human Organs,

Tissues, and Cells used in Transplantation (2011)

NHSBT. Strategic Objective for ODT. (2010-2013)

13

NHSBT and British Transplant Society. Guidance for Solid Organ

Transplant in Adults.

NICE guidelines December 2011 – CG135

NHSBT. Donor optimization guideline for management of the brain dead

donor – Oct 2012

NHSBT. Donation after Brainstem Death (DBD) - Donor Optimisation

Extended Care Bundle – Nov 2012

NHSBT. Approaching the families of potential organ donors – best

practice guidance – March 2013

Intensive Care Society Website - Organ Donation in Intensive Care:

http://www.ics.ac.uk/professional/organ_donation

NHSBT: ODT microsite: http://www.odt.nhs.uk/

Taking Organ Donation to 2020: a detailed strategy –

www.nhsbt.nhs.uk/to2020

Hospice UK - Care after Death – April 2015

CLOD position Terms and Conditions January 2015

Care of Severely Brain injured patient in A&E – WSHFT April 2015

http://www.ics.ac.uk/professional/organ_donation

http://www.odt.nhs.uk/

http://www.nhsbt.nhs.uk/to2020

14

4. Trust Organ Donation Team Structure

TRUST BOARD

Mike Viggers

Marianne Griffiths George Findlay William Brown

HOSPITAL MANAGEMENT TEAM

ASSISTANT DIRECTOR

Anthony Clarkson

REGIONAL MANAGER

Marion Ryan

TEAM MANAGER

Louise Davey Tracy Gibson

DONATION COMMITTEE CHAIR (Non- CLOD) Angela Fisher

CLINICAL LEAD (CLOD) Ryck Albertyn Dom Melville

SPECIALIST NURSE (SNOD) Tracey Thomas

Western Sussex Hospitals NHS TRUST

ORGAN DONATION COMMITTEE

CRITICAL CARE Louise Skelt – ITU manager WH – Helen Lane SRH - Emma D’Arcy Dr. Patrick Carr

EMERGENCY DEPARTMENT

WH – Matt Stanniforth Maxine Hacker Sarah Hall SRH - Sue Howard Gary Wright Kelly Bennet Steve Searle

THEATRES WH – Gail Collins SRH – Leslie Guppy

END OF LIFE Facilitators

Tim Hutson

DONOR FAMILY REPRESENTATIVE Angela Fisher

MORTUARY REPRESENTATIVE (TBC) COMMUNICATIONS REPRESENTATIVE

Jonathan Keeble Sue Hughes CLERICAL Rachel Bennet Una Dalrymple FINANCE Alison Ingoe Sandy Johnson

TRUST NHSBT

REGIONAL CLINICAL LEAD

Pardeep Gill Argy Zamparouli

15

CL-OD

Dr Ryck Albertyn

Communication

Department

Jonathan Keeble

Sue Hughes

ICU Manager

Louise Skelt ICU Links

SRH

Sr Emma D’arcy

Louise Bradley

Emma Eels

WH

Helen Lane

Chair / Non – Clod

Angela Fisher

Theatres

WH

Gail Collins

SRH

Leslie Guppy

ICU/Renal

Physician

Patrick Carr

Chaplaincy

Rachel Bennett /

Una Dalrymple

ED Consultant

WH

Matt Staniforth

(lead)

Mandy Grocutt

ED Sister

Maxine Hacker

SRH

Steve Searle

Sue Howard

Kelly Bennet

SN-OD

Tracy Thomas

Financial

Department

Alison Ingoe

Senior Management Representation:

Marriane Griffiths (CEO)

George Findlay (Medical Director)

(Finance Director)

Deputy CL-OD

St Richards

Dr Dom Melville

Volunteer Corps:

Betty McAnn

Susan Crook

16

5. Organ Donation Rates / PDA Benchmarking 2014/15

Donors, patients transplanted and organs per donor, 1 April 2014 - 31 March 2015 (1 April 2013 - 31 March 2014 for comparison)




Trust UK

DBD 4(2) 11(6) 3.0 (4.0) 3.8 (4.9)

DCD 5 (9) 8 (15) 2.4 (2.1) 2.7 (2.6)

Organs transplanted by type, 1 April 2014 - 31 March 2015 (1 April 2013 - 31 March 2014 for comparison)

Donor type Number of organs transplanted by type

Kidney Pancreas Liver Heart Lung

DBD 6 (3) 0 (0) 4 (2) 0 (1) 2 (2)

DCD 8 (13) 0 (0) 1 (3) 0 (0)

Totals 14 (16) 0 5 (5) 0 2 (2)

Between 1 April 2014 and 31 March 2015, Western Sussex Hospitals NHS Foundation Trust had 9 deceased solid organ donors, resulting in 19 patients receiving a transplant. 24 organs were donated but 3 were not transplanted

DBD & DCD Key Rates

17

WSHT Trust key metrics data 2013/14 (National PDA derived)

The percentages for each key metric are shown in below along with the number of patients at each stage. A national comparison and a time period comparison are again provided. A comparison against funnel plot boundaries has been applied by highlighting the key rates for the Trust as gold, silver, bronze, amber, or red. Note that caution should be applied when interpreting percentages based on small numbers.

18

Overview of lost opportunities

19

Neurological Death Testing

20

Referral to Specialist Nurse (SNOD)

21

22

Contra- indications

23

Family Approach

24

Proportion of approaches involving the SNOD

25

Consent Rates

26

Hospital Specific Data

A. DBD

B. DCD

27

PDA Benchmarking Rates

Reflection on potential Donation after Brain Death (DBD) for period of report.

The WSHfT trust continues to perform well against national and regional targets. Brain stem death testing

is performed universally where appropriate and referral rates continue at 100%. This year there were 4

potential DBD donors. All 4 potential donors became actual donors.

As for Key Metrics the Trust has attained 100% in all areas:

Referral rate 100%

Neurological testing 100%

Family approach rate 100%

SNOD involved in approach 100%

Consent rate 100%

Conversion rate 100%

The number of organs per donor [WSHFT 2014/15 3.0 (WSHFT 13/14 = 4.0; UK = 4.0)] has dropped and

potentially still indicates that work still remains around the implementation and universal use of the donor

optimization protocols designed to ensure that the most organs in the best condition are obtained.

Continued efforts to ensure brainstem death testing in all appropriate cases is essential as the organ

condition is superior with resultant greater success and longevity within the recipients. This will be

continuously emphasized to all relevant practitioners.

Focus wrt. to DBD donors should continue to be:

1. EARLY referral and involvement of the SNOD is now part of best practice and needs to be

continuously encouraged and emphasized. SNOD involvement impacts positively on consent rates.

2. Early and robust donor optimization via clearly defined protocols resulting in better organ quality and

recipient benefit. The official algorithms for donor management have been ratified and arelocally

available for implementation. Additionally, the traumatic brain injury protocol from St Georges for

optimal management of brain injured patients is being implemented pre BSD testing which dovetails

ultimately with the donor management pathway once brain death has been established. The level of

implementation of these protocols need to be formally audited

Reflection on potential Donation after Circulatory Death (DCD) for period of report.

Donation after Circulatory Death (DCD) – the trust has largely maintained its performance with regards to

the Key Metrics.

In summary:

28

Referral rate up from 60% to 68% - still shy of the national average of 76% and the national target

rate of 75%.

Family approaches with SNOD involvement – 100% up from 89% (UK 73% + national target 73%)

Consent rate 64% down from 72% (UK 54% + national target 55%)

Actual donors from consented donors 5/7 (71%)

3 ‘missed donors’

The reasons for maintained performance are greater awareness and motivation amongst staff of all levels.

Hard work by link nurses and the SNOD must be recognized. St. Richards ITU has maintained their referral

rate at 74% (2013/4 = 71%) with Worthing Hospital increasing its referral rate from 50% to 64%. Taking

nothing away from the achievements of this past year, there is definite room for improvement in the

approach and referral rates. The inclusion of assessment of organ donation potential on the critical care

unit at the morning safety briefing has improved awareness and referral.

Organ Donation from A&E

A&E remains a viable source of organ donors.

A & E continues to be a challenge from an organ donation perspective. Ongoing education remains the key

to encouraging early referral of potential donors enabling collaborative working between SNOD, ITU and

ED staff.

The potential is very small and this is reflected in the numbers. Only 1 missed true potential donor in the

trust over this period.

Work continues to ensure that donor potential however small is maximised with education and training and

a SNOD presence on a regular basis. Nursing and medical link personnel remain in place on both sites with

the expectation that over the coming year they will become even more involved with encouraging staff to

identify not only potential organ donors but Tissue donors too.

Organ donation from A&E is a complex process and currently within this trust must always be undertaken

via the respective ITUs. This is due to the complex and specific management requirements of both the

Donor and the Donor Family during this difficult time. Hence PRIOR to approaching the family in A&E all

the usual best practice elements such as collaborative requesting and SNOD presence should be ensured.

Additionally, close communication between the A&E staff and the ITU consultant is essential to ascertain

that there is space on ITU to accommodate the potential donor prior to any discussion with the next of kin.

This is due to the fact that donation currently cannot be facilitated from any location other than the ITU.

Unfulfilled expectation may be harmful to the family and organ donation in general.

29

6. Performance against 2014/15 Objectives

Item

Objectives for 2014/15 Actions Required to Deliver Objective Measurable Outcome /

Milestones Outcome

1 Embed new Specialist Nurse Organ Donation (SNOD)

NHSBT to recruit SNOD

NHSBT to train SNOD

SNOD to familiarise and assimilate into Trust (cross-site)

Fully integrated SNOD who is comfortable in role and familiar with all relevant staff.

Recommencement of all facets of trust training involving SNOD.

Completed

2 To increase Brain Stem Death testing Rates to 100% and optimise number of organs donated per donor

Local teaching regarding CBI guidelines so all staff understand the rationale and can embrace and use the guidelines effectively.

Display copy of CBI Guidelines and new detailed BSDT forms on OD display boards in coffee room.

CBI guidelines available with new detailed BSDT in Organ Donation folder on ITU- Staff to be aware

CLOD to discuss and/or email ALL ITU consultants on both sites with regard to use of CBI guidelines and more detailed BSDT form

CBI guideline and new detailed BSDT form to be included in ICU anaesthetic simulation and education training days.

CBI guideline and detailed BSDT form training to be included on annual SD programme

Use cardiothoracic scouts for ALL heart

The use of the

Catastrophic Brain

Injury Guidelines in all

patients suspected of

Brain Stem death, so

that all patients are

stable to test

use new detailed BSDT form so All tests are carried out consistently

All patients suspected of brain stem death to be stable and tested within appropriate time frame.

Maximum number of

Completed

100% KPI for DBD donors. Use of donor Management Protocol to be audited

Organs per donor still behind national average

30

donors to optimise potential of donation through Scout assessment and expert advice

Monitor number of organs donated per donor via PDA and local database.

Monthly review SNOD and CLOD of patients who were not able to be tested due to instability/electrolytes/temperature.

CLOD to feedback to other consultants via email when CBI guidelines and detailed BSDT forms not used

To increase organ donation awareness by feeding back at M&M meetings with regard to outcome/issues.

Feedback and evaluate progress/ non compliance of the action plan each quarter at Organ Donation Committee meetings- make a plan to overcome these issues

organs that can be

donated are donated.

Staff familiar, comfortable and compliant with new BSDT forms and CBI guidelines and used every time

Offer a consistent, excellent and caring service to potential donors and their families

Educate staff to refer ALL patients regardless

of diagnosis/age to SNOD (Embedded or on

call) where there is a plan to WLST or BSDT

in a timely manner allowing 3 hrs for SNOD

to attend if required.

SNOD team to respond quickly to pages and

deem unsuitable/suitable on information

given in a timely manner (within 1 hr if

marginally potential donor)

Planned approach with clinical staff prior to

discussing donation with families

Always check Organ Donor register for

patients’ wishes.

Ensure families are supported by people

(SNOD) with the right skills/ knowledge and

ALL patients where there is a plan to BSDT or WLST are referred for assessment of suitability for Organ Donation.

Increase potential donor pool within the Trust to increase donation rates

Partially complete

100% SNOD involvement in family approach

BUT referral of all potential DCD donors NOT achieved. Move to 100% referral of all ventilated withdrawals of treatment in progress.

OD potential is part of safety brief now

Organ donation pathway integration into ICIP still planned

31

have time to consider/discuss the benefits of

organ donation

Involve chaplain not only as religious support

but also as someone who can help families

who are grieving. Can spend time with the

families and help resolve any issues within

the Trust.

To have Organ Donation on Safety Brief for

handover to raise awareness and need to

refer

New developing computer system for ITU. To

work with IT lead, Zeynep Herron, to devise

Organ Donation page that flags patients

where treatment is to be withdrawn/BSDT

and asks nurse/doctor to refer to SNOD

team.

IT page to be set up that repopulates from

other data this admission such as

demographics, treatment plan, results.

Additional information to be added such as

how treatment was withdrawn and when,

accurate time of asystole, whose decision to

WLST and probable cause of death

Increase SNOD presence so nurses/doctors

can seek advice re suitability of potential

patients prior to BSDT or WLST

Increase SNOD presence to enable SNOD

to be involved early with potential donor

families and early breaking bad news

conversations.

32

Support/Empower Link nurses to raise

awareness to refer all patients where there is

a plan to WLST or BSDT

Feedback at monthly unit meetings face to

face or via email to Seniors

Set agenda item each quarter to discuss progress/ non-compliance of all action plans. Discuss methods to overcome/bring back on track

Increase awareness of organ donation in the public sector to promote discussion within families/friends

Donor recognition sculpture present in SRH/WH reception area near to coffee shops.

Smaller Marquette present in each chapel for quiet remembrance

Transplant Week- stands to be set up in both reception and canteen areas on both sites

Promotional leaflets regarding joining ODR to be constantly replenished

Select small group of volunteers to help with promotional work, replenishing stock around the Trust. All volunteers to be Trust vetted and CRB checked.

Lay chair to speak at general public/WI meetings to increase awareness in the community.

Involve chaplain team to oversee volunteers with help of lay chair during their initial period

Increase general awareness of organ donation throughout the Trust

Increase number of people on ODR in SE region

triggered general discussions/awareness within the general public, so families know what loved ones wishes are.

All leaflets fully replenished at all times

Transplant week- stands set up to raise awareness amongst staff and visitors to the Trust

Regular presentations to the community

Completed

Volunteer corps in place and inducted.

Excellent Transplant week activity throughout the trust

Smaller marquettes available & awaiting fixing in chapels

33

3 Cross – site implementation of A&E donation policy and algorithm

Engagement with A&E consultants and lead nurses.

Appointment of link consultant and nurse on both sites

Attendance of link personnel at organ donation committee meetings

Increase in potential donor recognition and referral to critical care within A&E

Completed at Worthing

Completed at St Richards

Needs assessment and updating on both sites

4 Family room St. Richards - redesign and refurbishment

Detailed design drawings

Identify sufficient funding

Clinician buy-in to project

New family with kitchenette and interview room

Project complete (incl. official opening)

5 CG135 compliance - full compliance

Consultant update training days (CG ½ days) and access to relevant materials.

Training of Critical Care nursing staff to perform as part of the organ donation bedside MDT

Signed off competencies

Partially complete

Regular presentation of key elements of the process at cross site CG ½ day (annual)

E- learning package currently in design with NHSBT regional office involvement

Organ donation competency part of ITU nurse signoff

6 Trust OD Policy review

Updated policy Partially complete

Awaiting final assessment by CLOD & SNOD

34

7. Strategic Responses to Issues Identified in 2014/15

Issues from 2014/15 Risk to Delivery Action to be Taken to Minimise Risk Delivery Lead

1. 100% referral rate for

potential DCD donors

Lack of awareness of ‘100% referral’ policy

Publicize widely to Drs of all levels; ITU sisters via

monthly meetings who will then cascade to bedside

nurses

SNOD

CLOD

2. Establish greater ‘buy in’

from both A&E’s to

encourage potential donor

recognition and referral to

ITU. As well as increasing

tissue donation from A&E

Lack of training opportunities/time for nursing staff

Lack identified A&E clinician link

Establish solid ED leadership and OD policy/traffic light

system

Active /enthusiastic link nurses

Establish solid process for ED tissue donation

Analyse ED PDA

SNOD

(CLOD/N- CLOD)

3. 100% utilization of DBD

Care Bundle with an

increase in number/quality

of organs

Lack of awareness/availabilty of care bundle

Make available draft checklist/proforma within ITU

donation files and advertise widely amongst nursing

and medical staff

Convert SOP document to editable PDF for use on ICIP

Training in DBD donor management

CLOD

SNOD

35

8. Objectives for 2015/16 and Monitoring Arrangements

Objectives for 2015/16 Actions Required to Deliver

Objective Measurable Outcome /

Milestones Delivery Lead Delivery Date

1. 100% referral rate for potential DCD donors

Widespread adherence to ‘100% referral’ initiative across both sites

PDA – 100% identification and referral of all ventilated patients undergoing withdrawal of treatment

Increased DCD donor approaches

SNOD

CLOD April 2016

2. 100% implementation of Donor Management Protocols for potential DBD donors

100 % implementation of DMP in all BSD pts.

To include use of Catastrophic Brain Injury Pathway

Increase in number of organs

per donor from Trust compared

to national average

Audit of practice showing

compliance

CLOD

SNOD April 2016

3. Film Project – complete commissioning and recruitment of participants

Secure funding/payment terms

OD film project subcommittee

Identify filmmaker

Identify participants/release forms

Timescale

Secured participants with signed disclosures

Completed films

N-CLOD

OD F/SC April 2017

4. Broader use of Organ Donation Volunteers

Complete training

Identify community projects

Displays at various community locations – GPs/pharmacies etc.

N-CLOD April 2016

36

5. Trust OD Policy review

SNOD & CLOD to meet to finalise

Updated policy CLOD

Deputy CLOD

SNOD

April 2016

37

9. Risks to Delivery of Objectives and Mitigating Actions

Objectives for 2014/15 Risk to Delivery Action to be Taken to Minimise Risk

Delivery Lead

1. 100% referral rate for potential DCD donors

Lack of awareness amongst key staff esp. bedside nurse and shift leader

Lack of beds to facilitate from ED (movement from HDU to wards)

Further education and awareness/ reinforcement SNOD

CLOD

2. 100% implementation of Donor Management Protocols for potential DBD donors

Lack of awareness amongst key staff esp. bedside nurse and shift leader

Further education and awareness/ reinforcement SNOD

CLOD

3. Film Project – complete commission and recruitment of participants

Lack of willing participants given wide potential exposure

N - CLOD

4. Broader use of Trust Volunteers

Continued motivation Constant interaction

N-CLOD

5. Trust OD Policy review

Nil Nil CLOD

DEPUTY CLOD

SNOD

38

10. Any Other Information

APPENDICES

A. NHSBT Trust DBD/DCD Data

B. FINANCE

C. Harefield DCD Heart Donation Protocol

D. Organ Donation Study Day 2014 feedback

39

APPENDIX A

NHSBT PDA data:

*Access to the above flowchart analysis can be obtained from the Clinical Lead Organ Donation

40

Organ Donation Income and Expenditure as at 31st Mar 15

Income

Balance brought forward from 13/14

21,893

NHS BLOOD/TRANSPLANT 1,000.00 NHS BLOOD/TRANSPLANT 2,631.00

Transferred to Anaesthetics m10 NHS BLOOD/TRANSPLANT 2,631.00

Transferred to Anaesthetics m10

NHS BLOOD/TRANSPLANT DONOR REI 8,344.00

50% Transferred to ITU WOR m11 4 donors

NHS BLOOD/TRANSPLANT - CLOD Q3 2,631.00


NHS BLOOD/TRANSPLANT CCG - DON 6,258.00

50% Transferred to ITU SRH m12 3 donors

NHS BLOOD/TRANSPANT - DONOR RE 6,258.00

50% Transferred to ITU WOR m12 3 donors

NHS BLOOD/TRANSPANT - CLOD Q4 2,631.00


Total Income - year to date 32,384

less :Expenses

expenses sculpture project 886824 520.00 714099ANGELA FISHER 394.87 Dying Matters 1 191.50 714126ANGELA FISHER 749.60 Dying Matters 2 105.00 HILTON AVISFORD AVIEVE010 4,195.00

Non PO OrganDonation Sculpture Unveil 165.79

714200Mrs Angela Fisher 507.03 5440KENADS LIMITED T 612.00

Non PO Inv SIN003416 336.00

Non PO

714241MRS ANGELA FISHER 179.44 714354Mrs Angela Fisher 60.95

APPENDIX B - Finance

41

Payment Stage 4 of 4 -5,000.00

RECEIPTING ERROR

CORRECTION FROM 13-14

Credit to be received month 6 14-15

Payment Stage 3 of 4 -5,000.00

RECEIPTING ERROR

CORRECTION FROM 13-14

Credit to be received month 6 14-15

a3 & a4 poster ref 1208226 510.00

HILTON AVISFORD AVIEVE010 -699.19

Non PO ADJ

5440KENADS LIMITED T -612.00

Non PO ADJ

714405Angela Fisher 90.40 InvAVIEVE010.101014 HILTON AVI 4,836.10

duplication 50054498 bb mth7 hilton avisford park -806.02

InvAVIEVE010.101014 HILTON AVI -3,495.83

correction Committee expenses 54.00

714445Mrs Angela Fisher 324.22 Xfer NHS B&T Dr Albertyn Q1-3 to Anaesthetics 7,893.00 714572ANGELA FISHER 158.40 714487Mrs Angela Fisher 108.00 Donor referral income m1-9 50% 4,172.00 Xfer NHS B&T Dr Albertyn Q4 to Anaesthetics 2,631.00 Donor referral income m10-12 50% 3,129.00 Donor referral income m10-12 50% 3,129.00

Total Expenditure year to date

- 19,439

Balance as at 31st March 15

34,838 Deferral of income in March '15

42

Appendix C – Heart Retrieval Protocol from DCD Donors

43

Appendix D –

WSHT Organ Donation Study Day 2014 Feedback Here is the feedback from the study day. We received a total of 45 evaluation forms. On the next page you can see the actual numbers of the different scores given for each presentation/workshop. NB. The low scores (1 &2) were mostly given by 3 people who gave uniformly low scores. I have presented 2 graphs: 1. The first represents actual numbers of scores given (1-5) in a column whose height is the total number of responses. 2. The second represents scores given as a percentage of the total number of responses given for each presentation/workshop. I have given a selection of comments at the end. This has been selective to prevent a lot of repetition e.g “Very informative”.

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sho

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sho

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ater

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1 0 0 1 1 0 0 0 0 0 0 0 2 1 1 2 3 0 0 0 0 1 0 0 3 4 10 12 10 3 2 1 11 12 4 3 4 25 19 14 14 10 15 6 12 14 8 9

5 18 15 10 15 29 21 32 12 7 10 25

44

45

46

Comments

Donation Overview: Albertyn Informative Good to have insight in to process that happens before harvest process (theatre staff) Well presented Information given to the point and excellent Good to alert those present to the safety briefing and donor management Good explanation, which placed the process in context Good talk Difficult to read slides. Too much information

Process mapping: Bowmar I feel more updated Given great insight in to the donation timeline and process. Helpful and informative. Very well presented and useful for day to day. Excellent Very informative Very interesting and aimed at my level of understanding. Some repetition.

King’s DCD retrieval: Jassem Interesting Brilliant to get perspective from retrieval. He started his presentation defending himself and his behavior in the past. A difficult session to understand and follow. Very informative. A bit long-winded. Very passionate about his role. Perhaps less chemistry information next time. Excellent teaching about why timing is important. Interesting but hard to understand. Not related to advertised subject of talk. Too in depth. Clever man. Information way over the top. Interesting but not well presented. Information above my ability to understand. Probably a bit too medical for many.

Harefield: Mohite Very interesting, clear and easy to understand but way too long. Above my understanding.

47

Interesting to see all the statistics Well presented Extremely informative and paramount to the day. Went on a little too long. Lots of information and very useful. All very important but slightly over my head. Optimisation really useful to my clinical area. I’m not sure who his presentation was for. Way too long. Too many busy statistical slides Too much information to digest. Lost. A lot of stats.

Breaking bad news workshop: Melville Demonstration useful in some ways Fantastic Very well presented and done sensitively. Executed really well and calmly. Excellent Interesting to see how the SNOD approached the questions of organ donation. It showed us how to use the right language to be most effective and just to be honest and open. Interesting but personally I felt uncomfortable watching it and did not feel a need for all the acting. I felt people weren’t allowed to express their opinion well and I was made to feel my opinions were wrong

BSDT workshop Very helpful. Good to see a demo Fantastic Excellent. Very informative. Very good Good revision. Really made it clear Interesting but ALL doctors need to learn not to ramble and go on for too long. Slightly odd watching YouTube of BSDT. OK. I thought he was a bit dismissive of some questions.

Donation experiences Very interesting. Sad but very important to hear. Very emotional and amazing to experience. Very overwhelming. Very helpful to us as nurses. Nice to hear real experiences. Brilliant Moorefield’s guy was best presentation of the day.

48

Thank you. This was the most powerful part of the day. I’m far too British for all these shows of emotion. Not very slick. Few delays. I think Simon was a bit too negative about his experiences. While the stories were moving I’m not sure what the purpose is. They would be fantastic presentation to the general public.

Stands- Moorefield’s Very helpful Excellent Not a great deal of info available. Didn’t have time to attend.

Stands- Tissue services Very helpful Brilliant. The literature is so important to provide in my area. Good info. Didn’t have time to attend.

Quality and usefulness of documentation Very good to recap and review all information Brilliant Haven’t received any!

Venue and catering Tea and coffee great. Food cold. Yummy. Very nice but it worried me a lot how much today has cost. Would PGMC not have been cheaper? Brilliant. Lovely lunch. Excellent. Extensive range and high quality. Vegetarian option not nice. Not enough water and not enough alternatives for those who don’t drink tea/coffee.

49

Most useful/thought-provoking thing Very emotional but fantastic. Precise and clear communication is essential to help families…. To be calm and gentle with giving any information. I am pleased that I attended the session. It has really helped me a lot. Increased awareness of organ donation requirements. I feel that any nervousness/fear I had regarding organ donation and approaching families for consent have been reduced No idea so much could be donated Over 60% of families regret refusing organ donation. Experiences of patient’s and donor families (Angela). I will definitely sign up on the ODR. The real life stories. The whole programme opened my eyes to organ donation.

Suggestions for improvement More sessions on the practicalities and logistics of retrieval. A bit more info on practical steps for us to increase the donor pool Very well organized. You have exceled from previous years. A list of abbreviations would have been useful. Too much reliance on PowerPoint. Nicer to be talked to. Would have been nicer to have speakers who had the confidence to talk to the audience rather than just rely on too many bar charts and PowerPoint presentations. I didn’t see the need to have the real life experiences. Couldn’t see the relevance of that session. Difficult to say how you could improve. Thank you very much. It has been brilliant. It would be beneficial to have a talk on the successes and failures. I am aware that things don’t always go according to plan (Simon). I’m more confused than before! Sorry! Good to have morning lectures and workshops in the afternoon. Some lectures were rushed. I would have liked to have more time to digest the lectures. To have presentations available before the day to make notes on To know the number of organs and tissues we can donate and the number of lives they could save. A shame more people couldn’t attend. Shorter breaks for an earlier finish. Cardboard folders look nice but not really needed.

1

Title

Performance Report – Month 9


Jane Farrell, Chief Operating Officer/Deputy Chief Executive

Prepared by

Adam Creeggan, Director of Performance

Giles Frost, Assistant Director - Operational Planning and Performance

Status

Disclosable

Summary of Proposal

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


Describes Quality Outcome KPIs


Trust Strategic Theme B - Provide the highest possible quality of care to our patients. This we will do through focusing on a range of measures to improve clinical effectiveness.

Trust Strategic Theme G - Ensure the sustainability of our organisation by exceeding our national targets and financial performance and investing in appropriate infrastructure and capacity.

Trust Strategic Theme F - Improve our performance against a range of quality, access and productivity measures through the introduction and spread of best practice throughout the organisation.


Describes KPIs linked to financial performance.


Describes KPIs linked to workforce.

Recommendation

The Board is asked to NOTE the report.

Communication and Consultation

N/A

Appendices

1: Key Performance Deliverables.

2: Operational Performance Scorecard.

3: Monitor Risk Assessment Framework Scorecard.

To: Trust Board


2

To: Trust Board Date: 28th January 2016

From: Jane Farrell, Chief Operating Officer/Deputy Chief Executive Agenda Item: 8

FOR INFORMATION

WSHFT PERFORMANCE REPORT: MONTH 9, 2015/16

1. INTRODUCTION

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

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

The Monitor Risk Assessment Framework

Other efficiency indicators, where relevant.

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

significance, or in year trend analysis.

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

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

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

2. SUMMARY PERFORMANCE

2.1 Based on provisional Month 9 positions, the Monitor Risk Assessment Framework performance is

notionally one point. This relates to continued ‘managed fail’ in Referral to Treatment (RTT) as

part of an agreed recovery planning process.

2.2 The Trust had 3 cases of C.difficile in December. This generates an aggregate volume of 30

cases in the year to date against a full year target of no greater than 39 cases.

2.3 Key indicators of operational pressure during December include:

10,821 A&E attendances compared to 11,101 in December 2014 (-2.5%).

4,851 emergency admissions compared to 4,461 in December 2014 (+8.7%). When

scrutinised by age group there was an 4.7% increase in 65-84 years and a 3.2%

increase in >=85 years December 2015 compared to December 2014.

3

Formally reportable delayed transfers of care totalled 3.59% for December 2015.

This excludes patients who are medically fit for discharge but have not been

classified as delayed transfers under national guidance as a multi-disciplinary case

review had not taken place.

Occupancy of funded bed stock was 92.2% for December 2015.

2.4 December saw the first of a series of industrial actions planned by the British Medical Association

(BMA) with relation to Junior Doctors terms and conditions. The first planned event was a 24 hour

withdrawal of labour on December 8th 2015 in all areas other than those with direct link to the

provision of emergency care. This action was postponed by the BMA late in the working day 7th

December, but was regrettably too late to prevent the enforced cancellation of 482 elective

admissions/attendances to support cover arrangements for the safe delivery of care.

3. PERFORMANCE EXCEPTIONS

3.1 A&E Compliance

3.1.1 The Trust was not compliant in December with 93.66% of patients waiting less than four hours

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

Trust was compliant for Quarter 3 in aggregate, with 95.1%.

3.1.2 Delivery of compliance has been significantly constrained by the access to beds at critical points

due to delayed transfers of care (DTOC). During December DTOCs peaked at 5.7% at the

Worthing site and 4.2% at St. Richards. In real terms this reflects an impact in ‘lost’ beds that

fluctuated between a base of c33 beds and a high of c60 beds during the month. This excludes

the effect of patients who are medically fit for discharge (MFFD), but have yet to be declared

‘delayed transfers’ following a full multi-disciplinary assessment. The inclusion of patient defined

as MFFD crudely doubles the effect on available bed stock. Combined with the known constrains

in implementing the Bed Reconfiguration programme have generated a highly challenging

capacity picture.

3.1.3 Latest national data relates to November 2015 and shows compliance of 87.0% for Type 1 A&E

units. Regional compliance for South of England was 88.0%, with Surrey/Sussex Trusts

(excluding WSHFT) generating aggregate compliance of 89.3%.

3.2 Cancer

3.2.1 The provisional position for December shows the Trust to be fully compliant against all 7 Cancer

metrics. Quarter 3 was fully compliant in relation to Monitor’s measure of aggregated

performance for the period.

4

3.2.2 Compliance is set within the context of an 11.1% increase in treatment activity, and a 20.7%

increase in 2 week urgent referrals April – December 2015 compared to the same period 2014.

3.2.3 For context, latest nationally published data relating to November 2015/16 shows national

aggregate compliance for cancer attendance to be 94.75% for 2 week rule (target 93%), 93.45%

for symptomatic breast (target 93%), and treatment within 62 days to be 83.46% (target 85%).

3.3 Referral to Treatment (RTT/18 Weeks) 3.3.1 The Trust completed 11,083 RTT patient pathways in December and is 3,013 (3.4%) cases

ahead of planned recovery volumes. Referrals were 1.50% lower than plan in-month, but remain

cumulatively 3.24% higher than plan for the year to date.

3.3.2 The percentage of patients waiting greater than 18 weeks in the period remained materially

unchanged in December at 86.87% versus 87.02% in November. Board members should note

that the combined effect of reduced referral volumes (decreasing the percentage of waiting list

that is compliant), and reduced working days for treatment with no reduction in patients tipping

across 18 weeks of wait having been referred in August 2015, make December the most

challenging month to sustain RTT compliance.

3.3.3 This is reflected in national data for November 2015 which shows compliance to have fallen to

92.1% for NHS providers. This figure does not reflect a number of large providers that are not

currently reporting RTT, agreed as part of ‘special measure’ arrangements. Inclusion of these

providers at their last reported position would give a notional compliance level of 91.9% against

the target of <92%. Across the South of England Region compliance was 91.4%, with

Surrey/Sussex Trusts (excluding WSHFT) generating aggregate compliance of 86.1%. Within the

Surrey/Sussex patch, Brighton and Sussex University Hospitals (77.0%) reported the highest

level of non-compliance.

3.4 Fractured Neck of Femur (#NOF) operation within 36 hours of admission

3.4.1 During December, 79.37% of medically fit Fractured Neck of Femur (#NoF) patients were

operated on within 36 hours of admission against a target of 90%.

3.4.2 There were 8.0% more trauma cases requiring surgery in December 2015 compared to

December 2014. This increase demand belies three days of significantly abnormal trauma

volumes, each containing 6 fracture neck of femur admissions compared to an expected level of

2 per day.

3.4.3 The surgical division reallocated elective activity in immediate response, and January is fully

complaint at 94.0% at the time of writing.

5

3.5 Diagnostic Test Waiting Times

3.5.1 Compliance marginally deteriorated in December to 1.69% from 1.43% in November. To provide

context, compliance does not reflect that the detailed recovery programmes in Gastroscopy,

DEXA (bone density) scans, non-obstetric ultrasound, and Neurophysiology were all delivered by

end December 2015 – a month ahead of the recovery timetable of January 2016.

3.5.2 These programmes reflect a reduction from 416 breaches at the end of September, to 16 at the

end of December in these diagnostic modes. Regrettably, delivery of recovery ahead of plan in

this mode was offset by a compliance blip in MRI on the Worthing site linked to unplanned

reduction in workforce and impact of atypical urgent demand.

3.5.3 In total 1,922 MRI tests were undertaken in December 2015 compared to 1,717 in December

2014 (+11.9%), despite which the factors described combined to generate 68 breaches (5.95%)

for this modality. Tactical responses to increase capacity on the Worthing site have been enacted

and compliance restoration is forecast for January.

3.5.4 Across all diagnostic modes the Trust continues to run significantly ahead of planned levels to

meet demand. During December, a total of 13,599 tests/procedures were carried out in

comparison to 11,575 in December 2014 (+17.5%). As per planned compliance recovery actions,

activity levels continue to exceed planned levels in key modalities:-

Imaging Tests: 10,443 December 2015 compared to 8,952 December 2014

(+16.7%)

Diagnostic Scoping: 1,868 scopes December 2015 compared to 1,484 December

2014 (+25.9%)

3.5.5 For comparative purposes, the most recent national data (November 2015) shows compliance

across England at 1.8%. For Trusts in the South of England Region aggregate compliance was

1.8%, with the Surrey/Sussex acute Trusts (excluding WSHFT) generating aggregate compliance

of 3.3%. Within the Surrey/Sussex patch, Brighton and Sussex University Hospitals (7.4%)

reported the highest levels of non-compliance.

4 RECOMMENDATION

4.1 The Board is asked to receive the Month 9 positions, and note the Quarter 3 compliance score of

1 point (Green) against the Monitor Risk Assessment Framework.

Adam Creeggan, Director of Performance

Giles Frost, Assistant Director - Operational Planning and Performance

20th January 2016

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

DECEMBER 2015

Description / Comments / Actions

Month YTD Projected O/T

93.66% 96.41% >95%

Actions:

1. Enhanced discharge planning arrangements

2. Augmented patient flow arrangements in conjunction with external partners

3. Dedicated operational delivery plan in place under the leadership of the Chief

Operating Officer



98.00% 94.13% >93%

Actions:

1. Dedicated weekly action focused delivery meeting under the leadership of the Chief

Operating Officer

2. Mitigation actions agreed with health partners including enhanced advice and

guidance for GP's from WSHT consultant staff prior to referral, improved feedback

mechanism for GP on appropriateness of referral, and real time access to referral data

by GP practice, conversion to a cancer pathways and volumes receiving definitive

treatment for malignancy.



96.32% 91.21% >93%

Actions:


Operating Officer

2. Mitigation actions agreed with health partners including enhanced advice and

guidance for GP's from WSHT consultant staff prior to referral, improved feedback

mechanism for GP on appropriateness of referral, and real time access to referral data

by GP practice, conversion to a cancer pathways and volumes receiving definitive

treatment for malignancy.

Cancer - 62 days from referral to treatment following screening contact Description / Comments / Actions


96.55% 95.67% >90%

Actions:

1. Augmented pathway management/tracking with enhanced oversight through DDO

led Cancer Delivery Group

2. Close working with the screening service to maximise the time available to the Trust

to secure capacity


Operating Officer

Patients with cancer can expect to commence treatment within 62 days following

referral after a positive screening test.Target

90%

Delays in receipt of onward referral from screening which reduces the time to secure

capacity to treat patients.

Cancer - Two weeks from urgent GP referral to first appt - Breast symptoms

Significant increases in demand level observed from Q1 2013/14.

Cancer - Two weeks from urgent GP referral to first appointment

Target

Target Patients with breast symptoms can expect to be seen within 2 weeks following an

urgent GP referral.93%

Significant increases in demand level observed from Q1 2013/14.

Key Performance Deliverables ReportA&E 4-hour waiting time target

Target

95%

Patients can expect to be admitted, transferred or discharged in 4 hours from arrival in

A&E

Significant increase in underlying acuity observed from early 2013/14

93.0%

Patients can expect to be seen within 2 weeks following an urgent GP referral for

suspected cancer.

75%

80%

85%

90%

95%

100%

Dec Jan

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

Dec Jan

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

Dec Jan

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec

70%

75%

80%

85%

90%

95%

100%

Dec Jan

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec

Actual Target

8a. Performance Report.Exception Report Page 1 of 2 Printed 22/01/2016 14:05


DECEMBER 2015Key Performance Deliverables Report



86.27% 86.75% >85%

Actions:

1. Augmented pathway management/tracking with enhanced oversight through DDO

led Cancer Delivery Group

2. Close working with the screening service to maximise the time available to the Trust

to secure capacity


Operating Officer



86.87% 86.75% < 92%

Actions:

1. Increase in internal capacity as per Monitor/NHSE agreed recovery plan


Operating Office



79.37% 90.66% >90%

Actions:

1. Improved tracking and escalation processes in place to manage fluctuations in

demand on daily basis

% Medically fit hip fracture patients going to theatre within 36 hours

Target

Increased levels of demand have impacted sustained compliance. Mitigating actions

implemented by the Surgical Division have significantly improved performance.

To ensure the best possible outcomes, hip fracture patients who are medically fit

should be operated on within 36 hours of admission. This standard is part of the 'Best

Practice Tariff' payment process under PbR.90%

Non-compliance an expected outcome of planned RTT recovery programme.

85%

Demand pressure exposing pathway efficiencies. Reduces the time to secure capacity

to treat patients.

92.0%

Cancer - 62 days from referral to treatment following urgent referral by a GP.

Target

Referral to treatment - Incomplete Pathways

Target All patients can expect to commence treatment within 18 weeks of a referral to

consultant.

Patients with cancer can expect to commence treatment within 62 days following

urgent referral by a GP.

70%

75%

80%

85%

90%

95%

100%

Dec Jan

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Dec Jan

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

Dec Jan

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec

8a. Performance Report.Exception Report Page 2 of 2 Printed 22/01/2016 14:05


DECEMBER 2015

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

2015/16

YTD

2015/16

Target Trend

NATIONAL AND OPERATIONAL PERFORMANCE TARGETS

O01A&E : Four-hour maximum wait from arrival to admission, transfer

or discharge85.99% 94.09% 95.73% 97.73% 98.22% 96.82% 97.39% 97.71% 97.28% 94.80% 95.47% 96.14% 93.66% 96.41% 95%

O02 Cancer: 2 week GP referral to 1st outpatient1

95.12% 94.15% 93.09% 89.63% 85.30% 92.13% 94.14% 93.68% 93.21% 94.00% 97.82% 97.85% 98.00% 94.13% 93%

O03 Cancer: 2 week GP referral to 1st outpatient - breast symptoms1

92.41% 92.41% 97.02% 84.88% 74.32% 85.51% 92.27% 96.55% 93.18% 83.24% 97.85% 98.54% 96.32% 91.21% 93%

O04 Cancer: 31 day second or subsequent treatment - surgery1

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% 100.00% 94%

O05 Cancer: 31 day second or subsequent treatment - drug1

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% 100.0% 98%

O06 Cancer: 31 day diagnosis to treatment for all cancers1

99.50% 98.85% 100.0% 98.93% 99.18% 99.57% 98.84% 99.59% 99.57% 100.00% 98.88% 99.18% 100.00% 0.0% 96%

O07 Cancer: 62 day referral to treatment from screening 1

100.0% 93.75% 89.47% 91.94% 100.0% 81.82% 100.00% 94.44% 97.96% 100.00% 90.20% 98.53% 96.55% 95.7% 90%

O08 Cancer: 62 day referral to treatment from hospital specialist 1

82.35% 100.0% 81.82% 93.75% 100.0% 85.3% 85.7% 78.1% 86.2% 81.5% 77.4% 69.2% 58.8% 81.14% N/A

O09 Cancer: 62 days urgent GP referral to treatment of all cancers 1

87.61% 87.24% 91.23% 84.80% 89.10% 86.94% 84.72% 87.50% 87.60% 88.00% 85.61% 85.45% 86.27% 86.75% 85%

O12 RTT - Admitted - 90% in 18 weeks 88.57% 88.45% 85.30% 85.88% 83.84% 84.70% 83.85% 83.54% 84.56% 83.32% 85.54% 83.73% 87.59% 85.51% 90%

O13 RTT - Non-admitted - 95% in 18 weeks 86.83% 86.06% 86.04% 84.50% 85.28% 86.45% 86.60% 84.74% 85.78% 81.32% 82.65% 81.49% 84.04% 84.20% 95%

O14 RTT - Incomplete - 92% in 18 weeks 89.64% 88.18% 87.71% 87.79% 87.87% 88.24% 87.66% 85.81% 84.99% 85.70% 86.61% 87.02% 86.87% 86.75% 92%

O15RTT delivery in all specialties

(Incomplete pathways)4 3 7 7 10 12 12 10 12 11 12 11 14 14 0

O16 Diagnostic Test Waiting Times 3.07% 1.46% 0.99% 1.17% 0.86% 1.43% 1.44% 3.43% 4.56% 6.28% 4.28% 1.43% 1.69% 2.80% <1%

O17 Cancelled operations not re-booked within 28 days 3 10 2 0 1 1 0 2 0 1 1 0 0 0 -

O18 Urgent operations cancelled for the second time 0 0 0 0 0 0 0 0 0 0 0 0 0 0 -

O19Clinics cancelled with less than 6 weeks notice for annual/study

leave41 84 30 24 17 19 26 33 35 14 30 15 25 25 -

O20 Mixed Sex Accommodation breaches 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0

O33 Delayed transfers of care2

3.40% 3.55% 3.69% 3.69% 3.77% 3.08% 3.43% 3.42% 3.17% 3.97% 3.41% 3.88% 3.59% 3.5% 3.5%

IMPROVING CLINICAL PROCESSES

O23 % hip fracture repair within 36 hours 90.3% 100.0% 98.5% 90.6% 98.5% 92.7% 93.7% 95.5% 90.6% 84.0% 93.9% 89.5% 79.4% 90.7% 90%

O24Patients that have spent more than 90% of their stay in hospital on

a stroke unit+

194.3% 97.2% 95.7% 96.7% 87.2% 94.4% 92.6% #N/A #N/A 93.9% 80%88.3%

OPERATIONAL PERFORMANCE

SCORECARD

89.2%

8b. Performance Report.SCORECARD Page 1 of 2 Printed 22/01/2016 14:06


DECEMBER 2015

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

2015/16

YTD

2015/16

Target Trend

OPERATIONAL PERFORMANCE

SCORECARD

OPERATIONAL EFFICIENCY

O36 Average length of stay - Elective 3.12 3.00 3.48 3.36 3.28 3.09 3.09 3.12 2.86 3.05 3.10 3.10 2.99 3.08 3.72

O37 Average length of stay - Non-elective Surgery 5.58 5.65 5.28 5.84 5.84 5.41 5.06 5.44 4.96 5.49 6.01 5.13 5.57 5.43 6.07

O38 Average length of stay - Non-elective Medicine 7.31 7.92 8.24 7.60 7.83 7.25 7.59 7.34 7.20 7.70 7.28 7.77 7.52 7.50 7.80

O39Day case rate - CQC basket of procedures

source: Dr Foster (reported 2-3 months in arrears)88.73% 85.93% 86.47% 86.77% 86.50% 85.32% 85.31% 84.93% 86.78% 87.50% #N/A #N/A #N/A 85.99% 75.0%

O40 Elective day of surgery rate (DOSR) 97.7% 98.1% 97.9% 98.5% 99.0% 97.5% 98.0% 97.1% 98.7% 99.1% 98.8% 98.3% 98.3% 98.2% 90.0%

O41 Did not attend rate (outpatients) 6.45% 6.62% 6.61% 6.60% 6.50% 6.54% 6.59% 6.46% 6.76% 7.18% 6.87% 6.48% 6.70% 6.61% 7.65%

SUSTAINABILITY

O43 Bank staff - % of all staff pay 6.59% 6.99% 6.44% 6.73% 6.57% 6.33% 6.20% 8.82% 6.76% 6.31% 6.51% 6.70% 6.22% 6.71% 7%

O44 Agency staff - % of all staff pay 5.76% 6.45% 5.99% 5.82% 6.62% 5.61% 6.48% 5.61% 8.54% 9.03% 10.36% 9.75% 10.69% 8.08% 2%

O45 Nurse : occupied bed ratio 1.913 1.791 1.785 1.866 1.846 1.846 1.944 1.949 1.982 1.875 1.844 1.826 1.904 1.891 -

O46 % nurses who are registered 72.50% 72.40% 72.18% 71.87% 71.64% 71.56% 71.65% 71.69% 71.64% 71.56% 71.42% 71.16% 70.76% 71.45% -

O47 % Staff appraised 77.75% 77.09% 77.54% 76.58% 77.61% 77.33% 76.69% 77.40% 78.70% 78.29% 79.41% 81.80% 81.90% 81.90% 90%

O48Sickness Absence: % Sickness

(reported one month in arrears)

34.51% 4.91% 4.34% 3.85% 3.56% 3.82% 3.65% 3.93% 3.86% 3.74% 3.83% 4.04% #N/A 0.00% 3.3%

O49 Staff Turnover: Turnover rate (YTD position) 7.83% 8.00% 8.12% 8.39% 8.57% 8.73% 8.87% 9.01% 9.16% 9.51% 9.37% 9.35% 9.18% 9.18% 11%

ACTIVITY

A01 Day Cases 4,543 4,911 4,571 5,168 4,879 4,562 5,395 5,518 4,950 5,252 5,491 5,600 5,220 46,867 45,551

A02 Elective Inpatients 688 661 722 686 659 660 819 836 671 679 685 687 581 6,277 7,389

A03 Non-elective inpatients 5,334 5,267 5,012 5,290 5,246 5,370 5,174 5,441 5,062 5,112 5,572 5,383 5,752 48,112 46,893

A04 Outpatient First attendances 14,564 15,704 14,240 16,425 16,443 15,321 17,861 16,981 14,319 17,079 15,991 16,774 15,481 146,250 142,905

A05 Outpatient Follow-up attendances 24,503 26,826 25,386 27,718 27,341 26,048 29,938 28,932 24,129 28,198 27,850 28,187 25,867 246,490 238,282

A06 Outpatients with procedure 4,581 5,146 4,527 4,707 5,046 4,935 6,095 5,878 5,095 5,761 5,541 5,353 5,109 48,813 41,474

A07 A&E Attendances 11,101 9,885 9,459 11,059 11,010 11,599 11,508 12,068 11,682 11,276 11,651 10,880 10,821 102,495 106,780

1 National reporting for these performance measures is on a quarterly basis. Data are subject to change up to the final submission deadline due to ongoing data validation and verification.

2 Data are provisional best estimates and will be amended to reflect the position signed-off in the relevant statutory returns in due course.

3 Staff sickness is reported one month in arrears.

Notes

8b. Performance Report.SCORECARD Page 2 of 2 Printed 22/01/2016 14:06

Mark Dennis, Head of Information Services

t: 01903 285273 (ext 5273)

DECEMBER 2015

Threshold Apr May Jun Q1Weighted

Score Jul Aug Sep Q2Weighted

Score Oct Nov Dec Q3Weighted

Score Jan Feb Mar Q4

Weighted

Score

(Forecast)

ACCESS

M1Maximum time of 18 weeks from point of referral to treatment in

aggregate – admitted90% 83.84% 84.70% 83.85% 83.84%


aggregate – non-admitted95% 85.28% 86.45% 86.60% 85.28%


aggregate – patients on an incomplete pathway92% 87.87% 88.24% 87.66% 87.66% 85.81% 84.99% 85.70% 84.99% 1.0 86.61% 87.02% 86.87% 86.61% 1.0

M5A&E: maximum waiting time of four hours from arrival to

admission/transfer/discharge95% 98.22% 96.82% 97.39% 97.46% 0.0 97.71% 97.28% 94.80% 96.63% 0.0 95.47% 96.14% 93.66% 95.10% 0.0

M6a All cancers : 62-day wait for first treatment following urgent GP Referral 85% 89.10% 86.94% 84.72% 86.96% 87.50% 87.60% 88.00% 87.53% 85.61% 85.45% 86.27% 85.77%

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

service referral90% 100.00% 81.82% 100.00% 94.12% 94.44% 97.96% 100.00% 97.09% 90.20% 98.53% 96.55% 95.48%

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

treatments94% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

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

treatments98% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

M8 All cancers : 31-day wait from diagnosis to first treatment 96% 99.18% 99.57% 98.84% 99.21% 0.0 99.59% 99.57% 100.00% 99.73% 0.0 98.88% 99.18% 100.00% 99.34% 0.0

M9a Cancer : two week wait from referral to date first seen - All patients 93% 85.30% 92.13% 94.14% 90.47% 93.68% 93.21% 94.00% 93.64% 97.82% 97.85% 98.00% 97.89%

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

breast patients93% 74.32% 85.51% 92.27% 84.08% 96.55% 93.18% 83.24% 91.13% 97.85% 98.54% 96.32% 97.59%

OUTCOMES

M17 Clostridium Difficile – meeting the Clostridium Difficile objective 39 0 5 2 7 0.0 3 3 5 11 0.0 7 2 3 12 0.0

M27Certification against compliance with requirements re access to healthcare

for people with a learning disabilityYES YES YES YES YES 0.0 YES YES YES YES 0.0 YES YES YES YES 0.0

3.0 2.0 1.0

Notes

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

ii Targets for admitted and non-admitted completed RTT pathways have been removed from Monitor's risk assessment framework with effect from 24 June 2015.

Monitor Risk Assessment Framework

0.0 0.0

2.0

Monitor Compliance Framework Score

0.0

1.0

0.0

1.0

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

0.0

0.0

0.0

8c. Performance Report.SCORECARD Page 1 of 1 Printed 22/01/2016 14:07

To: Trust Board


Title:

Organisational Development and Workforce Performance Report


Denise Farmer, Director of Organisational Development and Leadership

Prepared by:

Jennie Shore, Deputy Director of Human Resources

Status:

Disclosable

Summary of Proposal: This report details the Trust’s performance in relation to the supply, development and engagement of its workforce and the organisations culture. Implications for Quality of Care: Provision of high quality, engaged staff has a direct impact on the quality of care. Financial Implications:

Supports good financial performance.

Human Resource Implications:

As described.

Recommendation The Board is asked to NOTE the report. Consultation:

N/A

Appendices: 1: Recruitment KPI’S on TRAC for Medical Staff. 2: Workforce Scorecard.



To: Trust Board

Date: 28 January 2016

From: Denise Farmer, Director of Organisational Development

and Leadership

Agenda Item: 9

FOR INFORMATION

ORGANISATIONAL DEVELOPMENT AND WORKFORCE REPORT 1.00 INTRODUCTION 1.01 This sets out the key headlines relating to the Trust’s workforce at 31 December 2016. 2.00 SUMMARY OF PROPOSAL 2.01 Workforce Capacity There was a further net increase in the number of substantive staff of 38 wte. There was also

an increase in the number of substantive FTE worked of 23 wte. Substantive staff accounted for 87% of total capacity, noting that the budgeted establishment rose by 30 wte as a result of planned increases in bed capacity.

Compared to the same period last year, an additional 73 wte was employed within the Trust in

December and an additional 209 wte used. There has also been an increase in the budgeted establishment of 316 wte. This accounts for the gap in staffing levels, with the medicine division experiencing the majority of the misalignment.

During December bank usage marginally reduced whilst demand for agency staff increased to

its highest level in 12 months in all clinical divisions. 2.02 Recruitment activity

Whilst we have seen notable improvements in the visibility of the recruitment process, and its timeliness we believe that the entire recruitment pathway will benefit from the application of continuous improvement tools and the project is now scoped and underway with an aspiration of reducing the time to hire metrics from 13 to 8 weeks.

Nursing During December 14 registered nurses commenced with a further 24 during January. This

includes 6 from the Philippines who arrived in the Trust on 21 January. Man marking of every recruit against vacant posts is continuing with weekly recruitment huddles in place to ensure all actions are taken to expedite the time to hire. Monthly HCA campaigns are now taking place and over 40 offers of employment were made during December, with more anticipated in January.

Medical Consultant Recruitment

Within 2015, the Trust recruited 14 substantive Consultants (new and replacement posts) and with the support of the Executive team, there is now a planned approach for arranging Consultant interviews (AAC – Advisory Appointment Committee) for 2016 to avoid any recruitment delays, this entails having specific dates identified each month. Between January and April 2016 there are 9 AAC dates already booked to cover specialties in all Divisions.

Hard to fill specialties The hard to fill medical posts (various grades) within WSHFT are in line with other Trusts in KSS and London, and are predominantly Radiology, A&E, General Surgery and Orthopaedics.

A range of initiatives to improve recruitment, including use of consultancies to source applicants, skype interviews, new roles and incentive schemes continue to be trialed. Medical Training Initiative (MTI) and Fellowship posts are now being expanded to Ophthalmology which will support with the workload and future plans at Southlands, and the Trust has recently employed 2 new Radiology Training posts through HEKSS.

Specialty Doctor Grade A project is underway to transfer ‘Trust’ Registrar grades to the Specialty Doctor grade which provides them with a career path supporting the Consultant Grade and recognised within the Medical and Dental Terms and Conditions, and will be a preferred contract for recruitment going forward when the New Junior Doctor pay and contract is introduced in August 2016.

The recruitment KPIs together with actions to improve the time to hire metrics for this staff

group are attached in Appendix 1. Management Two senior appointments are currently being recruited to. These are: Head of Nursing (Medicine): Selection will take place on 4 February Chief Operating Officer: Final selection is due to take place on 10 February Other senior appointments recently made are: Head of IM&T: Ian Arbuthnot, who is anticipated to join the Trust from BSUH in April 2016. Director of Continuous Improvement: Anil Matthew, who will join the Trust from GSK on 4 April

2016 2.03 Staff Survey 2015 The key headlines from the 2015 survey have been published and we now await the detailed

findings by Division. In the meantime a steering group has been established to lead the development and implementation of the Trust’s response to the findings. With representation from divisions who will act as champions for staff engagement and pro-actively respond to divisional findings, it is anticipated that the profile of the survey will be strengthened. We will also be expanding the collection of relevant data on a regular basis to support our plans to improve engagement overall and staff ability to make improvements in particular.

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2.04 Industrial Action Over 100 junior doctors participated in industrial action between 0800 hours on Tuesday 12

January and 0800 hours in Wednesday 13 January, over a dispute with the DH about pay and terms and conditions. Actions taken by the Trust to mitigate the impact on services included releasing all bed holding consultants to work on inpatient areas, strengthening the number of pharmacists, phlebotomists, therapists and nurse specialists available on the wards, increasing GP presence in our accident and emergency departments and reinforcing our referral protocols to GP’s to avoid attendance and admission to our hospitals.

Further action planned over a 48 hours period between Tuesday 26 and Thursday 28 January

has been suspended by the BMA, pending further negotiations. If resolution is not reached, a full walk out will take place between 0800 and 1700 hours on Wednesday 10 February. This will cause significant disruption to services and emergency care in particular. The Board will be kept appraised of this developing situation.

2.05 EWTD Compliance Following a recent internal audit of the Trust’s rostering practices, it has been recommended

that regular monitoring against EWTD compliance is undertaken. EWTD regulations stipulate a maximum working of 48 hours per week, averaged over a 17 week reference period. A monthly report, extracted from Healthroster, has identified that there is a small number of staff who regularly work additional hours on the staff bank that takes their working week beyond 48 hours. Averaged over the reference period however no EWTD breaches have occurred. Notwithstanding this, hours will be regularly monitored through Heads of Department, Matrons and Heads of Nursing to ensure that staff health, wellbeing and safety is maintained.

For junior doctors, compliance with EWTD is monitored through a diary card exercise

undertaken twice annually, with findings made available to Divisions and the BMA. Actions are taken at specialty level to identify the reasons and address areas of non-compliance. Any planned changes to junior doctor rotas are checked for EWTD compliance, through the medical HR team, prior their publication and implementation.

2.06 Clinical Director Induction An induction programme for clinical directors, has been developed and will take place on

Friday 12 February. Contributions from Executive colleagues, Chiefs, Divisional Directors and corporate leads have been designed to support our recently appointed clinical directors new in post.

2.07 Price Caps for Agency Staff The price caps paid for agency workers, introduced by Monitor and TDA in November 2015,

are set to reduce from 1 February with a further reduction from 1 April. In advance of this the Trust has escalated the controls for approval above the rate cap to authorisation by an Executive Director and all agency providers have been informed that the Trust is seeking full compliance. Agencies have also been advised that they will be required to reduce their commission rates to the levels within the revised rate card. Discussions with key agency provider, will be taking place over the coming weeks to agree how the rate cap can be achieved.

In addition to the weekly reporting to Monitor on the use of non-framework for nursing staff, the

Trust will be required to report all overrides for medical staff, both in the use of non-framework agencies and capped rates.

This additional support to right size the labour, and agency market and reduce the financial

burden on the Trust is welcomed. Page 3 of 7

2.08 Operational Plans The Trust’s approach to workforce planning is a key tenant to the draft operational plan for

2016/17, due to be submitted to Monitor by Monday 8 February. Strengthened guidance from previous years, requires the Trust to demonstrate plans to achieve a sustainable workforce that drives down agency usage.

Divisional Workforce and Finance managers are working closely with Divisions to provide a full

set of workforce data that is aligned to activity and capacity and financial plans. 2.05 Workforce Efficiency

Sickness absence during November increased to 4% with the rolling 12 month position remaining static. Whilst the number of sickness episodes reduced, the proportion of staff on short and long term sickness increased. Facilities and Estates experienced an increase in month although the rolling 12 month position reduced again to 5.3%. The number of staff breaching a management trigger is broadly static and on average 15% of the workforce are absent during the month due to sickness. The number of staff on maternity leave each month averages 180, with a high proportion of staff from the Women and Children’s Division. Other absence, excluding annual leave, accounts for a further 1.3%. During December other absence was higher than usual. It is worth noting that the Medicine and Women and Children Divisions have a much higher percentage of ‘other’ absence. This will be explored further with the division.

2.06 Appraisals The number of appraisals remained broadly similar to last month at 81.9%, with improvements

made within Medicine and Women and Children. Urgent action is now required to address compliance within the Facilities and Estates Division. Additional training for managers has been identified and this will be delivered across February and March.

2.07 Workforce Skills and Development

Statutory and Mandatory Training Attendance on all statutory and mandatory training remains high, and is just above or below the Trust target this month.

DNAs

The DNA rate for training is currently 7.6% (an increase of 0.3% since last month).

Progress re staff who have never attended any mandatory training

The number of staff who have never attended any mandatory training, or have not attended any mandatory training for more than a year has decreased again this month and is currently as follows: Not attended any training for more than 12 months: 0 (figure for last month was 0) Never attended any Mandatory training (and started in the Trust more than 3 months ago): 13 (figure for last month was 6)

Page 4 of 7

This increase is disappointing and the names of the individuals have been escalated to Chiefs/ DDOs. And we will continue to work with Divisions to ensure that these individuals completed their training as soon as possible. Induction Training for New Starters The high level of new starters (320 planned for first 3 months of 2016) over the next few months is creating operational and cost pressures in providing Induction training for staff. A number of measures, including using additional, external trainers and external printing companies has been necessary to meet this demand. Evaluation of Staff Conference 2015

An evaluation report summarising the feedback from the fourth Staff Conference: “Where Better Never Stops”, which ran twice on 23 September and 27 November 2015 has now been published on staffnet and circulated to TEC. A total of 490 staff attended the conference this year, an increase of 265 delegates from 2014. Demand for places was high and there were approximately 40 staff on the waiting list in case any delegates withdrew. This year Divisions were allocated a pro-rata number of places and asked to nominate staff to attend. This resulted in a good spread of staff across the Divisions, although the numbers of Medical Staff attending is still low.

The focus of the Conference programme this year was providing an update on Patient First Programme, providing examples of Patient First in Action across the Trust, and launching the Patient First Improvement Programme. All of the speakers were approached and were selected to ensure that they fitted in closely with the theme of quality improvement. Two different Key Note speakers were secured for each conference. In September Jenny Moloney, from the Hospital for Sick Children, Toronto provided an invaluable insight into how to implement continuous improvement in a hospital setting. In November, Professor David Oliver, President of the British Geriatrics Society gave an entertaining presentation on the need to make acute care fit for an ageing Overall the feedback on all presentations was very positive. Delegates found the inclusion of the patient voice in some presentations very moving and powerful. Eleven Workshops were offered to delegates during the afternoon of the Conference. There was a wide range of highly participative workshops including experiencing a Schwartz Round, singing in a choir and having a go at using a new clinical simulation tool. The feedback on all Workshops was extremely positive.

There were 17 stalls in the coffee/ lunch area on a wide range of Trust subjects (e.g. Sexual Heath, Information Governance and Speaking Out.) There were also stalls from local hairdressers and a local spa offering mini massages and hair styling. The variety of stalls and the level of engagement and energy from the stall holders created a high level of participation during the breaks and feedback from staff was that they enjoyed the opportunity to find out more about Trust services and health and well-being initiatives.

There were a number of issues with the venue this year, the quality of lunch at the September Conference was poor and there were a number of AV problems on both dates. Whilst this was mentioned by a number of delegates, it has not impacted on the overall feedback for the day.

The overall feedback from the Conference has been very positive; “brilliant day, enjoyed every part of it”, “very valuable and interesting”, “a wonderfully inspiring day”. Staff left the Conference feeling inspired and motivated, comments included; “really felt proud to be part of the organisation”, ”very proud to be part of the NHS team and more importantly part of our Trust”, “I was left feeling enthusiastic and keen to implement change” .

Page 5 of 7

Future Conferences The Staff Conference Planning Group has reviewed the feedback from both dates and identified a number of changes for the 2016 Conference including sourcing a new venue, increasing delegate numbers even further, securing ongoing funding, making presentations more accessible and increasing the number of medical staff attending. .

2.08 Communications and Engagement

Membership Engagement Survey – Are we reaching you?

Working with the Trust’s Membership Committee, the communications team is running a Membership Engagement Survey, designed to measure the impact of communications activities with members and specifically how informed and engaged they feel. Members are a key part of the organisation and their feedback helps shape services and make improvements to all aspects of patient care. The survey, which is available on the Trust’s website here – www.westernsussexhospitals.nhs.uk/membersurvey, will help ensure the Trust is communicating as effectively with them as possible. Local media as well as some industry and national publications have picked up all stories issued by Communications over the past month: Thank you to the Friends this Christmas Patients staying in Worthing Hospital and St Richard’s Hospital in Chichester all received Christmas presents on 25 December. The special gifts were funded by the Friends of Worthing Hospitals and the Friends of Chichester Hospitals. In Worthing, a surprise present was also given to Janet Webber of the Friends committee, who has been the key present buyer and wrapper for more than 30 years. On Christmas Eve, Janet Webber, 78 from Storrington, visited Broadwater Ward where she received a bouquet of flowers and box of chocolates from Western Sussex Hospitals NHS Foundation Trust in recognition of her many years’ service to patients. The award coincided with a visit by the Vice-President of the Friends of Worthing Hospitals, Tim Loughton MP, and the Mayor and Mayoress of Worthing, Cllr Michael Donin and Ms Linda Williams. Thank you to St Andrew’s, Worthing Patients on the children’s ward at Worthing Hospital enjoyed a visit from Father Christmas and his merry band of elves from St Andrew’s CE School in Worthing on Wednesday 16 December. Staff and students from the school handed out gifts on Bluefin ward for the fifth year running.

Saving A&E for saving lives At the beginning of the month, we invited BBC South Today to St Richard's Hospital on one of the busiest days of the year for the NHS. The report by health editor David Fenton described the importance of the appropriate use of emergency services with the Trust’s Medical Director urging viewers to consider the full range of services available from pharmacies, GPs and 111, as well as A&E. The film is available to watch on our YouTube channel, where you will also find a number of other videos about Western Sussex Hospitals. Working with BBC South formed part of a wide range and ongoing set of communications activities in support of the national Stay Well This Winter campaign.

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Better births for Sussex mums Sussex families are benefiting from better births, in line with national findings by the Care Quality Commission (CQC). Western Sussex Hospitals NHS Foundation Trust, which runs maternity units at Worthing Hospital and St Richard’s Hospital in Chichester has contributed to the national trend in improved birth experiences. The CQC received survey responses from 211 women who had given birth in a Western Sussex hospital in February 2015. The Trust scored: 9.1 out of 10 for labour and birth, 8.7 out of 10 for staffing during labour and birth and 8.4 out of 10 for care in hospital after birth. The first two scores are in line with national results, but the Trust scored better than average for the final category. New walk-in sexual health clinic opens in Bognor Regis West Sussex Sexual Health is pleased to announce extended clinics every Wednesday in Bognor Regis. The new walk-in clinic began on Wednesday 6 January at the Shripney Unit from 2-7pm offering a full range of sexual health and contraceptive services. A further walk-in clinic and outpatients appointments will take place at the Bognor War Memorial Hospital every Monday from 5.30-7.30pm. Wednesday clinics will no longer be running at the hospital. Research Strategy (2015-2018) The communications team has provided support for the development of the Trust’s new Research Strategy (2015-2018), helping to creating an engagement plan and materials to encourage staff, patients, trust members and public to take part in an online survey. More details of the strategy are available here: www.westernsussexhospitals.nhs.uk Board Meetings Members of the public are welcome to attend our Trust Board meetings which begin at 10am on the following dates: 28 January 2016 | Boardroom, Worthing Hospital 3 March 2016 | Bateman Room, St Richard's Hospital 31 March 2016 | Boardroom, Worthing Hospital Do you have or do you know someone with Ulcerative Colitis or Crohn's Disease? You are warmly invited to our friendly awareness and information session hosted by Carla Hookway, IBD Nurse Specialist 4 May 2016, 6-8pm | Chichester Medical Education Centre, St Richard's Hospital To reserve a place at these events please email [email protected] telephone 01903 205111 ext 84038. Medicine for Members' meetings: The programme for 2016 is being arranged and will be publicised on our website shortly.

3.0 RECOMMENDATION


Page 7 of 7

http://www.westernsussexhospitals.nhs.uk/


Appendix 1

Recruitment KPI’s on TRAC for Medical Staff – January 2016

Position and Actions

Stage of Process Target Working

Days

Average Working

Days

Areas of delays/Issue Action to be taken / Comments RAG

T0 Start of authorisation to final approval

3 6 - Finance/Exec approval turnaround

- If requested by Medical HR on a Friday this will impact on number of days

- Medical HR Send/request approval where possible on a Monday/Tuesday

- Medical HR to pursue at day 3 and obtain audit trail for failure of KPI

AMBER

T0a Final approval to advertising start

2 3 - Most Finance/Exec approvals are signed off late on a Friday, therefore ideally advert would need to be released Sat/Sun to meet KPI of 2 days

- Target date to be extended to 3 days to enable advert to be released on Mondays

- Medical HR to check TRAC/action advert Monday morning

AMBER

T2 Advert closed to longlisting sent to manager

1 3 - Advert closes on a Friday pm or Saturday

- Close all adverts at midnight on Sunday

- Action Monday am

GREEN


Days

Average Working

Days


T3 Time taken to shortlist (recruiting manager)

5 11 - Applications are sent and 2 days are lost automatically due to the weekend

- Shortlist not being returned to Medical HR within 5 working days

-

- Extend target date to 8 as TRAC chasers go out at day 3 and 6 automatically

- 8 days will allow for a weekend and should therefore allow Medical HR to meet target date

- This is necessary especially for Consultant AAC’s as a larger panel and higher number of applications

RED

T4a Shortlist notification to invites to interview sent

2 0.2 No delays

GREEN

T5 Date of interview to outcome sent to Medical HR

1 2 - Medical HR act as the manager and request location/date/time from division at advert/shortlist stage. Delays due to panel member commitments e.g. exec team for Consultant AAC’s

-

- Potential AAC dates agreed for coming 12 months

- Retain audit trail for failure of KPI

AMBER


Days

Average Working

Days


T6 Offer notification to conditional offer letter sent

5 4 No delays There will be delays around junior doctors changeover period due to HEKSS appointing and transfer to Trust

GREEN

T8 From conditional offer sent to first reference requested

1 7 - There will always be delays around junior doctors changeover period due to HEKSS appointing and transfer to Trust

- Not within any Trusts control

RED

T16 Conditional offer sent to manager notified all checks complete

35 34 No delays - Can be improved further if OH clearances were returned in expected timeframe

- Option to tick OH as complete on TRAC if received verbal confirmation from OH (Mandi & Jo liaising with OH to resolve)

GREEN

T13 Receipt of final check to manager asked to agree start date with candidate

2 4 - Date is pre agreed verbally/awaiting outstanding pre- employment checks

- Medical HR to add date (provisional) to TRAC as soon as known

GREEN


Days

Average Working

Days


T12 Receipt of final check to start date actioned on TRAC

*5 13 - Outstanding Occ Health clearance

- Responsible Officer reference outstanding

- Being resolved between Mandi/Jo

- Medical HR to pursue Trusts as a priority and obtain audit trail for failure of KPI

AMBER

T14 Vacancy authorisation to start date

72 62 No delays GREEN

*2 day lenience within the TRAC system

WSHFT WORKFORCE SCORECARD Dec 2015

Key performance Indicators Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec2015/16

YTDTarget/ Ceiling Amber Limit Trend

1) WORKFORCE CAPACITY NB

Budgeted FTE 6286.8 6287.2 6287.2 6287.2 6431.3 6437.3 6437.3 6439.3 6520.1 6537.5 6538.4 6572.0 6602.0 6501.7 N/A N/A

Total FTE Used 6349.7 6329.4 6357.1 6393.3 6356.1 6249.6 6339.3 6337.6 6524.3 6362.1 6451.8 6481.0 6558.3 6406.7 N/A N/A

Total FTE Used Variance from Budget 62.9 42.2 69.8 106.1 -75.2 -229.7 -98.1 -101.8 4.3 -175.4 -86.5 -91.0 -43.6 N/A N/A N/A

Total FTE Used Vacancy Factor -1.0% -0.7% -1.1% -1.7% 1.2% 3.6% 1.5% 1.6% -0.1% 2.7% 1.3% 1.4% 0.7% 1.5% N/A N/A

Substantive Contracted FTE 5668.6 5687.6 5693.5 5701.8 5665.0 5664.3 5646.9 5627.8 5797.8 5641.8 5677.9 5703.5 5741.8 5685.2 N/A N/A

Substantive FTE Worked 5582.8 5592.1 5586.6 5599.8 5612.7 5571.4 5540.3 5531.8 5547.4 5496.1 5540.4 5603.8 5623.0 5563.0 N/A N/A

Substantive FTE Used Vacancy Factor 9.8% 9.5% 9.4% 9.3% 11.9% 12.0% 12.3% 12.6% 11.1% 13.7% 13.2% 13.2% 13.0% 12.6% N/A N/A

Bank Usage As % Of Total FTE Used 8.2% 7.2% 7.8% 7.8% 7.8% 6.4% 7.9% 7.2% 7.3% 7.3% 7.0% 7.3% 7.0% 7.2% N/A N/A

Agency Usage As % Of Total FTE Used 2.5% 3.0% 2.6% 3.0% 3.1% 3.0% 3.0% 4.0% 3.8% 4.0% 5.0% 4.7% 5.5% 4.0% N/A N/A

2) WORKFORCE EFFICIENCY NB

Rolling 12 Month Sickness Absence 1 4.0% 4.0% 4.1% 4.1% 4.1% 4.1% 4.1% 4.1% 4.1% 4.1% 4.0% 4.0% N/A 3.3% 3.3%

In Month Sickness Absence % 4.5% 4.9% 4.3% 3.8% 3.6% 3.8% 3.7% 3.9% 3.8% 3.7% 3.8% 4.0% 3.8% 3.3% 3.3%

In Month Maternity Leave % 2.8% 2.8% 2.6% 2.5% 2.6% 2.6% 2.5% 2.5% 2.5% 2.6% 2.5% 2.5% 2.5% N/A N/A

In Month Other Absence % 1.2% 1.2% 1.2% 1.3% 1.4% 1.3% 1.3% 1.3% 1.0% 1.5% 1.5% 1.9% 1.4% N/A N/A

In Month Total Absence % 8.5% 8.9% 8.2% 7.6% 7.5% 7.7% 7.5% 7.7% 7.3% 7.8% 7.9% 8.4% 7.7% N/A N/A

Sickness Episodes 1652 1568 1295 1324 1134 1214 1170 1168 1095 1220 1393 1327 N/A

Maternity Heads 193 203 191 184 187 197 193 179 183 186 181 184 N/A N/A N/A

In Month Long Term Sickness Absence % (28 Days Or More) 2.1% 2.1% 1.9% 1.8% 1.8% 1.8% 1.9% 2.1% 2.0% 1.9% 1.8% 1.9% 1.9% N/A N/A

In Month Short Term Sickness Absence % (<28 days) 2.4% 2.8% 2.4% 2.0% 1.8% 2.0% 1.7% 1.8% 1.7% 1.9% 2.0% 2.1% 1.9% N/A N/A

In Month Stress Related Sickness Absence % 0.7% 0.7% 0.7% 0.7% 0.6% 0.7% 0.7% 0.7% 0.6% 0.6% 0.6% 0.7% 0.7% N/A N/A

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

Number of Staff breaching Management Triggers for sickness absence 999 1032 1034 1024 990 994 1003 1025 1011 989 977 979 N/A

% of Staff (headcount) 15.0% 15.4% 15.4% 15.3% 14.8% 14.9% 15.1% 15.4% 15.2% 14.9% 14.6% 14.5% N/A

Rolling 12 Month Turnover 7.8% 8.0% 8.1% 8.4% 8.6% 8.7% 8.9% 9.0% 9.2% 9.5% 9.4% 9.4% 9.2% N/A 11.0% 11.0%

3) TRAINING & PERSONAL DEVELOPMENT NB

% Appraisals Up To Date 77.7% 77.1% 77.5% 76.6% 77.6% 77.3% 76.7% 77.4% 78.7% 78.3% 79.4% 81.8% 81.9% N/A 90.0% 80.0%

% In Date - All Mandatory Training 2 76.9% 77.6% 78.5% 78.0% 80.0% 81.1% 82.9% 81.5% 80.5% 79.6% 80.4% 81.5% 83.8% N/A 90.0% 80.0%

% In Date - Fire 86.4% 86.6% 88.4% 87.6% 89.3% 90.5% 90.9% 89.1% 89.8% 89.8% 90.2% 90.6% 92.6% N/A 90.0% 80.0%

% In Date - Infection Control (Role Specific) 86.4% 86.7% 88.2% 87.5% 89.2% 90.0% 91.3% 89.0% 89.5% 88.4% 89.2% 90.2% 92.3% N/A 90.0% 80.0%

% In Date - Back Training (Role Specific) 90.4% 90.7% 90.7% 90.3% 90.8% 90.4% 92.0% 91.3% 91.7% 91.5% 92.3% 91.7% 92.8% N/A 90.0% 80.0%

% In Date - Child Protection (Role Specific) 96.9% 96.9% 97.0% 96.8% 96.6% 97.5% 97.5% 96.1% 96.2% 96.0% 96.1% 95.9% 96.6% N/A 90.0% 80.0%

% In Date - Information Governance 86.0% 86.6% 88.3% 87.5% 89.1% 90.1% 90.7% 88.3% 87.5% 87.3% 87.7% 88.2% 90.7% N/A 90.0% 80.0%

% In Date - Adult Protection 75.5% 77.1% 80.3% 81.8% 85.3% 87.6% 90.2% 89.6% 90.9% 92.2% 93.6% 94.2% 95.5% N/A 90.0% 80.0%

Number of Staff with no mandatory training 11 19 20 19 12 14 9 6 8 7 6 11 13 N/A

Number of Staff > 12 months since any mandatory training 0 1 1 0 0 2 0 0 0 0 0 0 0 N/A

4) REAL-TIME STAFF FEEDBACK NB

Total Respondents To Survey 108 76 122 382 109 99 158 52 91 112 80 46 29 776 N/A N/A

% Respondents who would recommend this trust as a place to work 73.1% 65.8% 76.2% 61.0% 62.4% 76.8% 69.8% 63.5% 83.5% 83.0% 71.3% 69.6% 72.4% 73.0% N/A N/A

% Respondents happy with standard of care if a friend/relative needed treatment 88.0% 78.9% 82.0% 78.0% 87.2% 92.9% 83.0% 80.8% 89.0% 91.1% 88.8% 80.4% 89.7% 87.3% N/A N/A

Notes:1 Absence data is available one month in arrears2 An employee is counted as being up to date with all their mandatory training if their Fire, Infection Control, Back, Child Protection amd Information Governance training is up to date.


To: Trust Board


Title

Annual Equality and Diversity Performance Report 2015 (Summary Report)

Presented by

Denise Farmer, Director of OD and Leadership

Prepared by

Natalie Bailey, Workforce Manager and Equality & Diversity Lead

Status

Disclosable

Summary of Proposal

This report seeks to update the Trust Board on the annual equality and diversity monitoring data (for the period 1st October 2014 – 30th September 2015) and actions to be taken as a result of this analysis.


To have a greater understanding of the needs and cultures of all patients, particularly those from protected groups and the potential health inequalities related to this. Excellent care is far more likely to meet the needs of all patients when the workforce is drawn from diverse communities which is reflective of the population served, and when our staff are themselves free from discrimination.


Recognising equality and celebrating diversity is an integral part of the Trusts core business, Patient First and ‘We Care’. Data from the findings in this report feed into The Equality Delivery System 2 (EDS2) and the Workforce Race Equality Standard (WRES) these are both included in the 2015/16 Standard NHS Contract. The regulators, the Care Quality Commission (CQC), National Trust Development Agency (NDTA) and Monitor, will use both standards to help assess whether NHS organisations are well-led.


Increase in staff satisfaction and therefore less time and finance spent on employee relations issues. In addition, better understanding of health inequalities and therefore targeting right patient audience.


As described above. Also meets the requirements to publish annual data as part of the Equality Act 2010.

Recommendation


Consultation

Via Staff forums

Appendices

Please Note, a Full Report with all background information is available on the Trusts Internet and Staffnet.


1

Annual Equality & Diversity Performance Report 2015

SUMMARY REPORT

To be published 29th January 2016 subject to ratification at Trust

Board

Data Compiled From Period 1st October 2014 to 30

th September

2015

We are committed to making our publications as accessible as possible. If you need this document in an alternative format, for example, large print, Braille or a language other than English, please contact the Communications Office by: email: [email protected] or by calling 01903 205 111 ext 84038.


2

Table Of Contents

GLOSSARY OF TERMS…………………….……………..……………3 FOREWORD AND INTRODUCTION ............................................... 4

BACKGROUND AND THE YEAR AHEAD….…………………..…….5 HEADLINE DATA FOR OUR STAFF ............................................... 8

1 The staff ......................................................................................................................... 8 2 Staff Recruitment ......................................................................................................... 15 3 Staff Leavers ............................................................................................................... 16 4 Employee Relations Cases .......................................................................................... 16 5 Training ........................................................................................................................ 16 6 Equality and Diversity Training .................................................................................... 17 7 Staff Pay ...................................................................................................................... 17 8 Staff Satisfaction .......................................................................................................... 17 9 Real Time Staff Satisfaction - Friends and Family Test ............................................... 18

10 The Members............................................................................................................. 18 11 The Patients - Demographic Figures ......................................................................... 20 12 Patient Satisfaction .................................................................................................... 25 13 Real Time Patient Data .............................................................................................. 26 14 The level of Complaints ............................................................................................. 27

For a copy of the full report with all data, please click here …..

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Glossary A&E Accident and Emergency

AfC Agenda for Change (terms and conditions)

BME Black and Minority Ethnic

CQC Care Quality Commission

E&D Equality and Diversity

EDS2 Equality Delivery System 2

E-Learning Electronic Learning

ESR Employee Staff Record

F&E Facilities and Estates

FFT Friends and Family Test

GP General Practitioner

DMG Diversity Matters Steering Group

HR Human Resources

IG Information Governance

LGBT Lesbian, Gay, Bi-sexual and Transgender

Protected Characteristics

Age

Disability

Gender

Gender reassignment

Pregnancy and maternity

Race –this includes ethnic or national origins, colour or nationality

Religion and belief

Sexual orientation

Marriage and civil partnership

QH Quality Health

Stonewall Lesbian, gay and bi-sexual charity

WRES Workforce Race Equality Standard

WSHFT Western Sussex Hospitals NHS Foundation Trust

W&C Women and Children

YTD Year to date

4

FOREWORD

Firstly, I would like to recognise and thank our staff and supporters for promoting equality and diversity at Western Sussex Hospitals NHS Foundation Trust and for taking opportunities to embrace diversity. Over the past year I have been incredibly proud of how our increasingly diverse workforce have applied our patient-centred values and supported our patients to get the best from their experience in Hospital. We have made gains in improving the lives of our patients from protected groups and have engaged directly with the community around this. We continue to educate our staff to a high level in terms of equality and diversity training and the importance of this area now feels more apparent to staff in the organisation. I am very proud of the role our hospitals play in the community and our staff are integral to this. Ensuring we employ a representative group of staff for the community served is of utmost importance. With increasing numbers of patients with more and more complex needs using our services every year, we have enormous potential to act as a positive influence on the lives of people across all sections of society and to improve the quality of life they and their families can enjoy. Together we are determined to put our patients at the heart of everything we do and turn our very good organisation into a great one. Ensuring high quality, safe services are available to all sections of the community and provided by a workforce that reflects the diversity of our population is an essential part of this journey. This annual report provides us with an opportunity to review key results in relation to equality and diversity and celebrate the progress we have made so far. In addition, there are areas of action highlighted that we will drive forward over the course of the year and track progress through our Diversity Matters Steering Group.

Marianne Griffiths Chief Executive

INTRODUCTION

This is the fifth published report explaining how Western Sussex Hospitals NHS Foundation Trust (WSHFT/The Trust) assures itself that our staff and patients are not disadvantaged on the basis of group membership of one of the 9 protected characteristics (see glossary for the list of these). This report will do this by providing some background and highlighting future areas of exploration or improvement right at the start. This is followed by some relevant equality and diversity (E&D) headlines about staff, members and our patients. All the detail and raw statistics can be found in the full report by clicking on the link at the start of this report. Any reference to the local demographic is taken from the 2011 Census figures for West Sussex, unless stated.

This report will satisfy the legal obligation from the Equality Act 2010 to publish our equality monitoring data by 31st January each year. In addition to this, the Trust is currently nearing the agreement phase of EDS2 in order to publish and communicate our equality objectives by April 2016.

Gender reassignment has not been addressed in full in this report as this information is not currently collected for either staff or patients, however the Trust has started to collect this data for employment applicants/new starters this year and therefore a comparison year on year will be available in the 2017 report.

This full report was presented to the Trust Board and Diversity Matters Groups in January 2015, before publication on the Trust’s intranet and internet sites.

Natalie Bailey and Rebecca Ellman-Brown Equality & Diversity Team

01903 20511 extn 84616/84845 (Follow us on Twitter @WSHequality)

5

Background… WSHFT serves a population of around 450,000 people who live in a catchment area covering most of West Sussex.

The Trust runs three hospitals:

St Richard’s Hospital in Chichester Southlands Hospital in Shoreham-by-Sea Worthing Hospital in the center of Worthing

Some facts and figures about the Trust (2014/15):

Treated 198,000 inpatients and day cases Held 555,000 outpatient appointments Saw 134,000 people in the two Accident and Emergency departments Delivered 5221 babies Dispensed around 820,789 medicines Took 389,388 imaging exams (x-rays/scans)

Staff:

Employ over 6600 permanent staff and engage with a high number of flexible workers too

With over 70 Nationalities represented

Various Protected Characteristic forums established, LGBT, Disability and a recently established “Celebrating Cultures forum” to reflect our increasingly diverse workforce (incorporating BME and Religion & Belief forums)

Equality and diversity in 2015 and the year ahead…

Again, this year at the Trust we have seen many great examples of celebrating diversity at the Trust and a selection of these are detailed in this report. In addition, we are beginning to get better at recognising and publicising these on the staffnet and using notice boards and newsletters in the Trust. However, we can always do more to share great practice and exampled. We have raised the profile of equality and diversity further still this year and have hosted another E&D weeks held on all sites at the Trust, as well as 3 separate staff engagement events during the Thai staff lunches on all sites and an E&D stand at both staff conferences. We have also held 2 specific community diversity engagement events during this year, 1 in Worthing and 1 in Bognor. We do however need to explore the community events already taking place in relation to diversity and attend more of these.

Staff are more up to date with their E&D training and the content of this is refreshed on a regular basis. We are in the process of finalising our EDS2 submission in order to agree and publish our new equality objectives by April 2016.

Our local community is still changing, although Census data is only collected every 10 years to evidence this. At the Trust we have seen a further decrease in white British staff and other ethnic backgrounds are increasing. Just this year we have been to Spain, Portugal and the Philippines to recruit much needed nursing staff and the support we have given those staff to welcome them to the Trust and the areas has been really appreciated as shown in the recruitment case study in this report.

http://www.westernsussexhospitals.nhs.uk/about-us/st-richards-hospital/

http://www.westernsussexhospitals.nhs.uk/about-us/southlands-hospital/

http://www.westernsussexhospitals.nhs.uk/about-us/worthing-hospital/

http://www.westernsussexhospitals.nhs.uk/services-and-treatments/surgical-procedures/day-surgery/

http://www.westernsussexhospitals.nhs.uk/services-and-treatments/treatments-and-therapies/outpatients/

http://www.westernsussexhospitals.nhs.uk/services-and-treatments/treatments-and-therapies/accident-emergency/

6

We established a “Celebrating Cultures” Forum this year, replacing the previous BME network and Religion & Belief Forums and this group have already contributed to some changes and new initiatives within the organisation. There are still some areas of challenge and for the year ahead, these as well as some suggested solutions are summarised below:

There are a higher percentage of BME leavers to BME staff employed and LGBT leavers to LGBT staff – Celebrating Cultures Forum and LGBT Forum to write to all BME leavers within the last year to establish reasons and report back to DMG by April 2016.

The Trust is using a new recruitment system this year called TRAC and the data supplied for recruitment in Medical staff appears to have some discrepancies which require exploration by the recruitment team (high level of not stated at appointed stage). However, when looking at the results for non-medical staff there is a much higher success rate for white British staff through the recruitment process. For all BME staff apart from any other ethnic group there are less % wise shortlisted and appointed than applied. The Celebrating Cultures forum will ensure unconscious bias is included in all recruitment & selection and equality & diversity training from now on and explore a development programme for all BME staff including white non-British.

When looking at the last staff survey results (2015 survey), levels of discrimination remain the same. However, ethnic background remains the highest grounds for discrimination and the Trust should consider developing some support sessions or training, particularly for those staff who feel targeted by or patients – Celebrating Cultures Forum to present a proposal to DMG in April 2016.

Need to ensure the audit on service provision for patients with additional communication needs

(visually impaired) is completed and develop a separate action plan for this work – Lisa Ekinsmyth by summer 2016

Funding for the portable hearing loops needs to be secured and a programme of implementation agreed – David Clayton-Evans by summer 2016.

The E&D team within HR are to work with the Communications team to establish a calendar of community events each year to engage with and attend where relevant from an E&D perspective, as opposed to organising separate events – update in next year’s report.

The employee relations team to explore the trends in the disciplinary and grievance cases shown as more males appear affected than females – report findings to DMG in Summer 16.

Suggest re-running the mandatory training report in 6 months’ time as the results are currently showing slightly more females to males trained – report back to DMG Autumn 16.

As is the picture in the NHS in general, white British staff at the Trust dominate the higher pay bands (particularly so in agenda for change pay scales) – Celebrating Cultures Forum to explore whether non mandatory training can be recorded/reported and look into the introduction of a development programme aimed at all BME staff including white non –British – report back to DMG April 2016

Trust Membership profiles show that members currently are not completely representative of the community served. Communications team have developed a strategy to focus on targeting

7

men, under 60’s and minority ethnic groups through community engagement – Jonathan Keeble to provide an update in next year’s E&D report.

Equality patient data recording is still not taking place in many instances, making some of our protected group data fairly unreliable. Lisa Ekinsmyth to work on an action plan around this and present back to DMG in summer 2016.

We need to ensure that reasons for complaints are recorded for all complaints. Only currently happening in maternity services. In addition, the equality data form for complaints requires redesign in order that it can capture all protected groups and staff who deal with complaints need to be educated to understand how/why these should be completed – Tracey Neville/Delia Reed – Report back to DMG summer 2106.

A very recent national report on Transgender Equality commissioned by the UK Parliamentary Committee in January 2016 found the NHS is "failing in its legal duty" to provide equal access to services and guarantee zero tolerance of transphobic behaviour. It called for a "root-and-branch review" by the summer of the health service's treatment of transgender people. Our Trust does not monitor patients or staff by this protected characteristic and further work is required once all the details of the recommendations from this report are known – follow up by the LGBT Forum.

8

Headline data 1. The staff…

Age –

Gender -

0%

2%

4%

6%

8%

10%

12%

14%

16%

Under20

20 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 65 - 69 70+

WSHT 2014

WSHT 2015

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Female - Full Time Female - Part Time Male - Full Time Male - Part Time

WSHT 2014

WSHT 2015

The numbers of older staff employed at the Trust have increased for the second year running – staff aged over 50 now represent over 33% of our workforce. In addition the numbers of under 20 year olds employed have increased from 0.2% of our workforce to 0.4%

Gender split within the Trust has remained the same as last year – 22% male to 78% female. Although the gender split in the Trust does not reflect the local population, it is reflective of the NHS nationally.

The % of female staff working part time has increased since last year and for male staff this has dropped very slightly.

9

10

11

Disability –

Ethnicity –

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

White (NonBritish)

Mixed Asian OrAsian British

Black OrBlack British

Chinese Any OtherEthnicGroup

WSHT2014WSHT2015

Out of those declaring, 4% of our staff are disabled. This is the same % as the last 2 years.

Patients with a dementia – Following identification that staff are often unsure of how to approach someone with dementia and are not always sure how to answer difficult questions, a series of training events for non-clinical teams have been organised by the Trusts Dementia Nurse Specialist. In addition, focus groups were set up for staff to explain the impact of caring for patients with a dementia and specific support is required for BME staff who often feel targeted by these patients. This awareness has been raised in E&D training now also but also requires further thought to address.

Improving services for hearing impaired patients and staff – The Patient experience and customer care team have recently undertaken a piece of work to assess the current provision of hearing loops and services for the hearing impaired and have put together a proposal for improving this service. Funding is currently being explored and once secured, the introduction of portable loops across all clinical and training areas will mean greatly improved confidentiality, dignity and respect for this group of staff, patients and visitors.

Improving services for visually impaired patients and staff – The Trust has a translation service in place, both from a language and sign language perspective. This is due to be reviewed soon and along with this, we are currently completing an audit on the service provision for patients with additional communication needs using NICE guidance and involving relevant internal and external parties. A separate action plan for this under disability will be developed once the audit is complete.

White British staff make up 73.36% of our workforce, a further slight reduction from 73.65% last year. There has been a very small further increase in white non-British staff this last year as well as an increase in Asian/Asian British and Chinese staff.

71 Nationalities of staff are represented at the Trust now and these are celebrated by displaying flags from different countries, raising awareness of foods from around the world and communicating different countries cultural traditions at various times of the year.

The Trust published its Workforce Race Equality Standard (WRES report) in August 2015 and a copy of this can be found on the Trusts website: http://www.westernsussexhospitals.nhs.uk/your-trust/about/equality-diversity/

http://www.westernsussexhospitals.nhs.uk/your-trust/about/equality-diversity/

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Top 5 nationalities represented by staff at the Trust –

Great Britain Philippines Poland India Ireland

Recruitment of overseas staff 2015

In November and December 2015 the Trust recruited 18 overseas Nurses from Spain & Portugal. These

new Nurses have taken up various roles across Worthing and St. Richards sites, working within the

Emergency Floors, ITU and various surgical wards to name a few.

Maria Lopez Portero and Sonia Segade Vazquez, Staff Nurse’s Critical Care Unit (CCU) “The induction

we received from the unit we work on (CCU) has been perfect and we have felt really supported and

welcomed by all of the team .Things that we would recommend for improvement from the overall

experience of joining the Trust would be more practical support with accommodation, setting up bank

accounts and sorting out PINS and tax. We felt that some aspects of the general induction we received

were lost on us as we were new to the NHS. If an additional session was arranged before the full

induction starts, on how the NHS runs this would be really beneficial.”

Photo below of Maria left and Sonia right.

Louise Skelt, Matron for Critical Care “We have found the overseas recruitment very successful for ITU,

and have benefited from great new members to our team. We always ensure that all new recruits have a

clear induction, allocated study days and access to a nurse educator ensuring the new overseas recruits

having a slightly longer supernumery period to help support them with learning a whole new healthcare

system.”

Philippines Recruitment 2015

In June 2015 the Trust recruited 149 Filipino staff. The first cohort of these nurses is due to start on the

18th January. A schedule of welcome and induction has been planned, which includes opening of bank

accounts, accommodation support, meet and greets, tours of the hospital by Trust ambassadors and

information packs provided to them on living in the UK.

The Overseas Nurse Project group has been developed by the Trust Practice Development team. They meet regularly with all newly recruited overseas staff who then have the opportunity to feedback into this group.

http://www.enchantedlearning.com/asia/philippines/flag/flagquizbw.shtml

http://www.enchantedlearning.com/europe/poland/flag/flagquizbw.shtml

http://www.enchantedlearning.com/asia/india/flag/

13

79% of staff in the NHS are white British compared to just over 81% of staff in our Trust (white British and white non-British). White British staff in general dominate the higher

pay bands.

14

Religion or Belief –

Sexual Orientation –

0%

5%

10%

15%

20%

25%

30%

Atheism Buddhism Hinduism Islam Judaism Sikhism Other

WSHT 2014

WSHT 2015

0.50%

0.71%

0.48%

0.57%

0.74%

0.59%

0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

Bisexual Gay Lesbian

WSHT 2014

WSHT 2015

Staff with a Christian religion are still the largest % at 72.48% (slight reduction from 74.24% last year) of those who have declared. There has been little change in the split of staff religion/beliefs in the Trust over the last year apart from a slight increase in those considering themselves as Atheists.

Following the terrorist attacks in Paris, concern was raised by staff with an Islamic faith about how they might be perceived and support was provided by the Trusts Chaplain and communicated through Headlines.

Celebrating Cultures Group – Following the publication of last year’s annual E&D report, the results of the WRES report and the rise in white non-British staff the Trust established a Celebrating Cultures Group in 2015. This group has already met a number of times and has an action plan incorporating the previous BME network and religion and belief forums of the Trust.

71.69% of our staff declared their sexual orientation, a further increase on last years %.

1.9% of staff declare themselves as LGBT at the Trust which is an increase of 0.2% from last year but still below the 5-7% suggested by Stonewall as the average within the general population.

The Trusts LGBT network has been revitalised following the appointment of a brand new chair and has now increased its membership to 12.

15

Marital Status –

Maternity –

E&D awareness and events-

2. Staff Recruitment

0%

10%

20%

30%

40%

50%

60%

Divorced LegallySeperated

Married or CivilPartnership

Single Widowed

WSHT 2014

WSHT 2015There has again been very little fluctuation in the marital status of our staff this year.

An average of 2.81% of our workforce were on maternity leave at any one time in the reporting year, an increase from the 2.63% the previous year.

The Trust has introduced a new Maternity, adoption and maternity support (paternity) leave policy in 2015 to explain entitlements and revised shared parental leave allowances.

The Trust takes part in E&D week in May each year and uses any opportunity to promote E&D possible. We have carried out 5 staff consultation events and 2 patient/service user events around our E&D objectives/focus areas in 2015 and this will continue on an on-going basis and as progress towards EDS2. Further work is around mapping and attending already established community diversity groups.

For all medical staff, recruitment data form the new recruitment system TRAC to be explored to understand why there is such a high level of not stated at appointment stage.

There is a much higher success rate for white British staff through the recruitment process. For all BME staff apart from any other ethnic group there are less % wise shortlisted and appointed than applied. Action – Ensure unconscious bias is included in all recruitment & selection and equality & diversity training from now on and explore a development programme for all BME staff including white non-British.

16

3. Staff Leavers

4. Employee Relations Cases

5. Training

8

24

17

0

5

10

15

20

25

30

1st Oct 2012 -31st Sept 2013

1st Oct 2013 -31st Sept 2014

1st Oct 2014 -31st Sept 2015

Total number of Grievances 2013 - 2015

Male 43% Female

57%

Formal Disciplinaries by Gender - 2015

Male 35%

Female 65%

Grievances by Gender - 2015

The turnover figure for the Trust has risen to 10.30% compared to 7.91% for the previous reporting period. The number of leavers has increased from 526 in the 2014 reporting period to 681 for 2015. Turnover data has been analysed by generation and a retention steering group and staff group sub groups have been set up to develop retention strategies and analyse hot spot areas. In relation to the protected characteristics specifically, there is a higher % of mixed race leavers than the average turnover or than the % employed, therefore the Celebrating Cultures forum will write to those leavers and explore reasons for leaving more fully. When looking at sexual orientation, % of gay and bisexual leavers are also higher; LGBT forum to explore whether these recent leavers should be written to also and report back to DMG.

In total there have been 42 Disciplinaries in the reporting period and 17 Grievances raised. Grievances have seen the first decrease in over 3 years as shown in the graph to the left.

Similarly to the last two years, there are a higher percentage of disciplinaries for males than the percentage we employ as shown in graph below. Grievances for male staff have risen by 10% since 2014 and are higher than the percentage of males the Trust employs. Employee relations team to explore and propose appropriate action.

The percentage of training undertaken by protected characteristic is reflective of the percentage of the workforce apart from in gender where there was a higher percentage of female staff trained to that employed and a lower percentage of male staff receiving training. This report will be analysed again in 6 months’ time and re-presented to DMG in Summer 2016.

Action – to monitor non-mandatory training and introduce a development programme aimed at the Trusts BME staff (see section 7)

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6. Equality & Diversity training

WSHT % Up to Date 30th Sept 2012

% Up to Date 30th Sept 2013



Grand Total 68.30% 91.30% 92.20%

92.70%

7. Staff Pay

8. Staff Satisfaction Equality & Diversity related results – At the time of writing the national context/results are not known, however:

Band 1-3 Band 4-6 Band 7+

Medical

Less than

20k

Medical

20K-40K

Medical

40K-60K

Medical

60K - 80K

Medical

80K+

White British 79.2% 77.6% 77.3% 90.1% 59.5% 82.8% 61.2% 41.0% 50.6% 64.4%

White (Non British) 8.9% 11.3% 7.8% 5.3% 10.8% 3.4% 9.5% 12.8% 16.9% 11.0%

Mixed 0.7% 0.6% 0.9% 0.5% 1.9% 0.0% 1.9% 1.3% 6.5% 0.5%

Asian Or Asian British 4.8% 5.2% 5.6% 1.4% 19.8% 10.3% 18.3% 39.7% 14.3% 17.8%

Black Or Black British 1.6% 1.3% 2.0% 0.8% 3.3% 0.0% 4.1% 1.3% 6.5% 2.1%

Chinese 0.4% 0.3% 0.4% 0.5% 2.0% 0.0% 2.8% 0.0% 2.6% 1.6%

Any Other Ethnic Group 4.4% 3.6% 6.2% 1.3% 2.6% 3.4% 2.2% 3.8% 2.6% 2.6%

Characteristic

Category

% AfC

staff in

Category

% in Category for Paygroup

%Medical

Staff in

category

% in Category for Paygroup

The Trust has continued to meet its target of 90% up to date for E&D training in the last year and in fact, there has been a further increase this year to 92.70%. Medical & dental staff are the least up to date staff group at 84.5%. This may be due to a high number of these staff on fixed term contracts. E&D sessions have been running on each full health and safety day and induction course on each site, as well as ad hoc sessions. E&D training has been excluded from the health and safety updates for the second year due to over training previously and will be re-introduced in 2017. The training is also run as part of other courses such as Managing in the NHS and the content of the E&D training is updated and improved on a regular basis.

Data shows that pay is spread proportionately to those staff we employ in each group. However, again this year for ethnicity, there are over 10% more white British staff in band 7 and above than the percentage we employ in total and 3.6% less white non-British staff in band 7 and above roles. There is also a discrepancy in Asian/Asian British, Black/Black British and other ethnic groups (less paid band 7+ than the % we employ) Chinese staff are over represented in Bands 7+, however the numbers are small. This information was picked up and submitted as part of the WRES report also and this will mean a separate specific action plan being developed as part of this work. Action – Celebrating Cultures Group to explore a career development programme aimed specifically at our diverse workforce, including White Non-British staff.

Staff Survey 2015 – response rate of 54% - a reduction of 2% from last year’s survey. However there were many areas this year where results were improved.

% of staff believing the Trust acts fairly with regard to career progression/promotions regardless of protected group remained the same at 89%

% of staff experiencing discrimination from patients/service users remained the same as last year – 6%

% of staff experiencing discrimination from managers/colleagues remained the same as last year – 8%

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9. Real time Staff Satisfaction

10. The Members Membership Strategy 2015-18 Having achieved Foundation Trust status in July 2013, the Trust is answerable to its members. A responsibility of all foundation trusts is to recruit, communicate and engage with members as a way of ensuring service provision meets the needs of service users. A Trust Member can be any member of staff, anyone who has been a patient or carer within the trust since 1 January 2010 or anyone who lives in any one of the five local authority areas covered by the Trust’s catchment; Adur, Arun, Chichester, Horsham or Worthing. Members are aged 16+.

The current membership is not entirely representative of the community it serves. At the moment, women are over-represented and men are under-represented. The number of white British members accurately reflects the composition of the Trust’s catchment population, while all other ethnic groups are under-represented and those aged 60+ are over-represented, while all younger age groups are under-represented, particularly the 16-30 age group.

When looking at the grounds of discrimination, there has been a decrease on the grounds of other – (35% - 31%). This was the Trusts biggest increase area last year.

Those experiencing discrimination on the grounds of age remained the same as last year at 18%. There were increases on the grounds of: Disability (6% to 7%) Ethnicity (39% to 40%) Gender (13% to 17%) Religion (3% to 4%) Sexual Orientation (3% to 5%)

The highest protected group experiencing discrimination in our Trust remains ethnic background, where 40% of the discrimination lies. Discussions with staff suggest that much of this is from patients and more specifically from those who suffer with a dementia or are intoxicated. Celebrating Cultures Forum to focus on strategies to support this group of staff and propose actions to DMG.

As of November 2015, YTD figures show that 69% of staff would recommend the Trust as a place to work and 80% for care/treatment. Both of these figures show a slight reduction YTD from last year where they were 71% for recommending as a place to work, and 84% as recommending the Trust as a place for treatment.

We are still only able to break down this information by ethnic origin and it would appear that 85.3% of our respondents for question 1 and 70.4% for question 2 are white British and would recommend the Trust for treatment or to work, compared to 73.37% employed in total. When looking at other ethnic backgrounds the % is particularly low for White & Asian staff at 50% recommending for both questions (response numbers are however low.)

The questions that are included in this survey are agreed nationally for all Trusts, therefore it would seem unlikely we will be able to analyse these results by many further protected groups as each would be an additional question on the survey.

19

In order to make the Trust membership more representative of the community the Trust serves, the particular target groups are:

● Men

● Under 60s

● Minority Ethnic groups

0-16 17-21 22-29 30-39 40-49 50-59 50-74 75+Not

Stated

Members 3 80 157 298 441 701 2,648 2,914 362

0

500

1,000

1,500

2,000

2,500

3,000

3,500

Membership Age Profile Source MES Engage

Asian 0.95%

Black 0.30%

Mixed 0.31%

Other 0.16%

White 98.29%

Membership Ethnicity Summary

Asian

Black

Mixed

Other

White

Source MES Engage

20

So the approach for the next three years is to continue to recruit members from under-represented groups, while increasing the engagement and activity levels of existing and new members. The Trust will balance the representation of different groups by targeting the specific groups outlined above, while working to increase engagement levels among existing members.

● The Trust will target men though sports clubs, DIY stores and leisure centres and gyms.

● The Trust will target younger age groups through chambers of commerce, NHS Careers events,

visits to Mother and Baby clinics and through 6th form colleges.

● The Trust will target minority ethnic groups through the Trusts Celebrating Cultures Forum and

through contact with faith communities and partnership with local authority community

development staff.

11 The Patients

Demographic Figures October 2014 to September 2015

The following data is based on the activity for the 1 October 2014 to 30 September 2015. In each point of delivery (i.e. A&E, inpatient or outpatient) patients have only been counted once, but the groups are not treated as mutually exclusive (i.e. a patient may be counted up to three times – as an inpatient, outpatient and A&E attendance).

• There were a total of 131,885 inpatient admissions (electives, day-cases, emergencies and other categories) between 1 October 2014 and 30 September 2015. (This is higher than last year’s admissions; 117,245) This comprised of 80,142 different patients (76918 last year).

• There were a total of 590,447 outpatient attendances for 166,519 different patients. Again this is more than last year which was 519,063 attendances for 157,099 different patients.

• There were a total of 132,196 A&E attendances for 95,182 different patients. This was less than the last reporting period when it was 135,319 attendances for 96,839 patients.

Gender

Inpatients 2015 (2014) Outpatients

2015 (2014)

A&E 2015 (2014) Census

2011

Female 45,698 (57%)

57% 95,050 (57%)

57%

48,142 (51%)

50%

52%

Male 34,437 (43%)

43% 71,456 (43%)

43%

47,021 (49%)

50%

48%

The table above shows that the percentage of males to female inpatients, outpatients and A&E attendances treated within the last year is similar to the gender split as shown in the 2011 Census for the local population. The only change since last years data has been for A&E attendances where there were 1% more male attendances this year than last.

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Marital status (patients aged > 15)

Inpatients

2015 (2014) Outpatients

2015 (2014) A&E

2015 (2014) Census

2011

Single 12,159 (17%) 17%

25,223 (17%) 17% 29,589

(31%) 28% 31%

Married/Separated 26,760 (38%) 38%

53,260 (36%) 37% 23,524

(25%) 31% 54%

Widowed 4387 (6%) 7% 6,122 (4%) 5% 3391 (4%) 5% 7%

Not known 24,567 (36%) 34%

57,504 (39%) 38% 36,373

(38%) 35% n/a

Divorced 2,275 (3%) 4% 4,568 (3%) 3% 1948 (2%) 3% 7%

The picture for patients treated by marital status within the Trust is almost exactly the same as the results by each category in the last reporting period. The data shows that there is some disparity with the local population, with the key differences being the high percentage (above 30% in all types of patients) of not known for patients within the Trust, as well as us having treated in general approximately 20% less married/separated patients than the proportion of the population we serve. In general the Trust seems to have treated less of a percentage in all categories of marital status (apart from single persons in A&E which is comparable with the Census data), however with such a high level of unknowns, these figures would obviously increase in each category if we had full data.

Ethnic Origin

Inpatients


2015 (2014) A&E

2015 (2014) Local

Census

African 106 (0%) 0% 161 (0%) 0% 96 (0.1%) 0%

Any other Asian background

194 (0%) 0%

356 (0%) 0% 236

(0.25%) 0%

Any other Black background

47 (0%) 0%

82 (0%) 0% 70

(0.07%) 0%

Any Other ethnic Group

230 (0%) 0%

404 (0%) 0% 283

(0.3%) 0%

Any other mixed

background 275 (0%)

0% 458 (0%)

0% 479

(0.5%)

1%

Any other White

background 3,801 (5%)

4% 6800 (4%)

4% 6121

(6.43%)

5% 7.2%

Bangladeshi 120 (0%) 0%

211 (0%) 0% 117

(0.12%) 0%

British 59,377 (74%) 76% 112,547

(68%) 70% 66,808

(70.19%) 73% 88.9%

Caribbean 30 (0%) 0%

55 (0%) 0% 26

(0.03%) 0%

Chinese 66 (0%) 0%

156 (0%) 0% 78

(0.08%) 0%

22

Indian 174 (0%) 0%

296 (0%) 0% 230

(0.24%) 0%

Irish 239 (0%) 0%

451 (0%) 0% 315

(0.33%) 0%

Mixed White & Asian

144 (0%) 0%

217 (0%) 0% 147

(0.05%) 0%

Mixed White & Black African

95 (0%) 0%

154 (0%) 0% 115

(0.12%) 0%

Mixed White & Black Caribbean

77 (0%) 0%

107 (0%) 0%

97 (0.1%) 0%

Not given 14,687 (18%) 17%

42,669 (26%) 24% 19,693

(20.69%) 19%

Not Known 224 (0%) 0%

762 (0%) 0% 223

(0.23%) 0%

Pakistani 35 (0%) 0%

59 (0%) 0% 26

(0.03%) 0%

All BME or Non-White 3.9% There have been some very slight fluctuations in the percentages of patients treated by ethnic origin since last year and it appears that in general we have treated approx 2% less British patients this year than last. This is reflective generally of the picture we see in terms of employed staff, however the Census data is only updated every 10 years.

Age at first appointment, admission or attendance

Inpatients


2015 (2014) A&E

2015 (2014) Local

Census

0 to 4 2573 (3%)

10%

5269 (3%)

6%

4771 (5%)

8% (Under 20 in 2011 Census

6%

5 to 9 1356 (2%) 1% 6808 (4%) 4% 4757 (5%) 5%

10 to 14 984 (1%) 1% 5087 (3%) 3% 5072 (5%) 5%

15 to 19 1614 (2%) 2% 5392 (3%) 3% 5559 (6%) 6%

20 to 24 2594 (3%) 3% 5073 (3%) 3% 6652 (7%) 7% 6.8%

25 to 29 3398 (5%) 4% 6943 (4%) 4% 6172 (7%) 6% 7.1%

30 to 34 3712 (5%) 5% 7347 (4%) 4% 5082 (5%) 5% 7.6%

35 to 39 3272 (4%) 4% 7322 (4%) 4% 4640 (5%) 5% 8.2%

40 to 44 2996 (4%) 4% 7629 (5%) 5% 4702 (5%) 5% 9.8%

45 to 49 3611 (5%) 5% 9347 (6%) 6% 5248 (6%) 6% 10%

50 to 54 4194 (6%) 5% 10477 (6%) 6% 5178 (6%) 5% 8.8%

55 to 59 4313 (6%) 5% 10381 (6%) 6% 4512 (5%) 5% 8%

60 to 64 4703 (6%) 6% 11271 (7%) 7% 4078 (4%) 4% 8.9%

65 to 69 6569 (9%) 9%

15264 (9%) 10%

4871 (5%) 5% (Over 65

in 2011 Census

23

18.8%

70 to 74 6769 (9%) 8% 14499 (9%) 8% 4562 (5%) 5%

75 to 79 6728 (9%) 8% 13598 (8%) 8% 4547 (5%) 5%

80 to 84 6482 (9%) 8% 11265 (7%) 7% 4767 (5%) 5%

85+ 9483 (13%) 10% 12802 (8%) 7% 7809 (8%) 7%

There have been less under 4 year olds treated and more over 85 year olds treated in all categories since last years report. In other age brackets there are less fluctuations and apart from the extreme oldest and youngest groups as explained in previous reports, the Trust is representative of the population we serve.

Religion

Inpatients


2015 (2014) A&E

2015 (2014) Local

Census

Church of England

20,020 (25%) 25%

38,949 (23%) 24% 21,310

(68%) 20% 66.9%

Roman Catholic

2,815 (4%) 4%

5524 (3%) 3%

2728 (9%) 3% Not

known

Other religions

2,767 (3%) 3%

5367 (3%) 3%

497 (2%) 4% 33.1%

None 5,044 (6%) 7% 9423 (6%) 6% 6658 (21%) 7% n/a

Not Known 62% 61% 65% 64% 0% 66% n/a

Religion is still only recorded for less than 40% of the cases therefore little can be drawn from the following information. From those whose religion has been recorded, there appears to be a significant increase in A&E attendances for those with a Church of England religion. It is thought that maybe this has been used as a default instead of not known as this category is 0. Action - As with all patient data, work to be completed and staff to be educated to record relevant details to ensure all patient E&D data is as accurate as possible.

Learning disability

During the data period 430 outpatients, 220 inpatients and 280 patients who attended A&E were recorded as having learning disabilities. This is compared to 371 outpatients, 194 inpatients and 246 A&E attendances in the last reporting period.

Sight Impaired During the data period 108 outpatients, 64 inpatients and 57 patients who attended A&E were recorded as having blindness. This is newly recorded therefore no comparison to last year is available.

Hearing impaired During the data period 184 outpatients, 110 inpatients and 112 patients who attended A&E were recorded as having deafness. This is newly recorded therefore no comparison to last year is available.

24

Action - Although there are more categories of disability being recorded this year (leaning, sight impaired and hearing impaired) this appears to only be for A&E attendances. Again this requires work to be completed to ensure this is recorded consistently across all patients.

Pregnancy

The following shows a specific breakdown of ethnicity and age for patients admitted under or attending outpatient appointments under the 501 (Obstetric) or 560 (Midwifery) specialty codes (note: Midwifery inpatient episodes were inadvertently excluded from previous reports.

• 6454 admissions for 5249 different women (compared to 6260 admissions for 5297 women last year)

• 31,497 appointments for 7,558 patients (compared to 31,937 appointments for 7654 patients last year)

This outpatient figure includes a handful of male patients. Furthermore given the very low age of some outpatients (and the discrepancy between the inpatient and outpatient figures) it is likely that in a few cases the appointment will have been booked in the infant’s name rather than the mother – although it might be wrongly attributed to the specialty).

Ethnic code (obstetrics and midwifery only)

Inpatients


2015 (2014)

African 10 (0%) 0% 14 (0%) 0%

Any other Asian background 34 (1%) 0% 43 (1%) 0%

Any other Black background 4 (0%) 0% 5 (0%) 0%

Any Other ethnic Group 21 (0%) 0% 28 (0%) 0%

Any other mixed background 19 (0%) 0% 23 (0%) 0%

Any other White background 384 (5%) 6% 562 (7%) 7%

Bangladeshi 14 (0%) 0% 20 (0%) 0%

British 3071 (41%) 60% 4300 (57%) 59%

Caribbean 1 (0%) 0% 1 (0%) 0%

Chinese 9 (0%) 0% 11 (0%) 0%

Indian 24 (0%) 0% 28 (0%) 0%

Irish 12 (0%) 0% 21 (0%) 0%

Mixed White & Asian 7 (0%) 0% 9 (0%) 0%

Mixed White & Black African 5 (0%) 0% 6 (0%) 0%

Mixed White & Black Caribbean

6 (0%) 0%

8 (0%) 0%

Not given 1596 (21%) 30% 2436 (32%) 30%

Not Known 2337 (31%) 0% 40 (1%) 1%

Pakistani 4 (0%) 0% 2 (0%) 0%

Again, there is a large percentage of not given or not known in relation to ethnic backgrounds, impacting on the reliability of the above data however it does suggest a significant reduction in British inpatients in the last year which requires checking with the information team.

25

Age at first appointment, admission or attendance (obstetrics and midwifery only)

Inpatients


2015 (2014)

<15 0 (0%) 0% 0 (0%) 0%

15 to 19 143 (2%) 3% 166 (2%) 4%

20 to 24 921 (12%) 15% 997 (13%) 16%

25 to 29 1876 (25%) 29% 1978 (26%) 29%

30 to 34 2291 (30%) 31% 2420 (32%) 31%

35 to 39 1661 (22%) 17% 1525 (20%) 16%

40 to 44 687 (9%) 4% 435 (6%) 4%

45 to 49 174 (2%) 0% 29 (0%) 0%

>50 24 (0%) 0% 6 (0%) 0%

There has been some very slight fluctuations in the figures compared to last year but nothing significant. Although we have treated % wise more 20 to 39 year olds in obstetrics and gynae than the percentage we serve, this is to be expected as it would be the normal child bearing age. It is interesting to note that the % of older patients in this category is increasing and may impact on the staffing levels required to deal with potentially more complex births/pregnancies.

12) Patient satisfaction National Inpatient, Outpatient and Maternity surveys are conducted by the CQC on a regular basis. Our results and analysis of these can be found on the website and staffnet. However, although protected characteristic information is gathered by the CQC to some extent, it is not used to ascertain level of satisfaction by protected group and therefore its relevance is limited for this report. However, the Trust has recent examples from where the level of patient satisfaction has increased significantly as a result of focused work and one of these was in relation to our dementia patients:

26

CASE STUDY – Nostalgia Day

On Thursday 20 August, Boxgrove Ward took a step back in time to celebrate the 1940s and create an amazing vintage tea party experience for patients on the ward. The idea was to stimulate memories for patients and therefore staff donned historic dress and were joined by the Locksheath Classic Car Club and two of their classic cars to help achieve a historic atmosphere. There were lashings of scones, cream and sandwiches on hand courtesy of Doctors Orders, all served on vintage plates, tablecloths and stands supplied by the ‘19 four tea’ rooms in Havant. The wonderful atmosphere was enriched by the dulcet tones of Beck Short, a vintage singer dressed in military uniform who sang for patients on the ward. Amanda Parker, Director of Nursing, who came dressed in items from her own old nursing uniforms, gave a speech thanking the incredible work of Ward Sister Shelle Harris, the whole Boxgrove team and everyone involved in creating such a wonderful experience for patients. Shelle and her team organised the event to celebrate a golden era of which many dementia patients have nostalgic memories which they return to despite their disease. Shelle said: “The weather was against us but in true British style we carried on regardless, dug deep and pulled off a fantastic afternoon of laughter and tears and nostalgia and memories we can all keep. I would like to say a heartfelt thank you to everyone who played a part in making our Boxgrove Vintage Tea Party such a wonderful occasion.”

13 Real time patient data - This is the fourth year running that we have included this data as part of the E&D report, however this time we have only received the results by age and ethnic background. The adult inpatient survey was conducted between 1st October 2014 and 30th September 2015 in line with this report. In total there were 2755 responses, a reduction from last year which was 3976.

27

Age – The largest group surveyed this year as the 75-84 year olds at 28.25% of the survey, followed by 65-74 year olds (21.21%) and then over 85 years (18.55%). This is reflective of the populations served in general.

Ethnicity – 95.9% of our surveyed patients were white British compared to 88.9% of the population and 74% of our inpatients according to section 11 of this report.

14) The levels of complaints by protected characteristic

Total number of formal complaints during the reporting period = 598 The Trust collects data on protected characteristics of complainants in two ways; (1) recording data provided during the complaints investigation from the complainant or the health records on the trust’s complaints database (Datix) and (2) by collecting monthly data from all complainants whose case has closed through a survey to find out how they feel their complaint was handled. Four questions are asked about protected characteristics on gender, age, ethnicity and disabilities. The last time complaints data was reported on was for the 2012 Equality Monitoring Report so there is no year on year comparison, and since then complaints have been recorded for Ethnic Minority and disability as well as the previous gender and age protected characteristics. Action - The only service where the reasons for the complaint were recorded was in maternity. This needs work to ensure the reasons are captured and reported for all complaints. 14.1 Gender

Graph 14.1.1 Out of the number of patients who made complaints in the year reporting period, 69% were female, 36% males, compared to the overall percentage treated in the Trust according to section 9 of this report (57% female, 43% male). This means there are % wise more male complainants than female to those treated in general. Included in the above figure, there were 30 complaints about maternity services (the only service where reasons were recorded) of these:

Female 69%

Male 31%

Patient complaints - Gender

28

17 were clinical treatment

5 were about communication (oral)

3 were about staff attitude/behaviour

1 was about policy/commercial decisions

1 was about personal records

2 were about staff competence

1 was about test results 14.2 Age

Graph 14.2.2 Out of the 598 complaints received, age was not disclosed in 507 (84.78%) cases. These have been removed from the graph. It can be seen from the above data, that from the number of complaints received where age is disclosed, a very large percentage is from the middle-age bracket 40-64. Unfortunately this data is not wholly useful as much of the data is missing.

14.3 Ethnic Origin

0

26

41

24

0

5

10

15

20

25

30

35

40

45

Under 20 21 - 39 40 - 64 Over 65

Patient complaints - Age

65

1 1 0

10

20

30

40

50

60

70

White British Mixed white &black carribean

Mixed white &Asian

Patient complaints - Ethnic Origin

29

Graph 14.3.3 Out of the 598 complaints received, ethnic origin was also not disclosed in 507 (84.78%) cases. These have been removed from the graph. It can be seen from the above data that from the number of complaints received where ethnic origin is disclosed, a very large percentage is from the White British category. Although this data is not wholly useful as much of the data is missing, this result reflects the demographics of the overall percentage of patients treated at the Trust (see section 9). 14.4 Patient Association Complaints Survey The Patients Association, an independent charity, developed the Complaints Survey with a group of patients and complainants. The survey was tested in Mid Staffordshire and piloted and refined by 10 NHS Trusts over a two year period. In July 2014, the Patients Association developed a partnership with the NHS Benchmarking Network to manage and facilitate this project. From January 2015, the trust began its own survey. During the period July to December 2014, the trust had a response rate of 15%, therefore the results are not statistically relevant. A covering letter and survey form is issued to each complainant who makes a formal complaint to the Trust. Each letter and survey was sent to all cases considered to be closed (post 10 weeks) and the survey results were compiled by the Patients Association with a comparison of 23 other trusts. During the period January to August 2015, the trust had a response rate of 73% with its own survey and for those questions on protected characteristics, the following data was collected:

Gender

Gender

Answer Options Response Percent

Response Count

Male 30.8% 33 Female 69.2% 74

answered question 107 skipped question 0

Out of the number of patients who made complaints in the year reporting period, 69% were female, 31% males, compared to the overall percentage treated in the Trust according to section 11 of this report (57% female, 43% male). This appears to show 12% more females making complaints to those we treat.

Gender

Male

30

Age

Age


Response Count

Under 18 0.0% 0 18-29 4.8% 5 30-64 62.9% 66 65-74 15.2% 16 75-84 14.3% 15 85+ 2.9% 3


It can be seen from the above data, the largest percentage (63%) is from the 30 – 64 age bracket.

Disability

Do you consider yourself to have a disability?


Response Count

Yes 23.0% 23 No 77.0% 77


Out of the number of patients who made complaints in the year reporting period, 23% stated they had a disability, there is not a comparison to this in our patient demographic figures however Census data shows 7.5% of the local population has a disability.

Age

Under 1818-2930-6465-7475-84

Do you consider yourself to have a disability?

Yes

31

Ethnic Origin

Ethnic Background


Response Count

British 98.0% 96 Irish 1.0% 1 Any other white background 0.0% 0 Indian 0.0% 0 Pakistani 0.0% 0 Bangladeshi 0.0% 0 Any other Asian background 0.0% 0 Chinese 0.0% 0 Any other ethnic background 1.0% 1 White and Black Carribean 0.0% 0 White and Black African 0.0% 0 White and Asian 0.0% 0 Any other mixed background 0.0% 0 Caribbean 0.0% 0 African 0.0% 0 Any other Black background 0.0% 0


Out of the number of patients who made complaints in the year reporting period, 98% were British, compared to the overall percentage (74% British) treated in the Trust according to section 11 of this report. This is comparatively higher, however 24% of patients do not disclose their Ethnic Origin when they attend hospital and this data does not show how many patients have not disclosed.


To: Trust Board


Title

Financial Performance – Month 9

Presented by

Karen Geoghegan, Director of Finance

Prepared by

Alison Ingoe, Deputy Director of Finance

David Lowe, Assistant Director of Finance

Status

Confidential

Summary of Proposal

At the end of December the Trust reported a deficit of £4.8m against a planned break-even position. The financial risk rating remains a '2'. The performance in December means that the Trust is now forecasting an out-turn position of between £6m deficit and £10m deficit and that the risk rating will remain a '2'. The attached report provides further commentary and analysis of the financial position.


Financial planning principles have been established to ensure that expenditure budgets reflect anticipated activity levels and that agreed staffing levels are maintained.

Support for/integration with Corporate Objectives and Strategies

G1. Maintain an acceptable financial risk rating


These are noted within the Financial Performance Report


N/A

Recommendation

The Trust Board is asked to NOTE the report.

Consultation

N/A

Appendices

N/A


Finance Report Month 9 2015-16

Summary

Financial Sustainability Risk Rating A Surplus £k R Cash £k A

Plan Actual / Forecast Plan Actual / Forecast Plan Actual

Year to Date 3 2 Year to Date £k 6 (4,754) Year to Date £k 13,607 6,849

Year End Forecast 3 2 Year End Forecast £k 992 (8,227) Year End Forecast £k 11,729 3,894

Income £k A Operating Costs £k A Agency Expenditure RExpenditure as % of Total Paybill

(monthly) 2013/14 2014/15 2015/16

Plan Actual / Forecast Plan Actual / Forecast Medical 7.9% 10.9% 15.2%

Year to Date £k 300,065 300,717 Year to Date £k (282,492) (287,786) Nursing 4.3% 4.6% 11.0%

Year End Forecast 400,087 401,928 Year End Forecast £k (375,685) (385,651) Other Staff Groups 2.7% 2.7% 6.6%

All Agency 4.8% 5.8% 10.7%

Capital £k A Efficiency and Transformation Programme £k A Indicators of Forward Financial Risk A

Plan Actual / Forecast Plan Actual / Forecast Actual Forecast

Year to Date £k 14,401 9,597 Year to Date £k 13,371 11,737 Number of Indicators Breached 7 4

Year End Forecast £k 15,070 17,215 Year End Forecast £k 19,108 16,791 Number of Indicators 10 10

Key Risks:

1. Ability to exit premium rate workforce arrangements. Vacancies, long-term sickness and additional demand in key staff groups are driving signficiant increases in agency expenditure. The Workforce Transformation Group is overseeing action plans to

increase recruitment, redesign workforce roles and manage sickness, rostering and retention issues. Moves to framework agency and reductions in rates paid per shift are being put in place.

2. Management of patient flow to ensure that activity is able to be delivered within funded capacity and that numbers of patients medically fit for discharge are minimised. The Trust is working closely with health economy partners to ensure that the levels of fit

for discharge patients and community bed capacity is managed.

3. Delivery of savings within the efficiency programme. As in 2014/15 the Trust has a significant efficiency requirement in order to deliver its planned surplus. A shortfall is currently being forecast against the plan and pipeline schemes, including workforce

opportunities are being developed to mitigate the shortfall.

4. The affordability for commissioners to pay in full for over-performance above contracted activity levels. Executive-led discussions are currently underway to ensure that the Trust secures appropriate payment for the activity delivered.

At the end of December the Trust reported a deficit of £4.8m against a planned break-even position. The financial risk rating remains a '2'. The performance in December means that the Trust is now forecasting an out-turn position of between £6m deficit and

£10m deficit and that the risk rating will remain a '2'.

The Trust is reporting a Financial Sustainability Risk Rating (FSRR) of '2' for

December. The performance against all the individual metrics has deteriorated

due to the deficit reported in the month.

A further deterioration to the position was reported in December with a £1.86m

deficit in month bringing the cumulative position to a £4.8m deficit. Additional bed

capacity remains open to manage operational pressures, resulting in increased

agency expenditure.

The cash balance remains behind plan for the year to date. The income and expenditure

position is the most significant driver of this performance but has been offset by slippage

on the capital programme and an increase in the level of trade creditors.

At the end of December income is £0.6m higher than plan. Income from activities

is favourable in the year to date but income for PbR excluded items and seasonal

resilience are offseting PbR activity under-performance. Private patient income

continues to under-perform and is now significantly below plan.

The continued high levels of pay expenditure are driven by agency staff covering

vacancies and sickness. Additional bed capacity being opened towards the end of

December has increased staffing requirements and therefore temporary staffing

usage. Non Pay continues to show an adverse variance to plan, however the

majority of the costs are within PbR excluded drugs and devices which are recovered

in full within income from activities.

There is slippage against the capital plan of £4.8m year to date, mainly in

Endoscopy, Estates and Information Technology. The forecast has increased

due to expenditure on the Clinical Portal project which has received external

funding.

At the end of December, the Efficiency Programme delivered cumulative savings of

£11.7m against a plan of £13.4m (87.7%). The forecast out-turn is less than plan

and mitigating schemes are being developed to limit the shortfall.

There was a £0.2m increase in total agency expenditure in December, bringing the

average spend in Q3 to £2.3m. This is the second successive quarter of agency rises.

Nurse agency expenditure is now at similar levels to medical agency expenditure and is

significantly in excess of the agency cap of 4%.

Indicators breached are (i) unplanned decreased in EBITDA, (ii) FSR less than a '3' (2

indicators), (iii) FSR a 2 for one quarter, (iv) more than 5% of debtors > 90 day, (v) more

than 5% of creditors > 90 days, (vi) quarter end cash balance less than 10 days, (vii)

capital expenditure < 75% of plan for the year to date

Finance Report Month 9 2015-16 A

Financial Sustainability Risk Rating Plan Plan Actual Actual

YTD Metric Rating Metric Rating

Liquidity Ratio (2.3) 3 (6.4) 3

Capital Servicing Capacity Ratio 2.2 3 1.4 2

Income and Expenditure Margin 0.3% 3 (1.3%) 1

Variance in I&E margin as a % of income (1.7%) 2 (1.6%) 2

Financial Sustainability Rating 3 2

Financial Criteria SFP Weight Metric to be Definition Rating categories

4 3 2 1

Liquidity Ratio 25% Liquidity ratio (days) Working capital balance x 360 0.0 (7.0) (14.0) <(14.0)

Annual operating expenses

Revenue available for capital service

Capital Servicing Capacity Ratio 25% Capital servicing capacity (times) Annual debt service 2.5x 1.75x 1.25x <1.25x

Surplus/(Deficit) before exceptional items 1% 0% (1.0%) <(1.0%)

Income and Expenditure Margin 25% I&E Margin (%) Total Operating and Non Op Income

Actual Surplus/(Deficit) - Planned Surplus/(Deficit) 0% (1.0%) (2.0%) <(2.0%)

I&E Plan Variance 25% Operating Income

The Trust is reporting a Financial Sustainability Risk Rating (FSRR) of '2'. There has been a 2.11 day deterioration in the liquidity metric and a 0.17 reduction in the capital service metric from November due to the in-month

deficit. The income and expenditure margin as a percentage of income has declined to (1.3%) from (1.0%), whilst the variance in planned I&E margin has declined from (1.5%) to (1.6%) due to the phasing of the income and

expenditure plan and the impact of the in month performance.

An improvement in the income and expenditure position of £1.9m would be required in order to deliver a rating of '3' as at the end of December.

Variance in I&E margin as a % of

income

Finance Report Month 9 2015-16 Surplus R

Plan Actual Variance Plan Forecast Variance

£k £k £k £k £k £k

(Surplus) Deficit 6 (4,754) (4,760) (Surplus) Deficit 992 (8,227) (9,219)

Prev Yr Actual Plan Actual Variance Plan Forecast Variance

£k £k £k £k £k £k £k

Income 291,208 300,065 300,717 651 Income 400,087 401,928 1,841

Pay (193,246) (197,811) (200,235) (2,424) Pay (264,504) (268,422) (3,918)

Non-Pay (83,238) (84,682) (87,551) (2,870) Non-Pay (111,181) (117,229) (6,048)

EBITDA * 14,724 17,573 12,930 (4,642) EBITDA * 24,402 16,277 (8,125)

EBITDA % 5.1 5.9 4.3 EBITDA % 6.1 4.0

Profit / Loss on Disposal of Fixed Assets (102) - 3 3 Profit / Loss on Disposal of Fixed Assets - (9) (9)

Interest Payable (809) (685) (669) 16 Interest Payable (914) (893) 21

Interest Receivable 25 24 32 8 Interest Receivable 32 38 6

Depreciation (10,708) (10,732) (10,547) 185 Depreciation (14,288) (14,162) 126

Impairments (461) - - - Impairments - - -

Public Dividend Capital Dividend (5,185) (5,230) (5,711) (480) Public Dividend Capital Dividend (6,974) (7,614) (640)

Net Surplus / (Deficit) (2,517) 949 (3,961) (4,910) Net Surplus / (Deficit) 2,259 (6,363) (8,622)

Reverse Impairment 461 - - - Reverse Impairment - - -

Donated Assets (305) (1,521) (1,393) 128 Donated Assets (2,028) (2,675) (647)

Donated Asset Depreciation and Amortisation 695 578 599 21 Donated Asset Depreciation and Amortisation 762 811 49

Performance against Control Total (1,666) 6 (4,754) (4,760) Performance against Control Total 992 (8,227) (9,219)

Surplus % (0.6) 0.0 (1.6) Surplus % 0.2 -2.0

* EBITDA Earnings before Interest Taxation Depreciation and Amortisation

In December there was a further deterioration in the position with a £1.86m deficit being reported in month which brings the cumulative deficit to £4.75m. Over-performance in PbR excluded drugs and devices, which are funded at cost are substantially above

plan underpinning the favourable variance reported in income from activities. Further beds were opened towards the end of the month and agency costs increased significantly within nursing.

Year To Date Year Forecast

The cumulative over-recovery within Income from activities continues, however the position contains £3.2m of over performance relating to PbR excluded drugs and devices, which offsets under-performance against the elective activity plan. The pay overspend

has increased and remains driven by agency costs, with nursing agency expenditure rising in month. Further medical beds were opened towards the end of the month and with vacancies continuing , higher proportions of agency staff are being utilised. The key

driver of the non pay position continues to be PbR excluded drug and device usage which is offset by additional income.

Year to Date Full Year

(2,500)

(2,000)

(1,500)

(1,000)

(500)

0

500

1,000

1,500

2,000

2,500

3,000

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

£0

00

s

Surplus by Month

Budget

Actual

(6,000)

(5,000)

(4,000)

(3,000)

(2,000)

(1,000)

0

1,000

2,000

3,000


£0

00

s

Cumulative Surplus by Month

Budget

Actual

Finance Report Month 9 2015-16 Income A

Year To Date Year End Forecast

Prev Yr. Actual Plan Actual Variance Plan Forecast Variance

£k £k £k £k £k £k £k

Total Income 291,208 300,065 300,717 651 Total Income 400,087 401,928 1,127


Income £k £k £k £k Income £k £k £k

Clinical Commissioning Groups 208,055 221,624 224,936 3,311 Clinical Commissioning Groups 292,695 300,983 8,226

Specialist LAT 24,445 34,913 35,357 445 Specialist LAT 46,719 46,341 (378)

WSCC - Sexual Health 5,748 5,805 4,424 (1,381) WSCC - Sexual Health 7,734 6,671 (1,063)

NCA 3,166 6,021 5,969 (51) NCA 7,984 7,232 (751)

Other Trust Income 19,990 269 228 (41) Other Trust Income 3,000 302 (2,698)

Income From Activities 261,405 268,631 270,915 2,284 Income From Activities 358,131 361,529 3,336

Private Patients 4,727 4,925 4,047 (878) Private Patients 6,657 5,507 (1,150)

Education, Training and Research 7,749 7,691 7,634 (58) Education, Training and Research 10,251 10,206 (94)

Donated Asset Income 305 1,521 1,393 (128) Donated Asset Income 1,916 2,675 (733)

Other Income 17,022 17,298 16,729 (569) Other Income 23,132 22,011 (233)

Other Operating Income 29,803 31,435 29,803 (1,632) Other Operating Income 41,956 40,399 (2,209)

Total Income 291,208 300,065 300,717 651 Total Income 400,087 401,928 1,127

of which : PbR Drugs/Devices 18,283 21,486 3,203


At the end of December income is £0.6m above plan. Income from activities is favourable in the year to date but income for PbR excluded items and seasonal resilience are offseting PbR activity under-performance. Private patient income

continues to under-perform.

At the end of December income from activities is £2.3m above the Trust operational plan. Non-elective activity has remained high in month and there was also over-performance in day case activity and outpatient attendances. Elective

inpatient activity and income were below plan in month. PbR excluded drugs cumulatively exceed plan by £2,549k - the largest variances are the Cancer Drugs Fund and CCG funded home delivery drugs. The reported income position

includes £3,148k of seasonal resilience monies to reflect the initiatives agreed for the year to date with the CCG and the costs of community bed provision .

Private Patient activity continues to be significantly below plan and has remained at a similar level in December compared to November as bed capacity still continues to be constrained by Operational NHS pressures. Donated Asset income

remains behind plan but there was a catch up on project income in month, this is normalised in the position.

29,000

30,000

31,000

32,000

33,000

34,000

35,000

36,000


£'0

00

Monthly Income vs Plan

Budget Actual

29,000

30,000

31,000

32,000

33,000

34,000

35,000

36,000

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Mar

£'0

00

Income vs Prior Year

2014-15

2015-16

Finance Report Month 9 2015-16 Contract Performance A

Table 2. Activity and Income by Point of Delivery

Point of Delivery YTD Plan YTD Actual YTD Var YTD Plan YTD Actual YTD Var

FYE Plan YTD Plan YTD Actual YTD Var Daycases 45,551 46,867 1,316 29,280 28,693 (587)

Coastal West Sussex (and associate CCGs) 294,985 221,624 221,515 (109) Elective Spells 7,479 6,342 (1,137) 23,112 20,153 (2,959)

NHS England 46,719 34,913 35,357 445 Elective Excess Bed days 762 1,382 620 169 310 141

Integrated Sexual Health Services 7,734 5,805 4,424 (1,381) Non Elective Spells 38,895 39,947 1,052 71,065 72,851 1,786

Non Contract Activity 8,336 6,021 6,241 220 Non Elective short-stay 7,998 8,165 167 6,631 6,544 (88)

Reciprocal Overseas 358 269 228 (41) Non Elective Excess Bed days 14,894 19,606 4,712 3,314 4,391 1,078

Total 358,131 268,631 267,765 (866) Outpatients 422,661 441,553 18,892 45,045 45,112 68

A&E 106,780 102,495 (4,285) 11,353 11,376 23

NB: Variances are reported against Western Sussex Hospitals Planned Income Levels PbR exclusions 18,283 21,486 3,203

Critical Care 11,233 10,162 (1,071)

Maternity Pathway 9,417 8,298 (1,118)

OP Diagnostic Imaging 6,144 6,349 205

Sexual Health 5,190 4,437 (753)

Direct Access Pathology 5,782 5,503 (279)

Other Direct Access (Imaging and Dietetics) 2,188 2,083 (105)

Breast Screening 2,513 2,513 -

Other 11,895 11,560 (335)

CQUIN 6,019 5,945 (75)

Total 268,631 267,765 (866)

Table 3. - Reconciliation to Income Reporting Table 4. Contract Income by CCG and NHS England

£000s

Contract Monitoring Performance -(unadjusted ) 261,820 SUSSEX CCGs and NHS ENGLAND

CQUIN 2.4% 5,945 YTD Plan YTD Actual YTD Var

NHS COASTAL WEST SUSSEX CCG 209,843 208,471 (1,372)

Total Contracted Income 267,765 NHS HORSHAM AND MID SUSSEX CCG 3,442 3,396 (46)

NHS BRIGHTON AND HOVE CCG 2,836 3,408 572

Income Recharged non-contract NHS HIGH WEALD LEWES HAVENS CCG 173 148 (25)

NHS CRAWLEY CCG 307 524 217

Seasonal Resilience funding 3,148 NHS EASTBOURNE, HAILSHAM AND SEAFORD CCG 110 166 57

Maternity pathway payment (60) NHS HASTINGS AND ROTHER CCG 48 96 48

Cystic Fibrosis 158 NHS SOUTH EASTERN HAMPSHIRE CCG 4,289 4,316 27

Risk Share and NCA Credit Notes (271) NHS PORTSMOUTH CCG 155 426 271

Change to deferred Income for Maternity pathway 175 NHS GUILDFORD AND WAVERLEY CCG 324 175 (149)

NHS FAREHAM AND GOSPORT CCG 96 304 207

Total Income from Activities 270,914 NHS CROYDON CCG - 84 84

Subtotal CCG Acute Contracts 221,624 221,515 (109)

NHS England 34,913 35,357 445

Total 256,537 256,873 336

£'000

Estimated Values for YTD (incl CQUIN)

The Trust reports income based on the contract monitoring position for prior months and an estimate of income for the current month based on priced and coded activity in the month as available. An estimate is made for the value of uncoded spells and missing days and included within the reported income

position.

1) Context

The Trust and the CCGs are required to complete monthly financial reconciliations. The reconciliations for Coastal West Sussex and Associate CCGs have been completed for the period April - October. There are a number of outstanding data challenges which are being resolved through the escalation

process. The November reconciliation is due to be signed-off on the 18th February.

The monthly reconciliation for NHSE has been delayed due to staffing issues at NHSE. Following escalation, NHSE have assigned a new Finance Manager to support this contract. Pending resolution of one outstanding query, the month 1-6 reconcillation has been completed.

2) YTD Report

Trust internal monitoring information shows underperformance against the internal plan for Coastal West Sussex and for NHSE, with outpatient first attendances and elective activity lower than planned, as outlined in the income report. PbR excluded drugs and devices exceed plan. Non-elective activity and

income has exceed plan for the last four months months.

It is important to note that the performance indicated is compared to the Trust's plan and does not reflect the over-performance against commissioner contracts. The Trust is over-performing against the Coastal West Sussex CCG contract. The affordability of this level of performance to the CCG is being

discussed at Executive level.

£'000

Activity Volumes £'000

Table 1. Total Financial Values by Contract

This table represents the Trusts assessment of the performance against commissioners only with whom a Contract SLA has been agreed. There are some differences between the Trust's income plan and the agreed contract values due to QIPP assumptions

Page 5

Finance Report Month 9 2015-16 Operating Costs A


£k £k £k £k £k £k

Pay (193,246) (197,811) (200,235) (2,424) Pay (264,504) (268,422) 492

Non Pay (83,238) (84,682) (87,551) (2,870) Non Pay (111,181) (117,229) (5,938)

Operational Costs (276,484) (282,492) (287,786) (5,293) Operational Costs (375,685) (385,651) (5,446)


£k £k £k £k £k £k £k

Pay Pay

Management & Admin (25,654) (28,551) (27,215) 1,336 Management & Admin (38,259) (36,502) 1,593

Medical and Dental Staff (55,802) (54,737) (57,887) (3,151) Medical and Dental Staff (72,891) (77,558) (3,722)

Nursing & Midwifery (72,660) (73,776) (75,073) (1,297) Nursing & Midwifery (98,521) (101,118) (320)

Other Healthcare (27,213) (28,414) (28,074) 340 Other Healthcare (38,181) (37,234) 1,340

Estates (11,903) (11,997) (11,986) 11 Estates (16,113) (15,967) 180

Other Staff (14) (337) (0) 337 Other Staff (539) (43) 1,421

Total Pay (193,246) (197,811) (200,235) (2,424) Total Pay (264,504) (268,422) 492

Non-Pay Non-Pay

Services from Other NHS Bodies (2,795) (2,800) (2,769) 31 Services from Other NHS Bodies (3,708) (3,687) (620)

Purchase of Healthcare from Non NHS Bodies (2,089) (3,184) (3,111) 72 Purchase of Healthcare from Non NHS Bodies (3,186) (4,363) (520)

Drugs & Medical Gases - tariff (8,058) (9,738) (9,387) 351 Drugs & Medical Gases (15,874) (15,461) 35

Drugs & Medical Gases - PbR excluded (17,040) (16,615) (19,164) (2,549) Drugs & Medical Gases - PbR excluded (19,078) (23,164) (4,086)

Supplies and Services - Clinical (25,047) (25,291) (25,852) (561) Supplies and Services - Clinical (33,702) (35,261) (1,862)

Supplies and Services - Clinical PbR Excluded (1,692) (1,668) (2,322) (654) Supplies and Services - Clinical Pbr Excluded (2,078) (2,135) (57)

Supplies and Services - General (3,346) (3,590) (3,139) 451 Supplies and Services - General (4,700) (4,177) 409

Establishment Expenses (5,590) (4,982) (5,106) (125) Establishment Expenses (5,982) (6,808) (51)

Premises (10,500) (11,300) (11,242) 58 Premises (14,974) (14,851) 335

Education and Training (543) (536) (352) 184 Education and Training (1,278) (469) 204

Clinical Negligence Premium (4,021) (3,890) (3,890) - Clinical Negligence Premium (5,187) (5,187) -

Other Non-Pay (2,517) (1,088) (1,216) (128) Other Non-Pay (1,434) (1,666) 275

Total Non-Pay (83,238) (84,682) (87,551) (2,870) Total Non-Pay (111,181) (117,229) (5,938)

Total Expenditure (276,484) (282,492) (287,786) (5,293) Total Expenditure (375,685) (385,651) (5,446)

Year To Date Year Forecast

Pay. Cumulatively medical staff expenditure remains the largest driver of the reported pay position as vacancies and sickness absence continue. Further additional beds opened towards the end of December as planned and with vacancy pressures continuing a higher proportion of

agency staff are being utilised. New staff recruited from Europe started in month which will boost the substantive nursing complement and whilst some double running costs have been incurred in month during the supernumerary period, agency reductions are anticipated in future

months. In month, agency expenditure increased to £2.5m with expenditure in month of £1m on both nursing and medical agency. Favourable variances in management & admin and other healthcare staff continue and partially reduce this overspend. Non Pay: Drugs expenditure

continues to be the key driver of the non pay position with a £2.5m variance on drugs excluded from tariff underpinning the overspend. The increase in the cost of pathology consumables seen in November has decreased in month but the underlying run rate remains high and the

investigation is ongoing.

The overspend in pay continues and in December increased by £0.7m, to bring the cumulative position to an overspend of £2.4m. Nursing expenditure has increased from last month by £0.4m and medical expenditure has decreased by £0.3m in the same period. Non Pay cost remain

adverse to plan however this is largely due to PbR excluded drugs and devices which are offset by income.


20,000

21,000

22,000

23,000

24,000


£0

00

s

Monthly Pay

Budget Actual

0

5,000

10,000

15,000


£0

00

s

Monthly Non Pay

Budget Actual

29,000

30,000

31,000

32,000

33,000

34,000


£0

00

s

Monthly Operating Costs

Budget Actual

20,000

20,500

21,000

21,500

22,000

22,500

23,000

23,500


£0

00

s

Monthly Pay Yearly Comparison

2014-15 2015-16

Finance Report Month 9 2015-16 R

Agency Agency by Division

2013/14 2014/15 Plan Actual Variance Plan Actual Variance

£k £k £k £k £k £k £k £k

Medical and Dental Staff (4,543) (6,428) (3,701) (7,953) (4,252) Surgery (1,478) (3,195) (1,718)

Nursing & Midwifery (2,762) (2,802) (1,629) (6,162) (4,532) Medicine (2,623) (9,071) (6,448)

Other Healthcare (1,197) (1,563) (947) (2,147) (1,200) Core (2,103) (3,339) (1,236)

Management & Admin (395) (116) (11) (331) (320) Women & Children (229) (698) (469)

Estates (217) (453) (203) (340) (136) Corporate (60) (629) (569)

Other Staff - - - - -

Total

(9,114) (11,362) (6,492) (16,932) (10,441) (6,492) (16,932) (10,441)

Payroll Staff in post incl Bank Year To Date

Prev Yr Actual Plan Actual Variance Prev Yr Actual Plan Actual Variance

£k £k £k £k WTE WTE WTE WTE

Medical and Dental Staff (49,374) (51,035) (49,934) 1,101 699 762 705 (56)

Nursing & Midwifery (69,858) (72,147) (68,911) 3,235 2,602 2,796 2,546 (250)

Other Healthcare (25,650) (27,267) (25,927) 1,340 938 1,044 959 (84)

Management & Admin (25,539) (28,540) (26,884) 1,656 1,183 1,260 1,217 (44)

Estates (11,450) (11,794) (11,646) 148 681 742 656 (86)

Other Staff (14) (537) (0) 537 1 (1) - 1

(181,883) (191,319) (183,302) 8,017 6,104 6,602 6,083 (519)

Year To Date

Payroll & Agency Costs

Year To Date Year to Date

500

1,000

1,500

2,000

2,500

3,000

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Mar

£0

00

s

Agency Expenditure Comparison

2014-15 2015-16

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

Medical andDental Staff

Nursing &Midwifery

OtherHealthcare

Management& Admin

Estates

£0

00

s

Agency Type Comparison

2014-15

2015-16

Finance Report Month 9 2015-16 Divisional Performance R

Year To Date Year To Date Year To Date

PY Actual Plan Actual Variance RAG PY Actual Plan Actual Variance RAG PY Actual Plan Actual Variance RAG

£k £k £k £k £k £k £k £k £k £k £k £k

Contract Income 80,437 83,502 81,226 (2,276) R Contract Income 113,535 101,423 106,653 5,230 G Contract Income 20,072 29,189 30,131 942 G

Other Income 1,925 1,611 1,629 18 G Other Income 2,999 2,123 2,190 67 G Other Income 8,969 8,944 8,740 (204) R

Total Income 82,361 85,113 82,855 (2,258) R Total Income 116,533 103,546 108,844 5,298 G Total Income 29,041 38,133 38,871 738 G

Pay (47,160) (47,291) (46,653) 639 G Pay (57,719) (59,079) (61,827) (2,748) R Pay (35,422) (38,510) (38,484) 26 G

Non Pay (15,904) (15,664) (17,217) (1,553) R Non Pay (22,830) (20,771) (24,962) (4,191) R Non Pay (14,443) (17,192) (17,784) (592) R

Total Expenditure (63,064) (62,955) (63,870) (915) R Total Expenditure (80,549) (79,850) (86,789) (6,939) R Total Expenditure (49,865) (55,702) (56,268) (567) R

EBITDA Surplus/(Deficit) 19,297 22,158 18,985 (3,173) R EBITDA Surplus/(Deficit) 35,985 23,696 22,054 (1,642) R EBITDA Surplus/(Deficit) (20,824) (17,568) (17,397) 171 G

Year To Date Year To Date

PY Actual Plan Actual Variance RAG PY Actual Plan Actual Variance RAG PY Actual Plan Actual Variance RAG

£k £k £k £k £k £k £k £k £k £k £k £k

Contract Income 44,664 46,169 44,034 (2,135) R Contract Income - 0 - (0) - Contract Income 4 - - - G

Other Income 852 852 694 (158) R Other Income 3,764 3,961 4,085 125 G Other Income 2,423 13,051 11,896 (1,155) R

Total Income 45,517 47,021 44,728 (2,293) R Total Income 3,764 3,961 4,085 125 G Total Income 2,423 13,051 11,896 (1,155) R

Pay (22,527) (22,679) (23,197) (519) R Pay (11,669) (11,793) (12,222) (429) R Pay (8,031) (18,185) (17,889) 296 G

Non Pay (7,408) (7,479) (7,428) 51 G Non Pay (10,910) (10,820) (10,870) (50) R Non Pay 3,042 (10,111) (10,075) 36 G

Total Expenditure (29,935) (30,157) (30,625) (468) R Total Expenditure (22,579) (22,613) (23,092) (478) R Total Expenditure (4,989) (28,296) (27,964) 332 G

EBITDA Surplus/(Deficit) 15,582 16,864 14,103 (2,761) R EBITDA Surplus/(Deficit) (18,815) (18,653) (19,006) (354) R EBITDA Surplus/(Deficit) (2,567) (15,245) (16,068) (823) R

Year To Date

Women & Children: Consultant sickness continues to impact upon elective activity and

therefore income. However, sexual health activity has increased and is now favourable to

plan. Pay costs remain overspent as a result of covering medical staff sickness, vacancies

and parental leave. Nursing costs have increased as a result of recruitment to fill vacancies

and cover maternity leave within Midwifery. There has also been a requirement for agency

nursing to cover outliers within the Gynaecology Day Unit.

Facilities & Estates: Income decreased over the Christmas period both in car parking and

the restaurants with some compensating reductions in non pay but remains above plan overall.

Pay expenditure remains overspend although the in-month position was favourable due to

reduced temporary staff usage. Seasonal increases in utilities are now being seen although

utilities savings are being explored as part of the efficiency programme.

Surgery: Year to date the division is £2.3m below the income plan predominantly in elective

activity and in critical care. The pay position has deteriorated in month as a result of

increased nurse agency expenditure in Theatres. In addition, new European nurses started in

December who are supernumerary for the first month resulting in double running costs in the

current position with agency savings expected in future months. Non Pay expenditure

continues to exceed plan and the Division are exploring potential opportunities for product

standardisation in order to reduce costs.

Core: The favourable income position continues with increased activity in GP direct access

services. Pay remains favourable to plan, however, unexpected sickness at a consultant level

and the impact of hard to fill vacancies are increasing use of agency staff. Increased use of the

MRI mobile scanner on both sites, is the key driver of the adverse variance within non pay. A

recent tender has provided an opportunity for lower prices from February 2016. Increased

Pathology costs were reported in November and a rise to the underlying run rate has continued

into December, further diagnostic work is underway to fully understand the increase.

Corporate: Private patient income continues to be behind plan although there was no further

deterioration on November's position. Scope to increase income is restricted by a significant

increase in NHS bed days on both sites during the month and so no change in income levels

are foreseen for the remainder of this financial year. The favourable variance on admin and

managerial pay has continued for another month, sustained by the limited use of bank and

agency staff. Non pay remains favorable.

Medicine: Non Elective activity continues to perform ahead of plan both in month and year to

date, resulting in continued elevated agency nursing spend as the Division open ward capacity

using premium rate staff. Medical staffing costs are continuing to over spend against plan due

to vacancy pressures, long term sickness and maternity leave having led to an increased use

of agency staff. Non-Pay costs remained above plan for drugs and clinical supplies, with

increased income relating to PbR excluded drugs and devices partially offsetting this

expenditure but tariff drug expenditure remains a pressure.

Finance Report Month 9 2015-16 Statement of Financial Position

Plan Actual Variance Notes Plan Forecast Variance Notes

£k £k £k £k £k £k

Property, Plant and Equipment 272,649 271,375 (1,274) 1 Property, Plant and Equipment 272,958 273,047 89

Intangible Assets 389 265 (124) Intangible Assets 389 279 (110)

Other Assets - - - Other Assets - - -

Non Current Assets 273,038 271,639 (1,398) Non Current Assets 273,347 273,326 (21)

Inventories 6,649 6,128 (521) Inventories 6,052 5,808 (244)

Trade and Other Receivables 20,412 30,520 10,108 2 Trade and Other Receivables 20,248 25,147 4,899

Cash and Cash Equivalents 13,607 6,849 (6,758) Cash and Cash Equivalents 11,729 3,894 (7,835)

Non Current Assets Held for Sale - - - Non Current Assets Held for Sale - - -

Current Assets 40,668 43,497 2,829 Current Assets 38,029 34,849 (3,180)

Trade and Other Payables (34,974) (41,335) (6,361) 3 Trade and Other Payables (31,977) (33,697) (1,720)

Borrowings (579) (2,214) (1,635) Borrowings (2,122) (2,158) (36)

Other Financial Liabilities - - - Other Financial Liabilities - - -

Provisions (958) (590) 368 Provisions (1,034) (653) 381

Other Liabilities - - - Other Liabilities - - -

Current Liabilities (36,512) (44,139) (7,627) Current Liabilities (35,132) (36,508) (1,376)

Borrowings (27,205) (25,618) 1,587 Borrowings (25,047) (24,039) 1,008

Trade and Other Payables - - - Trade and Other Payables - - -

Provisions (2,780) (3,007) (227) Provisions (2,704) (3,007) (303)

TOTAL ASSETS EMPLOYED 247,209 242,373 (4,836)

TOTAL ASSETS EMPLOYED

248,493 244,621 (3,872)

Financed by: Financed by:

Public Dividend Capital 239,091 239,191 100 Public Dividend Capital 239,091 239,191 100

Retained Earnings (38,649) (39,584) (934) Retained Earnings (37,365) (37,335) 30

Surplus/(Deficit) for Year - - - (Surplus)/Deficit for Year - - -

Revaluation Reserve 46,767 42,765 (4,002) Revaluation Reserve 46,767 42,765 (4,002)

TOTAL TAXPAYERS EQUITY

247,209 242,373 (4,836)

TOTAL TAXPAYERS EQUITY

248,493 244,621 (3,872)

The Trust Balance Sheet is produced on a monthly basis, and reflects changes in the asset values, as well as movement in liabilities.


1. The variance on Property, Plant and Equipment is due to slippage of the capital plan and the

phasing of the expenditure, which the Trust expects to come back on plan during the year

2. Within trade and other receivables, accrued income (£6.9m) is higher than the planned amount due

to the timing of payments from the Trust's main commissioner in relation to seasonal resilience

invoicing and a delay in completing finance reconciliations with NHS England. Trade receivables are

£3.6m higher including £1.2m in prepayments and £2.3m due from Health Education England due to a

change in the process whereby the Trust, from Q3, has to raise an invoice to the organisation rather

than receiving a direct payment.

3. The trade and other payables relates to a higher than expected trade creditors balance than plan,

which is due to extended payment timescales and an increase in deferred income relating to the

SaCP (South Acute Programme) Information Technology project of £1.7m, off which £604k has been

recognised in the I&E position to match capital expendiutre on the scheme, in line with standard

accounting practice

The Trust Balance Sheet is produced on a monthly basis, and reflects changes in the asset values,

as well as movement in liabilities. The forecast has been updated to reflect the current financial

trajectory.

Finance Report Month 9 2015-16 Cash A


£k £k £k £k £k £k

Cash Balance 13,607 6,849 (6,758) 11,729 3,894 (7,835)


£k £k £k £k £k £k

EBITDA 17,599 12,929 (4,669) EBITDA 24,402 21,577 (2,825)

Non Cash I&E Items - (1,393) (1,393) Non Cash I&E Items - - -

Movement in Working Capital (9,953) (13,602) (3,648) Movement in Working Capital (10,401) (14,730) (4,329)

Provisions (228) 50 278 Provisions (304) (133) 171

Cashflow from Operations 7,417 (2,015) (9,432) Cashflow from Operations 13,697 6,714 (6,983)

Capital Expenditure (11,206) (9,625) 1,581 Capital Expenditure (15,070) (15,070) -

Cash receipt from asset sales - - - Cash receipt from asset sales - - -

Cashflow before financing (3,789) (11,640) (7,851) Cashflow before financing (1,373) (8,356) (6,983)

PDC Received - 101 101 PDC Received - - -

PDC Repaid - - - PDC Repaid - - -

Dividends Paid (3,487) (4,052) (565) Dividends Paid (6,974) (7,784) (810)

Interest on Loans and leases (730) (637) 93 Interest on Loans and leases (991) (991) -

Interest received 45 32 (13) Interest received 77 35 (42)

Donations received in cash - 1,393 1,393 Donations received in cash - - -

Drawdown on debt - - - Drawdown on debt - - -

Repayment of debt (1,579) (1,496) 83 Repayment of debt (2,158) (2,158) -

Cashflow from financing (5,751) (4,659) 1,093 Cashflow from financing (10,046) (10,898) (852)

Net Cash Inflow / (Outflow) (9,541) (16,299) (6,758) Net Cash Inflow / (Outflow) (11,419) (19,254) (7,835)

Opening Cash Balance 23,148 23,148 - Opening Cash Balance 23,148 23,148 -

Closing Cash Balance 13,607 6,849 (6,759) Closing Cash Balance 11,729 3,894 (7,835)

Year To Date Full Year

The cash balance remains behind plan for the year to date. The income and expenditure position has contributed £4.7m to the adverse cash variance against plan. The movement in working capital includes an increase above

planned levels in trade receivables, accrued income and prepayments of £10.1m. Accrued income relates to contractual overperformance which are invoiced and paid in arrears. An increase in the level of creditors, due to

restricting creditor payment runs, and an increase in deferred income (due to funding for the SaCP project) along with the phasing of the capital programme has offset the impact of the accrued income increase.


Finance Report Month 9 2015-16 Aged Debtors

Invoiced Debtors

1-30 days31-60

days

61-90

days> 90 days

£k £k £k £k £k £k

CCG's (276) 1,046 409 97 189 1,465

NHS England (in Health

Education England)(25) 3,008 832 46 210 4,070

NHS Trusts 23 588 261 166 1,117 2,154

Foundation Trusts 2 482 272 183 417 1,356

Other NHS 3 16 20 7 42 87

Non-NHS (4) 254 321 106 903 1,580

Total (277) 5,393 2,115 604 2,877 10,712

-3% 50% 20% 6% 27%

Provision for Bad Debts (including RTA Provision) (1,001)

Accrued Income (including Work in Progress) 13,487

Prepayments 3,575

Other Debtors 3,747

Total Trade & Other Receivables 30,520

The Trust debtors is a mixture of invoiced debtors, accrued income and prepayments as set out in the table below. It shows that the Trust has outstanding debtors of 31 days or more of £6.0m. The most

significant component of outstanding debtors greater than 90 days relates to other NHS trusts income of £1.12m. NHS debt has increased by £0.5m between November and December. Non NHS debt has

remianed broadly static in the month.

Other debtors consists of £2.0m of RTA debtors, £1.1m of Private Patients, £0.6m relates to Love Your Hospital (this includes £0.4m of capital items paid in January). The balance is made up of VAT and other

miscellaneous debtors

Accrued income consists of £8.8m of commissioner income, £0.4m of provider to provider income, £0.3m of medical training income, non-contracted activity £0.6m, drugs/pharmacy £0.6m, private patients

£0.3m, work-in-progress £2.4m and £0.1m of other miscellaneous including radiology, catering and clinical excellence awards.

OverdueWithin

TermsTotal

5,393k

2,115k

604k

2,877k

Debtors

1-30 days

31-60 days

61-90 days

> 90 days

Finance Report Month 9 2015-16 Capital A

Year To Date Year End Forecast


£k £k £k £k £k £k

Total Capital 14,401 9,597 4,804 Total Capital 15,070 17,215 (2,144)

Capital Full Year

Budget Actual Variance Plan Forecast Variance

Source of Funds £k £k £k Source of Funds £k £k £k

Depreciation (net of IFRIC 12) 10,734 10,546 188 Depreciation (net of IFRIC 12) 13,920 13,920 -

Technology Fund 2 for Inpatient Documentation - - - Technology Fund 2 for Inpatient Documentation 110 110 -

Loan Repayments (579) - (579) Loan Repayments (1,158) (1,158) -

Health Education England Funding 170 - 170 Health Education England Funding 170 170 -

Charitable Funds 1,014 - 1,014 Charitable Funds 2,028 2,028 -

Donation/Grants - 1,393 (1,393) Donation/Grants - 1,799 (1,799)

11,339 11,938 (600) 15,070 16,869 -

Application of Funds Application of Funds

Endoscopy 4,311 3,244 1,067 Endoscopy 4,311 3,245 1,066

Interventional Radiology Room 1,011 453 558 Interventional Radiology Room 1,814 1,814 -

RTT - Pre Assessment 282 413 (131) RTT - Pre Assessment 627 580 47

A&E Door 50 59 (9) A&E Door 50 59 (9)

Infection Control Isolation Room 150 13 137 Infection Control Isolation Room 450 - 450

Haemotology - 3 (3) Haemotology 200 200 -

IT Support - Ante Natal Care 118 - 118 IT Support - Ante Natal Care 118 118 -

Bed Capacity 437 232 205 Bed Capacity 100 401 (301)

Cardiology & Respiratory 40 147 (107) Cardiology & Respiratory 40 69 (29)

Other Service Developments not prioritised - - - Other Service Developments 773 183 590

Southlands Ophthalmology 650 546 104 Southlands Ophthalmology 2,000 921 1,079

Medical Equipment (including EBME) 1,642 573 1,069 Medical Equipment (including EBME) 1,972 1,330 642

Facilities & Estates 2,896 1,466 1,430 Facilities & Estates 4,230 3,332 898

Information Technology 2,730 2,141 589 Information Technology 3,216 4,495 (1,279)

Donated Funds 29 307 (278) Donated Funds 28 314 (286)

Misc - - - Misc - 154 (154)

Overprogramming Overprogramming (4,859) (4,858)

Total Expenditure 14,346 9,597 4,749 Total Expenditure 15,070 17,215 (2,144)

The main areas of underspend year to date relate to the endoscopy project, information technology,

Estates and Interventional Radiology Room. Endoscopy equipment spend has been deferred to

recognise apporpriate lead in times for procurement without compromising the programme overall. The

Information Technology and Estates schemes that have slipped will be recovered in full within the year.

The forecast assumes the following:-

- in agreement with the service that the Endoscopy equipment for Chichester and Room 5 in Worthing is deferred

to 2016/17

- service developments not already underway remain unspent for the current year

- remainder of funds for equipment replacement programme remain uncommitted

- a detailed action plan for those schemes currently behind schedule is being completed and will be shared with

the Capital Investment Group on a monthly basis

Year to Date

There is slippage against the capital programme of £4,804k year to date, mainly in Endoscopy, Estates, Information Technology and the Interventional Radiology Room. A monthly capital forecast has been completed, with

input from the divisions, which has identified slippage of £2.9m to offset against the over-programming. The forecast is updated monthly and is reviewed at each Capital Investment Group meeting. The forecast has

increased to include £1.8m of equipment for the SaCP project (Clinical Portal) which has been funded via a grant from the Department of Health.

Finance Report Month 9 2015-16 Efficiency and Transformation Programme A

Workstream Plan Actual Variance Plan Forecast Variance

£k £k £k £k £k £k

Back Office & Corporate Support 3,011 3,206 195 3,999 4,052 53

Business Case Benefits Realisation - - - - - -

Commercial Opportunities 1,954 1,629 (325) 2,766 2,401 (365)

Clinical Support Services 301 296 (5) 556 499 (57)

Facilities & Estates 658 579 (79) 862 844 (18)

IM&T 128 35 (93) 157 102 (54)

Medical Workforce 2,394 2,148 (245) 3,248 2,814 (434)

Medicines Management 278 311 33 367 386 20

Nursing Workforce 984 620 (364) 1,904 1,318 (586)

Operational Productivity 1,842 1,247 (594) 2,225 1,804 (421)

Terms & Conditions 274 260 (14) 274 274 0

Elective Patient Flow 170 - (170) 543 89 (453)

Non Elective Patient Flow 1,378 1,405 27 2,208 2,208 (0)

Efficiency Plan Total 13,371 11,737 (1,634) 19,108 16,791 (2,317)

Month 9 Cumulative (December) Plan vs Actual

At the end of December, the Efficiency Programme delivered cumulative savings of £11.7m against a plan of £13.4m (87.7%). Risks within the Commercial work-stream have been recognised in month which have reduced the forecast out-turn position.

Year to Date Forecast Out-turn

0

500

1,000

1,500

2,000

2,500

3,000

3,500

Back Office &Corporate Support

Business Case BenefitsRealisation

CommercialOpportunities

Clinical SupportServices

Facilities & Estates IM&T Medical Workforce MedicinesManagement

Nursing Workforce OperationalProductivity

Terms & Conditions Elective Patient Flow Non Elective PatientFlow

£0

00

s

Plan

Actual

MONITOR FINANCIAL RISK INDICATORS Indicators of Forward Financial Risk AYTD Forecast Q4

Number of Indicators Breached 7 4

MONITOR FINANCIAL RISK INDICATORS YTD RAG Forecast Year

End RAG

Position Explanation if Risk

Unplanned decrease in EBITDA margin in two consecutive quarters

R R

EBITDA is behind plan in

quarter but was on plan at

end of Q1

Financial risk rating (FRR) may be less than 3 in the next 12 monthsR G

FRR 2 for any one quarter

R G

Debtors > 90 days past due account for more than 5% of total debtor

balances R RDebtors over 90 days

account for 26.9% of the

total invoiced debts.

Performance due to some slow NHS payments.

This is under constant review.

Creditors > 90 days past due account for more than 5% of total

creditor balancesR R

Creditors over 90 days

account for 9.9% of the total

invoiced creditors.

NHS creditors account for 46.0% of the 90 day

balances, the remaining material balances relate

to specific non NHS creditors.

Two or more changes in Finance Director in a 12 month period

G GNot applicable Not applicable

Interim Finance Director in place over more than one quarter-end

G GNot applicable Not applicable

Quarter end cash balance <10 days of operating expenses

R R

Cash balance at end of

month is below 10 days

operating expenses

Movement in cash position against plan is

summarised on cash sheet

Capital expenditure < 75% of plan for the year to date

R G

Capital Expenditure is 66%

of plan year to date due to

the phasing of the

overprogramming

Capital expenditure reviewed by the Finance &

Investment committee, including forecast

Any particular occurrences that could have an impact on the

operation of the business of the Trust G G No plans to undertake a major acquisition,

investment or divestment. No plans for a major

change in capital structure.

YTD RAG Forecast Qtr

RAG

IMPACT MITIGATION

A A

Adverse financial

performance will impact on

the EBITDA margin and

CoS rating.

Performance across operational budgets will need

to improve and agency spend reduce. This will be

managed by exception through the director-led

deep dive reviews

A A

Non-delivery of efficiency

programmes will adversely

affect EBITDA and CoS

rating.

Enhanced infrastructure to support programmes

and enable delivery. Identification of new pipeline

schemes to enable headroom. Delivery of each

workstream is formally reviewed weekly by the

Programme Steering Group

A A

Non-recovery of income will

adversely affect will

adversely affect EBITDA

and CoS rating.

Regular discussions with the CCG Finance

Directors over system finances and affordability.

The anticipated level of income from commissioners may be in

excess of local health economy available funds.

Work through the local Contract Management

Group to validate and agree current levels of

activity and secure income

NEXT STEPS

Trust financial performance is adverse to plan and operational

performance is currently highlighting underlying cost pressures.

Slippage against efficiency and transformation programme. The Trust

must identify and deliver 'pipeline' schemes to ensure sufficienct

headroom so potential slippage on schemes is recovered in full

Formal risk assessment of plans supported

through external review. Additional support for

'high risk' work streams in place for 10 weeks to

mobilise delivery. Substantive PMO team

recruited in order to facilitate delivery

The Capital Investment Group, chaired by the

Director of Finance, continues to meet monthly to

oversee the 2015/16 plan and out turn. A

monthly forecast is now being produced, with

input from the divisions and an action plan is

being completed relating to those areas that are

currently behind plan but are forecasting to hit

this budget by March 2016

The indicators below have previously been identified by Monitor as indicators of forward financial risk against financial performance.

Although the new Monitor Risk Assessment Framework is now in place the indicators below still provide a helpful indication of

operational financial performance. The Trust will monitor performance against these as a helpful indicator of emerging risks in

addition to the Continuity of Service Rating and delivery against the control total surplus.

Action if Risk

FSR is 2 for the YTD

Comprehensive formal review of debtors and in

particular NHS partner organisations

Work is ongoing to clear the major non NHS

creditors

Not applicable

Not applicable

Review of accrued income and conversion to

debtors to enable cash to be collected. Work

continues on agreeing over-performance with the

Trusts Main Commissioners

The Trust is has been behind its financial plan

since quarter 2 and the the financial risk rating has

now dropped to a '2'.

An updated financial trajectory is being presented

to the F&I Committee in December outlining the

actions that need to be taken in order to deliver

an FSR of '3' in the financial year.

To: Trust Board


Title

Patient First Programme – Update Report


Marianne Griffiths, Chief Executive

Prepared by

Jenny Procter, Programme Director PMO

Status

Disclosable

Summary of Proposal

The purpose of this paper is to provide the Trust Board with an update on the implementation of the Trust’s Patient First Programme, our trust-wide approach to improving the experience and quality of care we offer patients. The Patient First Programme Board will oversee and assure delivery of all improvement and transformation work in the Trust.


The Patient First Programme’s key aim is to improve the quality of care for patients and improve patient experience and outcome.


Links across all of the Trust’s Strategic Objectives.


A number of workstreams within the Patient First Programme have resource implications and savings targets. These are now consolidated into and tracked through the Trust Efficiency and Transformation Programme.


A Workforce Transformation Workstream and an Organisational Development Workstream are now in place. Workforce impact will be assessed through these groups.

Recommendation

The Board is asked to NOTE progress on the development of the Patient First Programme.


Communication Strategy has been approved by the Patient First Programme Board.

Appendices

N/A

Patient First Programme – Update Report January 2016

1. Introduction

The diversity and complexity of the Patient First Programme has been brought into

sharp relief since the last update in November. The Patient First Improvement

Programme has made significant progress and all workstreams are now moving into the

delivery phase. The Trust Board has agreed True North metrics and breakthrough

initiatives which will now provide the focus for improvement effort over the coming year.

This is happening alongside an increase in focus on all transformation workstreams to

ensure planned improvement and maximum efficiencies are achieved in year.

This report provides a summary update of progress against key objectives and outlines

the priorities for February.

2. Context

Introduced in November 2014, Patient First is the Trust’s approach to ensuring safe,

high quality care for patients. The philosophy behind the programme is centred on:

The patient being at the heart of every decision

Empowering staff to build on existing high standards

Continuous improvement of services through small steps of change

Standardising practices to ensure consistency of service.

Patient First has a strong focus on safety and we have prioritised changes that directly support that focus. For example the introduction of daily Safety Huddles, where everyone working on a ward comes together at the same time each day to discuss how they will provide a safe service that day, including ensuring they have the right staff and resources.

3. Patient First Themes

a. Sustainability: The Workforce Transformation Programme is focussing on delivery

of the agreed efficiency programmes, the majority of which are on track and

delivering agreed improvements and values. The Programme is also addressing the

wider workforce issues that need to be addressed and principally reduced reliance on

temporary staffing. In line with a forecast increase in the substantive workforce,

decisions have been taken in January to stop non-framework agency in nursing.

Alongside realisation of the financial benefits, non-financial benefits are being

realised as a result of improvement actions. For example, as a result of a prolonged

period of intense domestic and international recruitment activity, the trend continues

from October for the number of qualified nurses joining the Trust exceeding the

numbers leaving.

Detailed work has also been completed to more accurately forecast the arrival of new

overseas nurses and to align this with the Trust’s activity plan. International

recruitment is a highly complex, multistage process which takes up to nine months

per candidate to complete. Based on this new information, the current recruitment is

likely to be completed in the autumn. In partnership with the agency, all opportunities

are being taken to shorten this timeline and internally we are seeking to align new

arrivals to the wards with the highest vacancy rates.

The Nurse Resource Management Programme is now being rolled out to all wards,

beginning with the Surgical wards. It is expected that temporary staffing usage will be

reduced by maximising the use of nursing establishments. Improvements will be

realised through more planned staff attendance that will result from allocation of

unallocated hours, proportionate annual leave throughout the year, proactive

sickness management and fair allocation of work hours.

High use of agency workers to address workforce shortfalls continues in the medical

workforce. Divisional reviews have taken place in January to identify opportunities to

stop some agency and a full impact assessment will be undertaken of where posts

are proposed for removal. Actions have been taken to reduce the pay rates for

agency workers to bring these in line with Monitor capped rates. This includes

negotiating Trust wide agency rates with the top four agency suppliers and

negotiations with individual workers.

b. Our People: The Kaizen Office is now fully established and the Director of

Continuous Improvement is due to take up post imminently. Lean green belt training

is scheduled to commence on 26th January and 18 of our staff will be trained in this

first wave. Improvement projects in orthopaedics, endoscopy, non-elective flow and

stroke will be run alongside the green belt training. We have also agreed with KPMG

to convert awareness training to yellow belt training and will be able to train 250 staff

starting from February. Staff offered yellow belt training will be pulled from the

following pools: staff involved in the Patient First Improvement System roll out, staff

working on Improvement Projects; clinical leaders and staff who already work in

improvement roles. It is important that staff are able to practice new improvement

skills.

The first wave of training in the Patient First Improvement System (PFIS) began on

22nd October and is due to complete in February 2016. Four wards are included in

the first wave and will be used to tailor the improvement method to Western Sussex

to support subsequent waves. The first four PFIS units are Botulphs, Fishbourne,

Clapham and Wittering wards. The training has been well attended by the ward

leadership teams and there is very high participation and enthusiasm for the training

and application of the method in their ward areas. Staff have developed ward

dashboards and have agreed the improvement priorities which will contribute to the

Trust’s True North metrics. The next four PFIS waves are agreed as Selsey Ward,

Lavant Ward, Theatres and Outpatients.

c. Quality Improvement: Work progresses in all current quality improvement projects.

The overall programme will be refreshed and reprioritised in the context of the agreed

True North metrics and breakthrough objectives in order to ensure that improvement

work is focused in the highest impact areas.

d. Systems and Partnerships: The Non-Elective and Elective Transformation

Programmes are now well into the delivery phase. The scope and timeline for these

programmes and critical dependence on the Workforce Transformation projects

makes delivery highly complex and challenging. Nonetheless, good progress is being

made in a number of patient flow improvement projects, including elimination of the

pre-assessment backlog, implementation of senior daily review, implementation of

bed reconfiguration proposals and agreement of a new theatre schedule. The next

phase of delivery requires implementation of the new theatre schedule and bay

flexing to maximise patient flow.

4. Planned Activity in February

Work will continue to support delivery of all improvement work within the Programme.

Specific actions include:

Patient First Improvement Programme

o Completion of PFIS wave 1 and preparation for wave 2

o Green and yellow belt training

o Launch of six improvement projects Review and alignment of all

transformation workstreams

o Full establishment of the Strategy Deployment Room

o Trust wide communications to raise awareness of the Patient First

Improvement Programme, PFIS and True North metrics.

Continued focus on domestic and international recruitment to maximise the

substantive workforce

Exit from non-framework nursing agency

Impact assessments to inform reductions in medical agency

Renegotiation of medical agency rates to below cap

Implementation of the new theatre schedule.

To: Trust Board


Title:

Operational Plan Objectives and Board Assurance Framework – Quarter 3 (2015/16)

Responsible Executive Director:

Mike Jennings, Commercial Director and Andy Gray, Company Secretary

Prepared by:

Mike Jennings, Commercial Director and Andy Gray, Company Secretary

Status:

Discloseable

Summary of Proposal:

This paper presents an update to the Board on:

Quarter 3 progress of programmes supporting the delivery of the Trust’s Corporate Objectives;

the Board Assurance Framework Quarter 3 (2015/16); and

the BAF Quarterly Tracker Quarter 3 (2015/16) supporting visibility in movement in mitigated risk scoreson a quarterly basis.

Implications for Quality of Care:

Quality is a key element of the Trust’s Corporate Objectives.

Link to Strategic Objectives/Board Assurance Framework:

The Trust’s Corporate Objectives cover the full range of the Trust’s strategic objectives.

Financial Implications:

Links to specific objectives and risks as identified.

Human Resource Implications:

Links to specific objectives and risks as identified.

Recommendation:

The Board is asked to:

REVIEW and NOTE progress against the delivery programmes contained within the OperationalPlan as at Quarter 3 (2015/16); and

REVIEW and NOTE the Board Assurance Framework and quarterly tracker.

Communication and Consultation:

Executive Team and Trust Executive Committee.

Appendices:

Appendix 1: Corporate Objectives programmes update to Quarter 3 2015/16.

Appendix 2: Board Assurance Framework to Quarter 3 2015/16.

Appendix 3: Board Assurance Framework Quarterly Tracker.

WESTERN SUSSEX HOSPITALS NHS FOUNDATION TRUST

To: Board Date: 28 January 2016

From: Mike Jennings, Commercial Director

Andy Gray, Company Secretary

Agenda Item: 13

FOR INFORMATION

OPERATIONAL PLAN AND BOARD ASSURANCE FRAMEWORK 2015/16 QUARTER 3 REVIEW

1. INTRODUCTION

1.1. At the Board March 2015 meeting the Board approved the Trust’s Operational Plan for 2015/16 detailing how the Trust will achieve the corporate objectives it had set itself for the year, delivered through a range of programmes, each with key aims, work-streams, milestones and measures of success identified.

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

1.3. This paper presents:

a) Quarter 3 progress of programmes supporting the delivery of the Trust’sCorporate Objectives

b) The Board Assurance Framework Quarter 3

c) The BAF Quarterly Tracker

2. RECOMMENDATIONS

a) REVIEW and NOTE progress against the delivery programmes contained withinthe Operational Plan for Quarter 3 of 2015/16

b) REVIEW and NOTE the Board Assurance Framework and quarterly tracker

Page 2 of 3

3. PROGRESS ON DELIVERING THE OPERATIONAL PLAN

3.1. For 2015/16 the Trust has published an Operational Plan that outlines how the Trust will achieve its corporate objectives for the year. The corporate objectives are linked back to the Trust’s key strategic themes outlined in the Patient First Programme.

3.2. Delivery programmes have been put in place to ensure that these corporate objectives are delivered. Each of these programmes are set out in the Operational Plan, highlighting the aims of the programme, the key work streams, the measures of success to be used and the corporate objectives supported.

3.3. Appendix 1 looks specifically at progress against each of these programmes in quarter 3, and incorporates comments on progress.

3.4. Good progress has been made across the range of objectives during Quarter 3. Please refer to the commentary for progress against the Q3 expectations. However, the following exceptions should be noted:

Quality Improvement(B5) Out Patients: There has been a delay in issuing the final diagnostic report whichhas caused a delay in the programme. The report is due to go to TEC at the end ofJanuary for approval, and will inform the ongoing work plan of improvement into2016/17.

Systems & Partnerships(C3) Cancer Services: There has been a delay in completing ongoing discussion withtertiary partners which has led to a delay in further pathway development.

Delivery & Sustainability(D1a) Workforce Capacity: During Q3 there has been some success in recruitment butcapacity gap continues to drive high usage.(D2a) Clinical Services Strategy: A Service Line Review is being carried out in Q4 toinform ongoing work on the Clinical Strategy.(D3) Private Patients: The work identifying sources of funding has been ongoing, but willnot be completed until the end of Q4.(D5) Finance: At end of Q3 the Trust has an FSR of 2 and is now forecasting a £2.4mdeficit for the end of year. Please see the Finance Report for more detail.

3.5. The quarterly progress report will continue be provided to the Board for the rest of the financial year.

4. BOARD ASSURANCE FRAMEWORK QUARTER 3

4.1. Executive Directors have reviewed the risks assigned to them, assessing the validity of the risks, their gross and net ratings, and the effectiveness of the controls and sources of assurance used to manage the risks.

4.2. The Quarter 3 review has identified a number of additional controls, areas of assurance and additional controls that are in place to mitigate risks of achieving the Trust Objectives. These are highlighted in red and in bold at Appendix 2: Board Assurance Framework to Quarter 3 2015/16.

Page 3 of 3

4.3. The Board should note the following in particular:

Objective B1(a,b,c): Reducing Mortality and Improving Outcomes: the Board had agreed a post-mitigated risk target of 12 for this objective. Following sustained improvements in outcome measures such as HSMR the post-mitigated risk score has now been adjusted to 8.

Objective B3(b): Due to the failure to recruit to the vacant Dementia Matron post the post mitigated risk score has been increased to 12 this quarter.

Objective D4(a): This risk relates to a mismatch between demand and capacity and while the Q3 ratings are maintained this will be reviewed during Q4 to determine if the risk level increases.

Objective D5(a) : this risk relates to maintaining a Financial Sustainability rating of 3 and the Quarter 3 post mitigated risk score has increased from 12 to 16.

Corporate Objectives 2015/16

Ref Corporate Objective Exec Primary Delivery Programmes/ Purpose Programme

Exec Lead(s)

Sub Sections Milestones Q1 milestones progress

A1 (a) Improve the overall experience patients receive from our

Trust

DNPS Develop and deliver the Trust’s 'Customer Care'

training programme

The Trust is introducing a major change to the way it

improves customer care by introducing ‘The Western

Sussex Way’ - an innovative approach to training,

recruitment, induction and appraisal, which seeks to

transform the way Trust staff interact with patients and their

carers.

DNPS &

DODL

Q1. Establish operational group which will meet quarterly to

develop annual work plan in response to triangulating patient

experience data.

Q2. Respond to national inpatient survey

Q3/Q4 : monitor progress against work plan

Q1 - PEEC now reviews the recommendations

from the Patient experience manager and

oversees the action plan to improve patient

experience

Q2 - We are reviewing patient experience

through the PEEC and monitoring the patient

experience action plan plus have commenced

a review of relevant NICE guidance.

The Trust is developing a plan for rolling out

the Customer Care training into the programme

for Annual Updates. The Ambassadors

programme continues to grow.

Q3 - Work continues to extend Customer Care

training in line with the roll out of 'Patient First'

training.

Action plan reviewed at each meeting -

indicative national inpatient report received but

not final CQC version with country wide

comparisons. Excepted in Q4

A1 b Patient, public and member engagement programme

To ensure constant improvement and value is added

through identifying issues and areas for improvement that

matter to our patients.

DODL Governors Q1 - scope and align current engagement processes to

ensure robust and efficient Support Membership Committee

in development and implementation of membership strategy

Increase opportunities for patient voice in planning services

and training staff

Q1/Q2 - Membership Strategy agreed and

work of Membership committee progressing.

Q3 - During this quarter the Trust launched

engagement programme to support the

development of Western Sussex Eye Care -

Southlands, Patient surveys, events,

information booklets as well as direct patient

involvement in design of the new build.

Re-launch of members newsletter offering by

weekly opportunities for feedback from

members including encouraging their support

of CQC inspection.

Direct patient engagement into MSK has

begun during Q3.

A2 a Continue to develop and deliver staff engagement and

leadership development programmes in order to

improve patient experience

DODL Develop the leadership strategy for the Patient First

Programme

The Trust has continued to support staff through its

Leadership Development plans, and is extending the

programme to cover Nurses and Managers as well as

Clinicians. The aim is to equip a cadre of staff to have the

skills to manage the Trust through the challenging future it

faces.

DODL Q1 - Draft Leadership 'compact' and strategy and agree

implementation process

Q2 - Agree Leadership development priorities and process

to inc priorities such as Lean, coaching etc

Q1 - Leadership framework drafted - to go to

Board 30/7/15.

Q2 - The mentoring and new consulting

Development Programmes for consultants is

progressing well. The development of training

plans for improvement techniques is also

making progress.

Q3 - Executives are developing their Leaders'

standard work and the development

programme to support the Patient First

programme. This is due to be finalised during

the next quarter.

Our People

1

A2 b Staff Engagement Programme

To ensure constant improvement and value is added

through enabling staff to identify and lead service

improvement.

DoDL Medical Engagement

Staff Survey

Q1 - Agree action plans inc staff side engagement and

methodologies for measuring progress

Agree action plan for Freedom to Speak up review

Q1/Q2 - MES action plan drafted. PF

Improvement Programme in place. Freedom to

speak up review, Action plan agreed by Board

Patient First Engagement events + road shows

delivered.

Q3 - MES Action Plan agreed by Executive

Team.

A3 To deliver coordinated and standardised service

improvement methodologies across the Trust in priority

areas

CEO Develop and implement service improvement learning

programmes for the Patient First Transformation

Programme (including Lean training) To encourage all

staff to adopt and use evidence-based service change and

improvement tools, to improve the quality of service they

deliver.

CEO Q1 - Select Partner to deliver service improvement training

programme

Q1 - Procurement process held - service

improvement partner selected. Programme

design phase is underway.

Q2 - Executive level planning sessions have

taken been to develop 'Lean' quality

improvement methodology across the

organisation. Interviews and assessment

centres for Service Improvement Team held,

currently in process of appointing. Initial 4 ward

areas for process improvement methodology

roll out have been chosen.

Q3 - Key roles for the Service Improvement

Team have now been appointed to. Roll out

has begun with the initial 4 wards, and a further

4 wards have been identified to take place in

wave 2.

Corporate Objective Exec Primary Delivery Programmes/ Purpose Programme

Exec Lead(s)

Comments Milestones Q1 milestones progress

B1 a MD Reducing Mortality and Improving Outcomes 1.

Implementation of care bundles for sepsis, AKI and cardiac

arrest.

MD Q1 - Agree Care bundles to be implemented

Q2 - Design mechanisms to monitor compliance

Q3 - Set targets and monitor progress

Q1 - care bundles agreed and piloting in some

clinical areas. Monitoring mechanisms partly

agreed.

Q2 - The AKI and Sepsis care bundles are in

place. Data collection and monitoring has been

underway during Q2. Cardiac data is beingB1 b Reducing Mortality and Improving Outcomes 2.

Implementation of 'Better Births@ Programme.

DNPS Q1. Plan to be developed with new Head of Midwifery

Q2. monitor progress against work plan



Q1 Stakeholder event held re better Births with

key themes looking at person centred care,

enhancing experience, engaging and involving

service users and staff, quality and

effectiveness and access & support with the

goal to identify end points not solutions.

Learning points will inform the programme

going forward.

Q2 - BID to be worked on for MLU, walk about

with Director of Works and Estates to format

plans. Made contact with CCG commissioner

to help secure funding to re-establish local

MLC. GAP /GROW programme

implementation date 5 October 2015. Awaiting

regional / national programme for preterm

programme. Community Laptops formally

approved by TEC on 23 September 2015 -

working through fit for purpose choice of

Laptop working collaboratively with IT -

purchase of laptops and then implementation

to be commenced. Attended regional meetings

and webinar's on ERP for CS. Working with

Simon Higgs to establish local aligned

programme. Many of programme essentials

are in place - requirement for care bundle

pathway.

Q3 - A further engagement programme is

being planned and due to take place April

2016.

Quality Improvement

Reducing Mortality and Improving Outcomes

2

B1 c Reducing Mortality and Improving Outcomes 3 (yr 1)

Introduction of a structured programme to review each

death in hospital and learn from each event.

MD Q1,Q2 - Scope methodology to identify structure review

process

Q3 - Implement review process

Q1 - Initial structured review process agreed.

Currently testing the process against 50 patient

notes before final sign off

Q2 - A detailed project plan for 15/16 has

been developed. Progress has been made

during Q2. A proposed review template has

been developed, but in testing it has been

identified that a series of further iterations will

be needed and building capabilities will need to

take place ahead of go live, these will take

place during the latter part of 2015/16.

Q3 During Q3 IT systems have been

developed to facilitate a 2 stage process for

reviewing all deaths. The content of review has

been tested and agreed.

B2 a DNPS Delivering Safe, Harm Free Care 1

Reducing Hospital Acquired Infections, we will better our

targets for C Diff, and maintain zero MRSA infections for

2015 16.

DNPS Q1. Develop 2015/16 work plan




Q1 - MSSA bacteraemia: reduce no. of

avoidable post 48 hour cases by 20% (i.e. to 4

for year)

All C Difff and MRSA have an RCA review

meeting to identify any lapses of care

C. difficile: limit 39 post 72 hr cases for year.

Stretch target: No more than 18 with significant

lapse of clinical care.

Q2 - On track against the 2015/16 work plan.

The figures at the end of Q2 are:

No. of MRSA case is 0.

Post 72 hours cases for C. difficile is 18.

Clinical lapses of clinical care is 7.

Q3 Post 72 hours cases for C. difficile is 18.

Clinical lapses of clinical care is 7.

Q3 On track 30 C Diff post 72 hours against a

target of 39. 12 Lapses of care against a target

of 18 (still awaiting outcome of 3 cases in

December regarding lapse in care . Zero

MRSA

B2 b Programme to reduce Falls within the Hospital

We will reduce the number of falls within the hospital.

DNPS Q1. Develop work plan based on output from QUEST Falls

Collaborative

Q2. monitor progress against workplan



Q1 - Falls collaborative meeting regularly, work

plan in place and pilot wards identified and

testing recommendations

Q2 - The Falls Collaborative meets regularly

where the work plan for 2015/16 is reviewed.

Action plans are in place and all Q2 targets

have been achieved, there has been

successful roll out across the pilot wards with

further wards added to the work plan for Q3.

Q3 - Trust Harm Free Care group now

established combining Falls(first half) and

pressure ulcer improvement work.

Work programme continues , all Q3 targets on

schedule.

Roll out plan for SWARM running to schedule,

Baywatch approach tested and roll out

underway across wards

Delivering Safe, Harm Free Care

Reducing Mortality and Improving Outcomes

3

B2 c Implementation of Electronic Prescribing and

Medicines Administration

To deliver significant patient safety benefits, enabled

through deployment of an IT system, by reinforcing best

practice in medicines prescribing and administration, and

providing clinical decision support for users, thereby

significantly reducing prescribing and medications

administration errors.

MD Q1: Rollout to Medical wards Chichester & DOME wards

Worthing (14 wards)

Q2: Rollout to Emergency Floor & Medical Wards Worthing

(7 wards); EPMA Paediatrics rollout; EPMA Surgical Pilot

Q3: Surgical rollout (13 wards); rollout to remaining areas,

i.e. OPD, Maternity, A&E, etc.

Q1 - On track as per Q1 milestone and roll

out.

Q2 - Rollout completed for all medical and

surgical wards on both sites including Private

Patient units. Extension to theatres underway

in qtr3. Plans being developed for maternity,

OPD and paeds for qtr4.

Q3 - Project plan in place and on track for Q3.

B3 a MD Improve our stroke services

To deliver improvements in quality of care as outlined by

Sentinel Stroke National Audit programme (SSNAP).

To review models of care including HASU provision within

the Trust. To work with the Sussex wide stroke review in

developing a Sussex wide service model for Stroke

MD Q1 - Additional stroke consultant in place, setting of

trajectory for improvement plan

Q2 - Monitor Improvements

Q1 - Submit Trust solution for configuration to CCG

Q2 - Engagement with the Sussex wide Review

Q3 - Agree plan in line with Sussex Wide Review

Q1 - The SNNAP grading is monitored each

quarter. Steady improvement throughout Q2

has ensured that the current Trust ratings of 'C'

for St Richards and a grade 'B' for Worthing

respectively are sustainable.

Q2 - The Trust has engaged with the Sussex

wide stroke review and the SOC was submitted

at the end of Q2 for review by TEC and the

Trust Board.

Q3 - The St Richards and Worthing Hospitals

sites have been rated as 'B' SNNAP' rating

during Q3.

The WSHFT model for Stroke care has been

presented to the South East Clinical Senate.

We are working closely with CWS CCG to gain

commissioner support for the WSHFT

preferred model of 'One service across two

sites'.

The Stroke Ward in Worthing (Botolphs) is

part of the first wave of Patient First

improvement wards, and the Chichester Stroke

Ward (Lavant) is due to come on line with this

programme as part of the second wave at the

beginning of March 2016.

B3 b DNPS Improve the care we provide to dementia patients

To continue to progress improvements in care to patients

with dementia, implementing our dementia strategy

DNPS Q1. Objectives identified. To be developed into workplan.

Appoint Dementia Matron




Dementia strategy group meets monthly and

reviews work plan set at beginning of 2015/16.

Matron post appointed to an candidate

withdrew shortly before start date - to be

reviewed and reappointed to.

Q3 Interviewed for the post and no

appointment made. This has been put out to

advert again with interview in Q4. Work plan in

place and reviewed each month at dementia

meeting

B4 Deliver quality improvements internally and as agreed in

partnership with our local Clinical Commissioning group -

Deliver CQUIN

CD Deliver the programme of quality improvements

specified through CQUIN's sought by the Trust’s

Commissioners through the CQUIN programme, both for

the CCG and NHS England.

CD Q1 Sign off of CQUINS for 1516 contract

Allocation of resources to achieve CQUINs 1516

Establishment of new project tracker and delivery board

meetings to programme manage achievement of milestones

within each project

Q1 - Q4 tracking and delivery of milestones as per each

individual CQUIN

Q1 -1516 CQUINS signed off and in contract

for CCG and NHS England contracts.

Q1 milestones all met.

Q2 - All CQUINS are on track for this quarter.

Q3 - Q2 CQUIN milestones all met. Q3

programme indicates on track. Report due for

agreement with CCG and of January 2016.

Delivering Safe, Harm Free Care

Delivering Reliable Care

4

B5 Improving the Patient Experience MD Out Patients

Transformation programme to review, redesign and

implement the end to end pathway in outpatients, in order

to improve the patient experience whilst delivering internal

efficiency and productivity improvements.

MD Q1 - Select external support to conduct diagnostic exercise

prior to service improvement

Q2 - Diagnostic work and delivery plan

Q3 and Q4 - as per delivery plan milestones

Q1 - External Partner selected. Diagnostic

phase underway.

Q2 - KPMG published its draft report to the OP

Diagnostic Steering Group, which has now

been reviewed and feedback given. Meetings

with key stakeholders have been held across

all work streams, and clinical engagement

progressed. The Trust is awaiting the output of

the remaining data analysis as part of the

diagnostic, which is to be presented in KPMG’s

final report, due in Q3.

Q3 - The final draft report has now been

received, this is due to go to TEC end of

January for agreement and approval. Once

agreed, this will inform the work programme

going forward into 2016/17.

C1 In partnership with our local Clinical Commissioning

Group develop our lead role in the local health economy

for unscheduled care

COO Develop System-Wide Urgent Care

1) Accountable Lead Provider role within 'One Call

One Team'

2) Play a lead role in LHE Urgent Care Review

(overseen by coastal cabinet)

COO/CD Q1 - Agree Lead provider scope and contractual

arrangements

Q3 - New lead provider arrangement in place

Q1-Q2 - Define scope and responsibilities for lead of urgent

care integrated system

Q1 - Vision for system wide urgent care set out

by Coastal Cabinet and within Coastal West

Sussex urgent and emergency care vanguard

application.

Contractual format and organisational form is

under discussion within Coastal Cabinet.

Q2 - New governance arrangements

established to support.

Q3 - Q3 -OCOT LP arrangement remains

unchanged. -

Urgent Care Oversight Group established

under new CC governance arrangements to

support the development of integrated care

prime provider type model.

C2 Develop and redesign our MSK pathways in response to

CCG specification

CD To design an integrated MSK service, linking from primary

to acute care. To implement the service in the second half

of the year.

CD Q1 - Agreement by CCG to appoint WSHFT as prime

provider

Q2 - Set up of project management governance structures

and resourcing of design and delivery groups

Q3 - Submission of final "bid" to CWS CCG and signing of

contract

Q4 - Implementation phase with "Go Live" at end of Q4

Q1 - CCG agreement to have WSHFT as

preferred bidder for MSk services. Governance

structure with steering board and key partners

involved developed. This will now be expended

to include primary care and commissioner

representation.

Q2 - Trust has been selected as preferred

provider. Process of selection of clinical

redesign partner complete. Project

infrastructure in place. 'Kick off' meeting held

for stakeholders on 2nd September.

Q3 - New go live date negotiated, indicative

date has been agreed as 1st July 2016,

contract approval for Q1 2016/17.

Facilitation of pathway work and demand and

capacity work has been undertaken in Q3 with

first stage report due January 2016. FBC

expected March 2016.

Systems and Partnerships

5

C3 Deliver improved cancer pathways for our population

through working with our tertiary partners

MD Improve and reshape our cancer services

The Trust intends to reshape its cancer services, to provide

an improved accessible and equitable service across the

Trust. The provision of all cancer services, including

individual tumour groups chemotherapy. To work with

partners to design and deliver a new radiotherapy

treatment facility at St Richards Hospital.

MD/CD Q1 - Finalise Heads of Terms and agree Implementation

plan with partners, confirm contract for Linaccs and

commence works

Q2 - Agree cancer pathways as priority areas

Q3, Q4 - Increase local provision of chemotherapy

Q4 - implement new cancer pathways

Q1 - Agreement reached with strategic

partners. Working on finer detail at present to

allow plans for radiotherapy facility to be signed

off by end August. New pathway for urological

cancer agreed by Board in July.

Q2 - Final agreement for Linacs with partners

due to complete in October, with detailed

planning work progressing.

Process in train to review priority cancer

pathways during Q3 with tertiary partners.

Q3 - delay in completing on-going discussion

with tertiary partners has led to a delay in

further pathway development.

C4 Implement Seven Day Working COO Implement the seven-day working programme

Plan and Initiate the introduction of seven day working

across the Trust, in conjunction with partner organisations

in the Local Health Economy

COO Q1 - Establish Governance Arrangements

Q2 - Agree Local Health Economy Plans and deliverables

Q3 - Monitor achievement of milestones in plan

Q1 - 7 Day system-wide development re-

established as 15/16 priority for Coastal

Executive (via Better Care Fund)

Q2 - New Executive Service Improvement

Group being established with a redefined work

programme of which 7 Day will feature.

Q3 -Agreed as a Coastal Cabinet development

for 16/17 - the Continuous Improvement sub

group to CC to oversee.

D1

To Deliver service Transformation Programmes in

priority areas such as Outpatients, Non Elective

Pathways, Elective Pathways, Workforce Redesign

CEO

Formation of Patient First Programme Board

Implement a new governance and delivery structure for the

main Trust transformation Programmes.CEO

Q1 - Agreement of formation of PF Transformation Board

and new governance structures

Complete: PF Transformation Board is in

place. Each transformation work stream also

has its own governance structure in place to

oversee the work of each individual

programme.

D1 a

Maximise workforce capacity through a dedicated

programme management approach

To transform the trust workforce through a transformation

programme

DoLD

Q1 - Formation of workforce transformation Board

Q1 - Identify and resource key programmes of change

Q2 onwards - delivery against identified milestones within

each project

Q1 - Programme management arrangements

in place + programme agreed.

Some slippage on PIDs and on delivery.

Q2 - Workforce transformation programme

established and reporting to F&I Committee.

PMO lead for workforce transformation

appointed.

Q3 - Some success in recruitment but capacity

gap continues to drive high agency usage.

D1 b Elective Care Strategy

Transformation programme to review the end to end

pathway in elective care to align capacity to demand and

ensure the Trust meets its 18 weeks and Cancer waiting

targets.

COO/CD Q1 - Hold planning event with key stakeholders to form the

key elects of the strategy

Q1 - Agree quick wins elective strategy and surgical

reconfiguration

Q1 - Engage appropriate external resource to facilitate

development of the strategy

Q2 - implement quick wins identified

Q2 - Agree Elective strategy

Q3 and Q4 - Implementation stage according to strategy

timeline

Q1 - Rapid Improvement diagnostic events

held, utilising internal resources and supported

by KPMG, to both identify quick wins, and to

inform the on-going development of a longer

term strategy.

Quick win PIDs under development ready for

implementation during Q2.

Q2 - Programme on track.

Q3 - Programme on track.

Delivery and Sustainability

6

D1 c Non Elective End to End Pathways

Deliver benefits realisation from new Emergency Floor at

Worthing Hospital. Review of the pathway at St Richards

Hospital to introduce the emergency floor model of care.

COO Q1 - Embedding of emergency floor systems and processes

Worthing

Q1 - emergency admission review

Q2 - scoping of SRH emergency floor options

Q3 - SRH emergency business case approved

Q4 - Implementation of SRH emergency floor

Q1 - Rapid Improvement diagnostic events

held, utilising internal resources and supported

by KPMG, to both identify quick wins, and to

inform the on-going development of a longer

term strategy.

Quick win PIDs under development ready for

implementation during Q2.

Emergency Floor service and workforce review

completed.

Q2 - Emergency Floor and workforce review

completed. All NEL flow improvement

programmes on track.

Q3 - SRH EF development completed and on

target to open early/end Q3.

D1 d CD Develop Southlands Hospital including the relocation

of Ophthalmology services

Invest in Southlands Hospital to develop it as a thriving

ambulatory care centre, with Ophthalmology at the heart of

the development.

CD Q1 - OBC approved

Q1 - Appoint principle design contractor and work up full

design

Q2 - Approve Full Business Case

Q3 - Appoint building contractors

Q4 - begin construction

Q1 - OBC Approved in Q1. Principle supply

chain manger appointed through procure 21

process. Design programme underway.

Resultant detailed design timeline for project

means that FBC not expected until Q3.

Q3 - FBC is going to Trust Board and F&I

Committee in January 2016. Once approved

building contractors will be appointed, and

construction will begin in Q4.

D1 e Implement improvements in our Endoscopy services

Invest in Endoscopy to enhance patient experience,

improve patient flow and efficiency. Reduce operational

risk through an equipment replacement programme. To

maintain accreditation from the Joint Advisory Group at St.

Richard’s and re-achieve accreditation at Worthing – a ‘kite

mark’ of a well-run Endoscopy service.

COO Q1 - hand over of facility - equipping unit

Q3 - unit fully operational

Q1 and Q2 - WH Endoscopy Capital

development on track.

Q3 - WH Endoscopy development opened as

per plan.

D2a To refresh the clinical services strategy MD Review the Trust’s Clinical Services Strategy MD Q1 - Review of current clinical services strategy in line with

national vision

Q2 - refresh Clinical strategy

Q1 - Work begun within the health economy,

exploring urgent care models with partner

organisations in line with the 5 yr fwd view.

Further work has been undertaken on the

cancer strategy as referenced in C3.

Q2 - Work continues to progress with the Local

Health Economy in line with Five Year Forward

View. Internally, the Trust continues to lay the

foundations of the Patient First Strategy, which

will be the foundation for the clinical strategy

refresh.

Q3 - Work has started to look at sustainable

services across hospital sites at a speciality

level. A 'bottom up' approach across the

specialities will inform the vision of the Trusts'

strategic direction for clinical services. Work

will continue to secure buy in across the

organisation will develop into 2016/17.

7

D2b Review Trust organisational form in line with 5 year

forward view and the Dalton Review, and emerging

risks in the local and national context

CD Q1- Document Trust Outline vision of future models of care

Q2 - Agree with LHE partners strategic direction for LHE

Q1 - initial future model of care outlined in the

Coastal West Sussex urgent and emergency

care vanguard application. Also outlined some

key concepts for the future strategic direction

for the LHE - these concepts have been

discussed set out in conjunction with Coastal

Cabinet.

Q2 - There are strong links with (Reference C1

in Systems and Partnerships) 'Urgent Care HE'

objective. Will progress in tandem with that

piece of work.

Q3 - In light of new national planning guidance

organisational form will follow result of STP

(find out what it means).

D3 To exploit the Trust's commercial opportunities,

including Any Qualified Provider tenders and Private

Patient activity, to support our core NHS business

CD Develop and expand Private Patient Services, including

a new business case for development of a new unit in

Worthing.

CD Q1 - review funding approach and assess possible partners

Q1 - development of further opportunities not dependant on

bed base as per efficiency scheme

Q2 - Engage partner - finalise OBC

Q3 - OBC approved -develop FBC

Q4 - approval of FBC

Q1 - Approach has been made to both an

intermediary to assess options in the equity

funding market, and to the local LIFT co. to

assess the market appetite to fund

development through that route.

On-going investigation and development of

opportunities in ophthalmic, and Women's

services.

Q2 - Obtaining final detailed quotes of funding

routes through local LIFT company. Market

appetite has been confirmed.

Approaching alternative funders through soft

market test in Q3, to inform paper on

recommended funding approach.

Q3 - An initial report from Market Assessment

is due to be presented to F&I Committee this

month. Funding of development needs to be

resolved before material progress can be

made.

D4 Maintain an acceptable Monitor governance rating

throughout the period

COO Achieve primary Quality Measures of RTT, cancer and

A&E waiting times

COO Q1 to Q4 - tracking delivery of and compliance against

targets

Revised RTT Recovery and Sustainability

Programme agreed in partnership with CCG

and submitted to Monitor and NHSE. All other

access targets on track to deliver.

Q2 - RTT Recovery Programme remains on

track to deliver and subject to on-going

external overview and scrutiny. All other

access targets remain on track.

Q3 - as above. Potential risks to Q4 being

evaluated in light of system resilience

concerns.

D5 To Maintain a minimum Monitor Continuity of Service

Rating of 3

DoF To Maintain a minimum Monitor Financial Sustanability

Risk (Formerly COSR) Rating of 3

Dof Q1 to Q4 - tracking delivery of and compliance against

financial plan

As at end of Q1, Trust performance is in line

with financial plan and Trust is reporting

delivery of a Continuity of Service rating of 3As

at the end of

Q2 - the Trust has achieved a SFP rating 3

although I&E performance is less than

planned.

Q3 - At end of Q3 the Trust has an FSR of 2

and is now forecasting a £2.4m deficit for the

end of year.

8

D5a Delivery of the Efficiency Programme DoF Embed sustainable Programme Management

arrangements to support the delivery of the efficiency

programme

Dof Q1 - Confirm transition arrangements to in house team

Q1 onwards - Tracking delivery of efficiency programmes

Q2 onwards - Continued tracking of 1516 and on going

rolling programme of pipeline schemes

Q4 - Finalise 1617 programmeQ1 - In house team in place and aligned with

work-streams. As at end of Q1, Trust is

reporting minor slippage of £35k against a plan

of £2.9m (delivery of 98.8% of target)

Q2 - As at end of Q2 Trust is reporting delivery

97% of the plan. During Q2 the transformation

work streams are now incorporated into the

Efficiency programme in full.

Q3 - At end of Q3 the Trust has an FSR of 2

and is now forecasting a 2 for the end of year.

D6 Delivery of capital programme DoF Delivery of capital programme within resources available

and on time to maintain Trust assets and deliver service

improvements

Dof Q1 - Embed new governance arrangements for capital

programme through the Capital Investment Group

Q2 - on-going tracking of delivery

Q1/Q2 - Capital Investment Group established

and in operation.

Q3 - Delivery of 2015/16 Capital Programme in

line with forecast, and over programing being

managed through Capital Investment Group.

D7 To Refresh the Trust Estates Strategy DoF DoF

Q1 : Milestone : Completion of Seven Facet Survey

Q2 : Milestone : Refreshed Estate Strategy to Board

Q3 : Milestone : Develop implementation and compliance

plan against Estate Strategy

Q4 : Milestone : Monitor on-going implementation and

compliance plan

Q1 - Executive Team discussed Premises

Assurance Model in June 2015. Director of

Estates and Facilities developing action plan

and timeline for implementation.

Q2 - An update on the Estates Strategy is

being presented at October Board. This will

include the timelines for the on-going plans for

Seven Facet Survey, and compliance plan.

Q3 - An update on the Estates Strategy was

presented to the Trust Board in October,

consultation is underway. Strategy to be

finalised by the end of Q4.

*

Include

9

DRAFT BOARD ASSURANCE FRAMEWORK 2015/16 QUARTER 3 Report

Risk Description Existing Controls Sources of Assurance Control / Assurance Gap Action Plan Board Oversight Arrangements Risk Register > 16

Co

rpo

rate

Ob

jecti

ve R

ef

:

Ris

k E

xe

c L

ead

ie. Actions already fully implemented to

manage risk

ie. Evidence relating to the specific measures

under 'Existing Controls'. Can be positive (+)

or negative (-) : State whether assurances are

(+) or (-) and the Date received / Frequency

what additional actions need to be

taken to manage this risk OR what

additional assurance do we need

to seek

TARGET RISK

SCORE

Action Plan Summary (actions

with timescales planned to

close identified gaps)

Likelihood Impact Total Likelihood Impact Total

A1 (a,b) DNPS We incur adverse feedback regarding patient

experience from our patients and the public

and media.

4 4 16 Provision of patient monthly safety metrics to

provide public assurance.

Review of RTPE feedback to ensure that

public concerns are identified and resolved in

a timely fashion.

Monthly Divisional Integrated Performance

Review Panel meetings

Stakeholder engagement and feedback : Peer

reviews of Care & Compassion : Review of

the Safety Thermometer.

Partnership working with the Patients

Association.

The Communications Team work closely with

the local press in the handling of media

relating to the Trust.

National Staff survey results

Sit & See review

CQC Insight report : Friends & Family Test

Routine meeting with CCG Lead of Quality

Healthwatch Involvement

National in-patient and out-patient surveys,

and monitoring of action plans at Board

and/or Quality & Risk Committee (+)

Monthly Quality report and Board, including

RTPE data & Friends & Family Test (+)

Routine quarterly & exceptional reports to

Management Board and Quality & Risk

Committee regarding CQC (+)

Healthwatch - monthly meetings established

Patients’ stories to the Trust Board

Increased referrals into the organisation

through the choose and book process or

other routes

Partnership working with the Patients

Association.

Friend & Family test results

RTPE and real time staff survey responses.

Governors involved in Patient Engagement

and Experience committee

3 4 12 3 x 3 = 9 Q1 develop Operational group to

oversea patient experience

feedback and develop annual

action plan

Quality and Risk Committee Q1 and Q3 if

required

516 : 699

A2 (a,b) DODL Compromised delivery of performance,

change management and staff engagement

due to inadequate leadership

3 3 9 Ongoing delivery of accredited programmes

Working with partners to develop further

appropriate programmes to support our

priorities

Evaluation of programmes Staff survey

results

Leadership Strategy and

Development Plan to support Patient

First Programme

3 3 9 3 x3 =9 Leadership Strategy and

Development Plan being

developed.

Through Board as part of monthly

Workforce report

A3 CEO Inappropriate or insufficient focus and

resourcing causes us to fail to deliver the

appropriate pace and scale of improvements

to underpin the Patient First Transformation

programme.

4 4 16 Service improvement priorities and resources

agreed by Executive Team and supported

through new Efficiency and Transformation

Programme delivery arrangements.

Resources to be flexed as necessary to

deliver priorities

Quarterly annual plan progress report to

Board

CIP delivery reports to F&I Committee and

Board

Patient survey results (re priority relating to

customer care)

Monthly performance reports to Board

2 4 8 3 x3 =9 Continued focus on Continuous

Improvement planning and

agreement of True North metric.

Recruitment to Kaizen Office part

complete.

Through Board as part of Patient First

Reporting.

B1 (a,b,c)

MD

We fail to implement care pathways

adequately in order to improve mortality

3 4 12 Care bundle progress monitored at monthly

Divisional Integrated Performance Review

Panel meetings.

Development of site-specific metrics to

demonstrate processes in place and working

Reporting of care bundle process metrics to

Board.

Feedback data from Enhancing Quality (EQ)

programme to Board

Reporting of site specific care pathway data

to Board

Monthly diagnosis group-specific mortality

reporting to Board

Quality Board to monitor Quality Strategy

3 4 12 3 x 4 = 12 On-going monitoring and

enhancement of plans through

Quality Board

Through Board as part of monthly quality

report.

B2 (a,b,c) DNPS Patients receive below standard care resulting

in avoidable harm

4 4 16 Regular reporting to Board.

Reporting of incidents by staff.

Inquests (+/-)

Root cause analysis findings (=/-)

M monthly reporting of harms ie falls /

pressure in juries/MRSA/C Diff (+)

RCA meetings for C Diff and Grade 3/4

pressure ulcers identify

avoidable/unavoidable harm (+/-)

Whistleblowing by staff.

Triangulation of vacancy rates v

harm events by ward

3 4 12 2 x4 =8

Through Board as part of monthly quality

report.

556 : 699 : 651 :

747

Gross Risk Rating Net Risk Rating

Patient First Strategic Theme : Quality Improvement

Strategic Objective : (B1) : Reducing Mortality and Improving Outcomes

Patient First Strategic Theme : Our People

Strategic Objective : (A1) : Improve the overall experience that patients receive from the Trust

Strategic Objective : (A2) : Continue to develop and deliver leadership development programmes in order to improve patient experience

Strategic Objective : (A3) : Continue to develop and deliver standardised service improvement methodologies programmes across the Trust in priority areas

Post-Mitigation

scores of >16

reviewed at

Quality and Risk

Committee

Strategic Objective : (B2) : Delivering Safe, Harm Free Care

In depth Risk Review assigned to the

Committee indicated (at the interval

indicated) or covered through reporting

arrangements indicated.

Reporting required only if post mitigated

Risk Score Band is greater than Target

Risk Score Band

Page 1 of 3

B3 (a) MD Failure to deliver improvements in stroke

services

4 5 20 Trust participating in Sussex wide

engagement group

3 2 6 3 x 4 = 12 Q1 Monitoring arrangements in

place via SSNAP - Completed

Q1 Operational performance

improvement delivered via Stroke

Operational Group - performance

continues to improve

Q1 To review models of care

including HASU provision within

the Trust- on-going

Through Quality and Risk Committee Q3 if

required

B3 (b) DNPS Failure to implement our Dementia Strategy 3 4 12 Dementia Group meets monthly(+)

Work Plan in place for 2015/16 which

includes achievement of metrics(+)

Dementia Group overseen by Adult/Children's

Safeguarding strategy group

update reporting to Trust Board Recruitment to dementia matron

position - actions currently being

overseen by Matron for

Medicine.Currently out to advert.

2 4 8 2 x4 =8

Q1. Review and enhance existing

monitoring arrangements

Through Quality and Risk Committee Q3 if

required

B4 MD We fail to programme manage the quality

improvements relating to CQUIN

3 4 12 Programme management approach to EQ /

CQUIN and enhanced recovery programmes

through an Executive led CQUIN Delivery

programme

Strengthen capacity within Information Team

Monthly board report on CQUIN and EQ to

show timeliness of data

2 4 8 3 x 3 = 9

Q1. sign off of CQUINS for

2015/16 contract - completed

Through Monthly Finance reports Finance

and Investment Committee

B5 MD Failure to improve the patient experience in

Outpatients through transformational change

programme

4 5 20 Governance structure under auspices of

Patient First transformation Board defined.

Tracking of patient experience and complaints

via Board sub-committees

3 4 12 3 x 3 = 9 Output of work to date presented

to Board seminar- September

2015


Reporting.

C1 COO Failure to reach consensus on system wide

service model with partners.

4 4 16 Ongoing engagement with our commissioners

through Coastal Cabinet to ensure success of

integrated work streams including the Lead

Provider development.

Manage Divisional unscheduled care

programmes to improve access and

discharge arrangements.

Coastal Cabinet and Single Performance

Conversation (SPC) meeting papers.

Review of Annual Plan progress at Divisional

Integrated Performance Review Panel and

Board meetings.

Demand and acuity remains high risk.

3 4 12 3 x 4 = 8

1. Principals of NEL Model

agreed and Vanguard Bid

cemented

2. Elective strategy agreed with

Commissioners and joint working

strengthened

3. Elective and Non Elective

Transformation Programmes

established

Through Quality and Risk Committee Q1

and Q4 if required.

C2 CD Failure to be named as Lead Provider for MSK

services and/or failure to deliver service

redesign in a sustainable way.

5 4 20 On going engagement with partners to

redesign pathways

Internal engagement with clinical leads to

ensure care pathway design is robust and

successfully integrated with WSHT services.

Ensuring channels of communication remain

open with Stakeholders nd Partners

Reporting to Executive Team on progress

and developments in the bid as it is

developed. (+)

Reporting to Finance and Investment

Committee. (+)

Legal Advice Taken.

3 4 12 3 x 4 = 12 Named as Most Capable

Provider. Contract negotiations

progressing.

To Board as required Q1, Q2, Q3, Q4.

C3 MD Failure to deliver a new radiotherapy

treatment facility at St Richards Hospital

4 4 16 Regular Board updates on progress in

partnership arrangements

negotiations on-going and being

reported via Board

2 4 8 2 x 4 = 8 Q1. Finalise Heads of Terms and

agree implementation with

partners.

To Board Q2 and Q4 if required

C4 COO Failure of Partners to support system wide

delivery arrangements

4 4 16 Internal working group established 3 4 12 2 x 4 = 8 7 Day whole system development

agreed as priority for Coastal

Executive

Q1. Establish wider governance

arrangements

Through Quality and Risk Committee Q1

and Q4 if required.

D1 CEO Failure to implement an appropriate

Governance and Delivery Structure for the

Patient First Programme Board

3 4 12 Interim Structures agreed 3 3 9 3 x3 =9 Q1 : formation of workforce

transformation Board.

Transformation Board

established. Additional PMO

support sourced and regular

reporting to F&I established


Reporting.

D1a DOLD Failure to deliver on programmes of work

reduces affordable capacity and impacts on

patient care and sustainability

4 4 16 Structured reporting to Board on workforce

issues

4 4 16 3 x3 =9 Q2. Workforce Transformation

Programme


Reporting.

738 : 516 : 735

Strategic Objective : (B3) : Delivering Reliable Care

Strategic Objective : B5 : Improving the Patient Experience

Strategic Objective : (C3) : Deliver improved Cancer pathways for our population through working with our tertiary partners

Patient First Strategic Theme : Delivery and Sustainability

Strategic Objective : (B4) : Deliver quality Improvements internally and as agreed in partnership with our local Clinical Commissioning group - Deliver CQUIN

Patient First Strategic Theme : Partnerships

Strategic Objective : D1 Formation of Patient First Board

Strategic Objective : (C1) : In partnership with our local Clinical Commissioning Group develop our lead role in the local health economy for unscheduled and planned care pathways

Strategic Objective : (C2) Develop and redesign our MSK pathways in response to CCG specification

Strategic Objective : (C4) : Implementing Seven Day Working

Strategic Objective : D1 (a) Maximise Workforce Capacity through a dedicated programme management approach

Page 2 of 3

D1b COO Failure to agree Elective care Strategy

impacts on patient care and efficiency of the

Hospitals

4 4 16 Preparation for planning event underway 3 4 12 3 x 4 = 12 Q1 : planning event with key

stakeholders

All on track

Q2 Agree Elective Strategy


Reporting.

D1c COO Failure to deliver benefits of new Emergency

floor and implement similar at SRH

3 4 12 Emergency Floor operational on-time 3 3 9 3 x3 =9 WH model and impact

assessment informing SRH

development


Reporting.

D1d CD Clinical model fails to deliver patient benefits

and required efficiency

4 4 16 Business case well developed Detailed work on-going as part of

FBC development.

3 4 12 3 x3 =9 Detailed design work underway.

Full Business case due to Board

end of November.

Through Finance and Investment

Committee Q2 and Q4 if required.

D1e COO Failure to implement improvements impacts

on patient experience, patient flow and

efficiency.

3 4 12 Work on programme to deliver new service 3 3 9 3 x3 =9 Through Quality and Risk Committee Q1

and Q4 if required.

D2 (a,b) MD Insufficient clinical engagement and/or

management focus compromises scale and

pace of delivery.

4 4 16 Executive led delivery meetings in place and

regular reporting on progress.

Reports to Executive Team on progress and

developments (+)

3 4 12 3 x 4 = 12 Through Quality and Risk Committee Q2

and Q4 if required.

D3 CD Inappropriate or insufficient focus and

resourcing causes us to fail to deliver growth

in market share in private patient, and in other

areas of opportunity. Market share may also

reduce as a result of lack of focus, leading to

reduced levels of financial contribution.

4 4 16 Commercial Director appointed to manage

commercial agenda.

Resources approved to support private

patient strategy.

Creation of Joint Private Practice Committee.

Improved process to perform competitor and

market analysis in place.

Efficiency programme monitoring of both

private patient and commercial opportunity

agenda. (+)

Joint Private Practice Committee minutes. (+)

Reports to Executive Team. (+)

Reports to Finance and Investment

Committee. (+)

Provide regular reporting on Private

Patient Activity to F and I Committee.

Lack of Market Share Analysis.

Capacity Issues

3 4 12 3 x3 =9 local LIFT company engaged to

explore investment appetite.

Specialist advice sought.

Other funding routes being

actively pursued.



D4(a) COO A mismatch between demand and capacity

leads to access targets not being met

4 4 16 Ongoing engagement with our commissioners

through Coastal Cabinet to ensure success of

integrated work streams including the Lead

Provider development.

Reporting to Coastal Cabinet monthly and

Clinical Commissioning Group to monitor the

delivery and effectiveness of planned and

unscheduled care demand management

schemes.

Coastal Cabinet and Service Delivery Board

meeting papers.

Daily and weekly reporting of high-risk areas.

Daily heat map reporting.

Monthly reports to the Board.

Exception reports from Directors of Clinical

Services to Chief Operating Officer.

Anticipating further operational

challenges as the Trust maintains

seasonal escalation into Q4.

System Resillience Risk Register

in place.

3 4 12 2 x 4 = 8 Daily Senior System Resilience

calls established across Local

Health Economy, on-going.

Ongoing resource requirements

agreed (Q1 and Q2).

Continued focus on mitigating

potential workforce issues that

could cause increase in risk to

successful management of

demand.

Through Board as part of monthly

reporting on performance

D4(b) CoSec Corporate Governance processes not

systematically embedded in organisation

leading to gaps in implementation and

development.

3 3 9 (i) Development of Annual Company

Secretary Work plan

(ii) Additional Resilience Development

Progress against work plan developments

reported via Audit Committee. (+)

Work embedded in routine practice. (-)

1. Resilience plans in development 2 4 8 2 x 4 = 8 Recruitment to Board

Administrator and Governance

Assistant completed. Resillience

work underway.

Through Audt and/or Quality and Risk

Committee Q2 and Q4 as required.

D5 (a) DoF Ability to manage financial pressures

generated from additional demand and deliver

productivity improvements required. Local

Health Economy Sustainability and ability of

commissioners to afford any increases in

activity above contracted levels.

4 4 16 Financial Plan reviewed at F&I and approved

at Board Service

Contract with commissioners reflects activity

plans and is transparent about collective risk

Monthly financial performance report to

Board and F&I Committee

Efficiency programme reports to F&I

Committee

Cash and Liquidity report monthly to F&I

committee

Efficiency Programme Steering group meets

weekly and reviews delivery of plans and

development of pipeline schemes to mitigate

risk

New Income / Activity reporting

developed and presented to Finance

and Investment Committee

4 4 16 3 x 4 = 12 2015/16 Contract agreed

reflecting realistic activity levels.

Financial Sustainability rating 3

delivered Q2

Through Board and Finance and

Investment Committee as part of monthly

Finance reports

D5 (b) DoF Failure to deliver efficiency programme 4 4 16 Programme Management Office recruited to. All PIDs have a Quality Impact Assessment

which is formally tracked via the efficiency

steering group.

3 4 12 3 x 4 = 12 Workforce Transformation Lead

now in place, will provide

additional support to workforce

programmes.

Through Board and Finance and

Investment Committee as part of monthly

Finance reports

D6 DoF Slippage against agreed Capital Programme

and/or in-year investment requirements

exceed available resources.

4 4 16 Embedding of new Governance arrangements

for Capital Investment Group

development of on-going monitoring and

reporting mechanisms.

Capital Programme remains over-

programmed and is being mange to available

resource.

3 4 12 3 x3 =9 2015/16 Plan Approved Through Finance and Investment


461 : 621

D7 DoF Lack of identification of key Estate issues that

may impact implementation of clinical strategy

3 4 12 Enhanced arrangements through Capital

Investment group Routine reporting via Finance and Investment

Committee

Plan approved 2 3 6 3 x3 =9 Estates Strategy Overview to be

presented to October Board



Strategic Objective : D1 (c) Review of Non Elective pathways (patient flow)

Strategic Objective : D6 : Delivery of Capital Programme within resources available and on time to maintain Assets and Service Improvements.

Strategic Objective : D7 : Refresh of Estate Strategy

Strategic Objective : D1 (b) Develop Elective Care Strategy

Strategic Objective : D5 : Maintain a minimum Continuity of Service Rating of 3

Develop Southlands Hospital including relocation of Ophthalmology services

Strategic Objective : D1 (e): Implement improvements in Endoscopy services

Strategic Objective : D2 To refresh the clinical services strategy

Strategic Objective : D3 Exploit the Trust's commercial opportunities, including Any Qualified provider tenders and Private Patient activity, to support our core NHS business

Strategic Objective : D4 Maintain an acceptable Monitor Governance Rating throughout the period

Page 3 of 3

Quarterly BAF Monitoring 2015-16 to Quarter 3 Appendix 2 Ref Lead Mitigated Risk Values

Target Risk

Score

Score at 1st Apr 15

Q1 Q2 Q3

Q4

Patient First Strategic theme : Our People

Strategic Objective Principle Risk

A1 (a,b) DNPS Improve the overall experience that patients receive from the Trust

We incur adverse feedback regarding patient experience from our patients and the public and media.

9 12 12 12 12

A2(a,b) DODL Continue to develop and deliver leadership development programmes in order to improve patient experience

Ongoing delivery of accredited programmes Working with partners to develop further appropriate programmes to support our priorities

9 9 9 9 9

A3 CEO Continue to develop and deliver standardised service improvement methodologies programmes across the Trust in priority areas

Inappropriate or insufficient focus and resourcing causes us to fail to deliver the appropriate pace and scale of improvements to underpin the Patient First Transformation programme.

9 8 8 8 8

Patient First Strategic theme : Quality Improvement


B1 (a,b,c)

MD Reducing Mortality and Improving Outcomes

We fail to implement care pathways adequately in order to improve mortality

12

12 12 12 8

B2 (a,b,c)

DNPS Delivering Safe, Harm Free Care Patients receive below standard care resulting in avoidable harm

8 12 12 12 12

B3 (a) MD Delivering Reliable Care Failure to deliver improvements in stroke services

12 12 6 6 6

B3 (b) DNPS Delivering Reliable Care Failure to implement our Dementia Strategy 8 8 8 8 12

B4 MD Deliver quality Improvements internally and as agreed in partnership with our local Clinical Commissioning group - Deliver CQUIN

We fail to programme manage the quality improvements relating to CQUIN

9 8 8 8 8

Target Risk

Score

Score at 1st Apr 15

Q1 Q2 Q3 Q4

B5 MD Improving the Patient Experience Failure to improve the patient experience in Outpatients through transformational change programme

9 12 12

12

12

Patient First Strategic theme : Partnerships


C1 COO In partnership with our local Clinical Commissioning Group develop our lead role in the local health economy for unscheduled and planned care pathways

Failure to reach consensus on system wide service model with partners.

12 16 12 12 12

C2 CD Develop and redesign our MSK pathways in response to CCG specification

Failure to be named as Lead Provider for MSK services and/or failure to deliver service redesign in a sustainable way.

12 16 12 12 12

C3 MD Deliver improved Cancer pathways for our population through working with our tertiary partners

Failure to deliver a new radiotherapy treatment facility at St Richards Hospital 8 8 8 8 8

C4 COO Implementing Seven Day Working Failure of Partners to support system wide delivery arrangements

12 16 12 12 12

Patient First Strategic theme : Delivery and Sustainability


D1 CEO Formation of Patient First Board Failure to implement an appropriate Governance and Delivery Structure for the Patient First Programme Board

9 9 9 9 9

D1a DOLD Maximise Workforce Capacity through a dedicated programme management approach

Failure to deliver on programmes of work reduces affordable capacity and impacts on patient care and sustainability

9 12 16 16 16

D1b COO Develop Elective Care Strategy Failure to agree Elective care Strategy impacts on patient care and efficiency of the Hospitals

12 12 12 12 12

D1c COO Review of Non Elective pathways (patient flow)

Failure to deliver benefits of new Emergency floor and implement similar at SRH

9 9 9 9 9

D1d CD Develop Southlands Hospital including relocation of Ophthalmology services

Clinical model fails to deliver patient benefits and required efficiency

9 12 12 12 12

Strategic Objective Principle Risk Target Risk

Score

Score at 1st Apr 15

Q1 Q2 Q3 Q4

D1e COO Implement improvements in Endoscopy services

Failure to implement improvements impacts on patient experience, patient flow and efficiency.

9 9 9 9 9

D2 (a,b)

MD To refresh the clinical services strategy Insufficient clinical engagement and/or management focus compromises scale and pace of delivery.

12 12 12 12 12

D3 CD Exploit the Trust's commercial opportunities, including Any Qualified provider tenders and Private Patient activity, to support our core NHS business

Inappropriate or insufficient focus and resourcing causes us to fail to deliver growth in market share in private patient, and in other areas of opportunity. Market share may also reduce as a result of lack of focus, leading to reduced levels of financial contribution.

9 12 12 12 12

D4 (a) COO Maintain an acceptable Monitor Governance Rating throughout the period

A mismatch between demand and capacity leads to access targets not being met

8 12 12 12 12

D4 (b) CoSec Maintain an acceptable Monitor Governance Rating throughout the period

Corporate Governance processes not systematically embedded in organisation leading to gaps in implementation and development.

8 8 8 8 8

D5 (a) DoF Maintain a minimum Continuity of Service Rating of 3

Ability to manage financial pressures generated from additional demand and deliver productivity improvements required. Local Health Economy Sustainability and ability of commissioners to afford any increases in activity above contracted levels.

12 16 12 12 16

D5 (b) DoF Maintain a minimum Continuity of Service Rating of 3

Failure to deliver efficiency programme 12 16 16 16 16

D6 (a) DoF Delivery of Capital Programme within resources available and on time to maintain Assets and Service Improvements.

Slippage against agreed Capital Programme and/or in-year investment requirements exceed available resources.

9 12 12 12 12

D7 DoF Refresh of Estate Strategy Lack of identification of key Estate issues that may impact implementation of clinical strategy

9 6 6 6 6

This report can be made available in other formats and in other languages. To discuss your requirements please contact the Company Secretary on 01903 285288.

To: Trust Board


Title

Quarterly Submission to Monitor – Quarter 3 (2015/16)


Marianne Griffiths, Chief Executive

Prepared by

Andy Gray, Company Secretary

Status

Disclosable

Summary of Proposal

The Board is required to approve the Quarterly Self-Assessment prior to submitting to Monitor. Monitor will assess the trust’s performance for the last quarter and will discuss any issues in a review meeting the date of which is to be confirmed.


No direct implications – the report seeks assurance that quality of care standards are maintained.


Links to key objectives of (i) Maintain an acceptable financial risk rating; (ii) Maintain a Monitor Governance rating of no worse than Amber Green throughout the year.


No direct implications – the report seeks assurance that the financial plan is maintained going forward.


N/A

Recommendation

The Board is asked to APPROVE the submission.


To public Board meeting.

Appendices

1: Internal checklist.

2: Governance submission.

To: Board of Directors Date: 28 January 2016

From: Andy Gray, Company Secretary Agenda Item: 14

FOR DECISION

QUARTER 3 2015/16: MONITOR QUARTERLY SELF ASSESSMENT

1. INTRODUCTION

1.1 The Board of Directors is asked to review the Trust’s performance as presented and the attached self-certification checklist attached at Appendix 1. The Board is asked to note the statement at Appendix 2 which is required to be signed by the Chair and Chief Executive.

1.2 The Board should note that following the Quarter 2 submission Monitor rated the

Trust as having (i) a Financial Sustainability Rating of 3 and (ii) A Governance Risk Rating of ‘Under Review’ ; Requesting further information”.

1.3 Monitor advised that “The trust has been assigned an ‘Under Review’ governance rating and a FSSR of 3 but has FSRR metrics of 2 on the following measures of financial robustness and efficiency underlying the financial sustainability risk rating: capital service coverage and income and expenditure (I&E) margin.

2 SUMMARY OF SUBMISSION 2.1 The return covers the period 01 October 2015 to 31 December 2015. In making

this return, the Board of Directors is considering performance against the Annual Plan for 2015-16, derived from the Operational Plan submitted to Monitor. The Board should note that the Trust is declaring non-compliance against Referral to Treatment Targets.

2.2 In signing the Financial declaration the Board is not confirming that it anticipates that the trust will continue to maintain a Financial Sustainability Risk Rating (“FSRR”) of at least 3 over the next 12 months. The declaration, at Appendix 2, states the reasoning for this.

3 RECOMMENDATION

3.1 The Board is asked to APPROVE the submission to Monitor.

Appendix 1

Monitor Quarterly Reporting Exception Checklist The following checklist is taken from the Compliance Framework (note that this has not been updated into the 2013 Risk Assessment framework which supersedes the Compliance Framework) FOR THE PERIOD 1 October 2015 to 31 December 2015

Lead Quarter 3 2015/16

Finance / KG Unplanned significant reductions in income or significant increases in costs

No. Appropriate notifications to Monitor re changes in plan.

Finance / KG Requirement for additional working capital facilities

No

Finance / KG Failure to comply with the NHS Foundation Trust Annual Reporting Manual

No

Finance / KG Discussions with external auditors which may lead to a qualified audit report

No

Finance / KG Transactions potentially affecting the financial risk rating and/or resulting in an ‘investment adjustment’

No

Governance/AG Removal of director(s) for significant contractual or non-contractual dispute with another NHS body

No

Finance / KG Adverse report from internal auditors No

Governance/AP Risk of failure to maintain registration with the Care Quality Commission

CQC comprehensive Inspection during December 2015. Report awaited. No significant issues raised at the time.

Governance /AP/AG

Significant third party investigations that suggest material issues with governance e.g. fraud or Care Quality Commission reports of ‘significant failings’

No

Governance/AP Care Quality Commission responsive or planned reviews

Neonatal themed review undertaken as a part of the comprehensive inspection. No significant issues raised

Governance/AP Outcomes or findings of Care Quality Commission responsive or planned reviews

Awaiting formal feedback

Governance/No Other patient safety issues which reflect quality governance issues (e.g. serious incidents)

None identified. All SIRS’s investigated and submitted within time frames . One Never event submitted in October - Positive feedback to the investigation report received from CCG and CQC

Finance / KG Performance penalties to commissioners

All Enforcement notices from other bodies implying potential or actual breach of any other requirement of the licence, e.g.:

o Health and Safety Executive or fire authority notices

o Material issues impacting on the trust’s reputation

o Adverse reports from overview and scrutiny committees

o Patient group and Healthwatch concerns

No No No No

Appendix 2

Worksheet "Governance Statement" Click to go to index

In Year Governance Statement from the Board of Western Sussex Hospitals

The board are required to respond "Confirmed" or "Not confiirmed" to the following statements (see notes below)

For finance, that: Board Response 4

For governance, that: 11 Not Confirmed

Otherwise: Confirmed

Consolidated subsidiaries:

Signed on behalf of the board of directors

Signature Signature

Name M. Viggers Name K Geoghegan

Capacity Chairman Capacity Director of Finance

Date Date

The board confirms that there are no matters arising in the quarter requiring an exception report to Monitor (per the Risk Assessment Framework page 22, Diagram 6) which have not already been reported.

The board anticipates that the trust will continue to maintain a Continuity of Service risk rating of at least 3 over the next 12 months.

The board is satisfied that plans in place are sufficient to ensure: ongoing compliance with all existing targets (after the application of thresholds) as set out in Appendix A of the Risk Assessment Framework; and a commitment to comply with all known targets going forwards.

Number of subsidiaries included in the finances of this return. This template should not include the results of your NHS charitable funds.

Not Confirmed

The board is unable to make one of more of the confirmations in the section above on this page and accordingly responds:

A RTT: Compliance was compromised in 2014/15 by a significant and sustained rises in demand above planned levels. In order to ensure sustainable delivery, the Trust has submitted detailed recovery plans to restore aggregate compliance. RTT completed pathways exceed the planned volumes in recovery plans, however referral demand (particularly in Urgent/Cancer) have compromised recovery as planned. In response, in September 2015 WSFHT implemented a Programme Management Office to use all NHS funded capacity (IS and NHS) through the provision of a single point of waiting list co-ordination and management for all NHS patients waiting over 18 weeks commissioned by CWSCCG.

Through this action and continued over-performance in the volume of RTT completed pathways, the Trust has seen significant reduction in the waiting list size and the backlog component from September 2015. The Trust continues to work closely with Monitor, NHSE Surrey and Sussex Local Area Team, Coastal West Sussex CCG and the IMAS 18 week Intensive Support Team.

Finance: As advised in December the trusts FSR rating has dropped from 3 to 2 at the end of Q3. While we have undertaken extensive recruitment locally and oversees significant workforce challenges remain. No new Medical engagements are outside of the national Agency Caps and we have taken robust steps towards complying with all new agency rules. All discretionary spend now requires Executive approval. We will continue to demonstrate leadership across the local health system. However, maintaining or improving the position is dependent on the management and sharing of risk across our local health economy to both minimise delays as well as enhancing system resilience during winter.

The underlying causes are consistent with those previously disclosed;

Significant levels of agency spend caused by workforce shortages across nursing and medical posts.

Workforce capacity constraints are having a knock-on effect on our ability to provide elective activity in the way we had planned to do so

The number of patients fit for discharge but unable to transfer into a community or alternative care setting has increased significantly. Despite delivering £18m Efficiency programme the issues identified above have combined to exert significant pressure on our overall financial performance. While the Board is committed to recovering the position we recognise that this is challenging and not without risk.

Documents

Meeting of the Board of Directors AGENDA – MEETING IN PUBLIC