Highland NHS Board
3 February 2009
Item 3.8
PERFORMANCE REVIEW GROUP
Report by Roger Gibbins, Chief Executive
The Board is asked to:


Note that the Performance Review Group met on Monday 5 January 2009 with attendance
as noted below.
Note the Assurance Report and agreed actions resulting from the review of the specific
topics detailed below and the Balanced Scorecard (attached).
Panel:
Mr Garry Coutts, Chair
Dr Ian Bashford, Medical Director
Mr Quentin Cox, Chair, Area Clinical Forum
Dr Roger Gibbins, Chief Executive, NHS Highland
Ms Elaine Mead, Chief Operating Officer
In Attendance:
Ms Margaret Brown, Head of Service Planning
Miss Irene Robertson, Board Committee Administrator
Apologies:
Dr Ian Bashford
Mrs Ann Bethune
Mr Stuart Caldwell
Mr Ian Gibson
Respondents:
Dr David Alston, Chair, North Highland CHP
Mr Bill Brackenridge, Chair, Argyll & Bute CHP
Ms Pam Courcha, Chair, Raigmore Hospital
Ms Sheena Craig, General Manager, North Highland CHP (videoconference)
Mr Stuart Denholm, Clinical Director, Raigmore Hospital
Ms Susan Eddie, General Manager, Raigmore Hospital
Mr Derek Leslie, General Manager, Argyll & Bute CHP (videoconference)
Mrs Gillian McCreath, Chair, South East Highland CHP
Mr Okain McLennan, Non-Executive Director, on behalf of Mrs Ann Bethune, Chair, Mid Highland
CHP
Mrs Gill McVicar, General Manager, Mid Highland CHP
Dr Eric Baijal, Director of Public Health (items 5 & 6)
Mr Jim Docherty, Clinical Lead, Day Case Centre Project (item 1)
Mrs Anne Gent, Director of Human Resources (items 2b & 2c)
Mr Malcolm Iredale, Director of Finance (item 8)
Mrs Christine McIntosh, Cancer Network Manager (item 3d)
Ms Heidi May, Director of Nursing (item 3b)
Mr Bill Reid, Interim Head of eHealth/Head of eHealth Implementation Services (item 7)
Mrs Donna Smith, General Manager, Surgical & Anaesthetics Directorate, Raigmore Hospital
(item 1)
Mrs Margaret Walker, Smoking Cessation (item 5)
Mr Andrew Ward, Commissioning Officer, Day Case Centre Project (item 1)
Working with you to make Highland the healthy place to be
1
TOPICS DISCUSSED
1) Review and Update of Assurance Report: Referral Management
 Sickness Absence
 KSF & PDP
 Waiting Times – Inpatients/Outpatients/Day Case
 Annual Review Action Plan Update
2) Overview of Balanced Scorecard:a) Delayed Discharges
b) Healthcare Associated Infection (HAI)
c) Waiting Times - Diagnostics
d) Breast Cancer
3) A&E Attendances
4) Smoking Cessation
5) Alcohol Brief Interventions
6) CHI Update
7) Finance
2
DATE OF NEXT MEETING
The next meeting will be held on Monday 2 March 2009 in the Board Room, Assynt House,
Inverness at 1.30pm.
2
IMPROVEMENT COMMITTEE – ASSURANCE REPORT
Meeting on 5 January 2009
1
TOPIC: DAY CASE CENTRE PROJECT
A dedicated day surgical facility is required to enable NHS Highland to achieve several specific performance measures and deliver on waiting
time targets. The Committee received a presentation detailing progress to date with the project and outlining the next steps.
Issues/Risks
Financial implications – ability to
deliver project within estimated
budget.
Assurance
Progress to date is in line with the
project plan and the design has
been completed in line with the
original brief.
Ongoing review and scrutiny of
costs by Asset Management.
Actions
The project to progress to the tendering stage. Action: A Ward
The Committee to be advised on progress.
Remit to Asset Management Team to manage the contingency.
Full business case to be developed for submission to NHS Highland
and the Health Department which will require to identify costs.
Action: S Eddie
2
REVIEW OF ASSURANCE REPORT
Issues considered had been identified as ‘high risk’ and likely to miss targets.
Issues/Risks
Sickness Absence
NHS Highland not on trajectory to
achieve 4% target by March 2009
Assurance
Some improvement shown in last
month’s figures, demonstrating
positive impact of interventions.
Ongoing action in the operational
units to address issues.
Actions
Develop audit approach to review and reflect on successful initiatives,
both internally and externally. Action: A Gent/GMs
KSF and PDP Implementation
Current level of recording of
PDPs is only 14%
87% of staff now have completed
KSF outlines.
Managers in conjunction with KSF Team to progress uptake of PDP.
Action: Operational Managers
3
IMPROVEMENT COMMITTEE – ASSURANCE REPORT
Meeting on 5 January 2009
2 Topic: Review of Assurance Report (cont’d)
Issues/Risks
Assurance
Waiting Times –
15 week target achieved at
inpatient/daycase/outpatients
December 2008. Congratulations
waiting over 15 weeks and 12
to everyone involved.
weeks by March 2009
Work ongoing towards meeting
Ability to sustain targets.
12 week target.
Annual Review Action Plan
To ensure implementation of
actions arising from the 2008
Annual Review
Actions
Sustainability to be discussed at the Planning Group in January 2009.
Action: GMs
TCI reports to be circulated to the Improvement Committee.
Action: M Brown
Now part of the LDP process and
will be subject to review in midFebruary 2009
Update Action Plan and inform the Committee of the outcome of the
mid-year review. Action: M Brown
3
TOPIC: REVIEW OF BALANCED SCORECARD
Issues considered had been identified as ‘high risk’ and likely to miss targets.
Issues/Risks
Delayed Discharges
Breaches of 6 week target
Assurance
North and SE CHPs reasonably
confident about meeting the
target.
Actions
Situation and actions to continue to be monitored both locally and
through the Highland and Argyll & Bute Partnerships.
Action: J Baird/GMs
Healthcare Associated
Infection (HAI):
NHS Highland is unlikely to
achieve the target of 30%
reduction of SAB by 2010, and is
not meeting trajectory figures so
far this year
The numbers of SAB remain with
projected confidence intervals.
Evidence elsewhere indicates that actions will take at least 12 months
to achieve desired outcome. Refocusing action plan on blood culture
management and undertake evaluation and comparison of outcomes
between the wards implementing the Scottish Patient Safety
Programme bundles and those where the programme has not yet
been introduced.
Breakdown of figures in each category (SAB/MRSA/MSSA) to be
provided.
Action: H May
4
IMPROVEMENT COMMITTEE – ASSURANCE REPORT
Meeting on 5 January 2009
3 Topic: Review of Balanced Scorecard (cont’d)
Issues/Risks
Assurance
Hand Hygiene – failure to achieve Training and support ongoing for
90% compliance at last audit
audit commencing 14 January
2009.
Waiting Times – Diagnostics
Diagnostic tests target not on
trajectory for March 2009
Action
Undertake a programme of activity to raise general public awareness
of hand hygiene. Action: H May
To ensure capacity across the area is maximised. Action: GMs
Overall, confident that 6 week
target will be achieved by March
2009.
Raigmore - Endoscopy capacity
issue
Short term actions being taken with capacity support from Belford.
Action: S Eddie
North CHP – Ultrasound additional staff time required
Bid to Planning Group. Action: S Craig
Breast Cancer
Improvement trend not
maintained in Quarter 3
4
Actions being taken to recover the To explore utilisation of capacity elsewhere in Highland.
Action: C McIntosh/GMs
position
TOPIC: A&E ATTENDANCES
Issues/Risks
Concerns regarding this target as
a basis on which to measure
increased self management and
primary care services
Assurance
Actions
Meeting held with Scottish Awaiting guidance from Scottish Government regarding target.
Government to identify LDP Action: M Brown
development target for 2009-10
5
IMPROVEMENT COMMITTEE – ASSURANCE REPORT
Meeting on 5 January 2009
5
TOPIC: SMOKING CESSATION
The Committee received a presentation which showcased the excellent work being undertaken in South East Highland CHP
Issues/Risks
Not achieving target
6
TOPIC: ALCOHOL BRIEF INTERVENTIONS
Issues/Risks
Not achieving trajectory
7
Assurance
Actions
Good model of practice to be Service to be remodelled to match resource to demand, in order to
achieve target by March 2010. Action: E Baijal/GMs
shared
LDP trajectory for 2009-10 to be reprofiled. Action: E Baijal
Assurance
Activity currently being measured
Actions
Update on percentage uptake and number of registrations to be
prepared for next meeting. Action: E Baijal
TOPIC: CHI
Issues/Risks
Roll out of Radiology target
Assurance
Actions
Work ongoing to achieve delivery Action Plan is being developed through LDP process 2009-10.
Action: B Reid
of target
8
TOPIC: FINANCE
The Committee received a presentation on the financial position
Issues/Risks
Achievement of savings
impact on services
Assurance
Actions
and Savings plan on target to be Impact assessment of implementation of savings plan on service
delivery required for 2008-09 and 2009-10. Action: M Iredale/GMs
achieved
Report required on development of whole systems saving plan.
Action: L Kirkland
6