Balanced Score Card
Review of July 2015 Data
Balanced Scorecard
Finance
Quality
&
Safety
Patient
Access
Human
Resource
Management
Finance
Finance Report - July 2015
• Actual outturn YTD July 2015
• Group budget €164.2m (2014 €159.9m)
• Group actual expenditure €164.1m (2014 €167.7m)
• Group actual surplus €138k ( 2014 deficit: €7.8m)
• CUH Budget €154.2m (2014:€148.6m)
• CUH /SMOH actual expenditure €154.6m (€156.0m)
• CUH /SMOH actual deficit €375k (2014 €7.4m)
• Mallow Budget €10.0m (2014:€9.7m)
• Mallow actual expenditure €9.5m (2014 €10.3m)
• Mallow actual surplus €514k ( 2014 deficit €560k)
Forecast 2015
• Group Budget €282.58m (2014 €284.9m)
• Group projected expenditure €282.2m (€284.2m)
• Group Projected Surplus €358k ( surplus 0.7m)
• CUH Budget €265.3m (2014:€262.8m)
• CUH projected actual €265.4m (€265.2m)
• CUH projected Deficit €79k (€2.4m)
• Mallow Budget €17.3m (2014:€17.5m)
• Mallow Projected Actual €16.8m (€16.8m)
• Mallow Projected Surplus €461k
CUH Summary Budget v Actual Expenditure June 2015
Pay €k Non-Pay €k Income €k Total
CUH
-106
-777
831
-52
-5
5
-0
-106
-782
836
-52
Mallow
66
-82
110
94
Total
-40
-864
946
42
SMOH
CUH-SMOH
CUH Budget v Actual Pay YTD - June
2015
2015 Actual
Budget €k €k
Variance €k % Variance 2014 Actual €k
v 2014 Variance
€k
Medical/Dental
31,818
32,095
-270
-1%
31,271
-824
Nursing/Midwifery
43,227
43,834
-607
-1%
44,018
184
Paramedical
15,969
15,925
44
0%
15,968
43
Housekeeping
5,984
6,598
-614
-10%
6
-240
Catering
1,972
1,970
2
0%
2,065
96
Portering
3
2,878
65
2%
3,011
133
Administration
8,837
8,908
-71
-1%
8,889
-19
Other Staff
1,736
2
-103
-6%
1,751
-88
-1560
-1%
113,330
-716
Total
112,486 114,047
CUH Actual Non-pay Expenditure €k YTD
July 2015 v 2014
CUH Group –Surplus / (Deficit) percentage %
CUH Debtor days – July 2015
CUH AGENCY COSTS €k 2013 – July 2015
CUH Agency Costs – June 2015
CUH Average Nursing & HCA Agency WTE’s per Week 2013-15
CUH Average Specials /Other Nursing & HCA Agency WTE’s per Week 2014-15
Cost Containment Plan
Patient Income 2013 – July 2015
Mallow Budget v Actual YTD June 2015
Budget €
Pay
7,530
Non Pay
2,149
9,679
Income
-1,113
Total
8,566
Actual € Variance €
7,485
45
2,436
-287
9,921
-242
-1,788
675
8,134
433
% Variance
0.60%
-13.40%
-2.50%
60.70%
5.00%
Patient Access
CUH Weekly INMO Trolley Report
Week ending 14th August 2015
Daily Trolley Numbers – June – August 2015 (23/8/2015)
Ambulance Turnaround Times (June)
ED – 6hr & 9hr Target
(9hr – 77.4% - 6hr – 59.6%)
(17th August)
R
Delayed Discharges - 2015
January – August (18th August)
30
24
25
23
22
21
20
18
1514
0
18
17
18
17
14
15
17
14
13
16
13
12
11
10
5
22
20
19
15
10
20
19
18
17
17
21
10
12
Inpatient – Day case Waiting Lists
Total Waiting List – 14/08/2015
Wait category
0-3 Months
3-6 Months 6-8 Months 8-12 Months 12-15 Months 15-18 Months 18-24 Months 24-36 Months Grand Total
ACTIVE
383
221
75
142
77
67
31
1
997
PREADMIT
176
41
10
7
3
3
6
1
247
SUSPENSION
40
4
2
3
2
1
599
266
85
151
83
72
38
2
1296
ACTIVE
206
104
33
68
21
10
3
1
446
PREADMIT
107
28
1
7
SUSPENSION
17
1
52
2
145
1
19
330
132
35
75
22
12
3
1
610
929
398
120
226
105
84
41
3
1906
18 Month Breaches (54)
18 Month Breaches by Speciality
30
30
25
20
15
10
6
4
5
4
3
2
2
1
1
1
0
G Fulton
B O'Reilly
C Burke
M Hewitt
J Coulter
P Kelly
Vascular
Gynae.
Gynae.
Gynae.
Gynae.
Cardiology
C Brady
E Andrews
M McCourt
P Redmond
Gen Surgery Gen Surgery Gen Surgery Gen Surgery
15 Month Breaches - December 2015 (313)
7
Cardio Th
10
Cardiology
11
Pl Surgery
51
G Surgery
3
Respt
15
Urology
1
N/Surgery
73
Vascular
142
Gynae
0
20
40
60
80
100
120
140
160
15 Month Breaches by Specialty
Outpatient Waiting Lists
Patients in breach of the 18m deadline- 30th June
Patients Currently in Breach 0f 12mth Target
Medical Patients to be seen by the 31/12/2015 (1,382)
Surgical Patients to be seen by the 31/12/2015 (5,244)
Women and Children Patients to be seen by the
31/12/2015 (2,329)
Scope Waiting List
Scopes Routine – June 2015
R
Medical ALOS
(June Dashboard)
G
New Patients Treated with Radiation Oncology - July
2015
Reason for Treatment Delay - July 2015
Quality & Safety
Time to Surgery
(June Dashboard)
G
ALOS – Excluding LOS over 30 days
(June Dashboard)
G
Cancer KPI – Breast-Lung-Prostate -Jan – July
Serious Reportable Events (SRE’s)
11 SREs communicated in 2015
7 communicated in July & August
• 3 environmental events
• serious disability for patient associated with a fall whist
in hospital
• 3 care management events
• Maternal death, serious disability associated with a
diagnostic error & stage 3 pressure ulcer after
admission
• 1 surgical event
• Unintended retention of a foreign object post surgical
procedure
Reportable Events
Re
Reportable Events
portable Events
Patient Experience - Complaints
Complaints received - July 2015
9
• Safe and Effective Care
6
• Access
2
• Dignity and Respect
2
• Communication and Information
1
• Accountability
1.73% of complaints investigated within 30 working days
Patient Experience - Complaints
1
3
Alleged
inappropriate
behaviour
Appointment
5
Treatment and
Care
1
Delivery of
Care
1
Accessibility
/ Resources
1
2
Admission
Medication
1
Hygiene
1
Parking
1
1
Communicatio
n Skills
Human
Resources
Risk Register
Risk Register update in June 2015
49 Open Risk Assessments on register
• Update & amendments made to 11 risk assessments
• Closed 6 previously identified risks - CUH 16, CUH 31,
CUH 44, CUH 45, CUH 46, CUH 49
• Reopened 1, CUH 39 - Theatre Staffing
• Four new risks identified CUH 52, CUH 53, CUH 54, CUH
55
• 6 risk assessment escalated to CEO South / South West
Hospital Group for consideration of additional controls
• CUH 17, CUH 39, CUH 52, CUH 53, CUH 54, CUH 55
Reducing Healthcare Acquired Infection (MRSA)
(June Dashboard)
G
Reducing Healthcare Acquired Infection- C diff
(June Dashboard)
G
Reducing Healthcare Acquired Infection
(June Dashboard)
G
National Early Warning Score
National Early Warning Score programme extending to include sepsis
recognition and treatment
•National sepsis screening tool and pathway
•Implementation on implementation
•Audit results indicate a decrease in compliance - a number of measures identified
for improvements
•Mandatory online education nurses, NCHDs and consultants- you must do it
to work here
•Commitment that NEWS score will be used in all patient handover e.g. ward,
virtual hospital, bed management
•Commitment to ISBAR
•Support for an electronic tool
Irish Maternity Early Warning Score - New Modified IMEWS Chart rolled out
in CUMH, ISBAR sticker for IMEWS developed and in use
NEWS Implementation
(June Dashboard)
G
IMEWS Implementation
(June Dashboard)
G
HIQA Reports - Portlaoise
Presentation at EMB and Executive Quality & Safety Committee
Self assessment report submitted against S/SWH Group template
• Filling of permanent Director of Midwifery post, Clinical
Director post and experience Risk Manager post
• Critical Care Capacity
Human Resource Management
Sick Leave – July 2015
6.0%
5.06%
5.0%
4.45%
4.39%
4.0%
3.5%
3.5%
3.5%
3.5%
3.5%
3.5%
Gen. Support
Other
3.08%
3.0%
2.40%
2.0%
1.51%
1.0%
0.0%
Med/Dent
Nursing
H & SCP
Man. Admin
Staffing & Costs
EWTD Compliance
Capital Projects
Project
Status
MRI Unit
Paediatric Unit
Completed and operational
Phase 1 - build programme commenced in July
Phase 2 – submitted for capital funding
Mental Health Unit
Acute Medical Assessment Unit – Phase 3
& Endoscopy Unit
Completed and operational
Completed and operational
Radiation Oncology Unit


Cystic Fibrosis/ Respiratory Ward
Ward refurbishment completed – operational from October
Blood Sciences Project
Design Team appointed – request for managed service approved
Oncology Service



Planning permission granted
Enabling works to commence in November 2015
Expansion of Day Unit – plan signed off – submitted for
Philanthropic funding (ACT)
Refurbishment of Ward 2D – capital funding in place
Medical Oncology Centre – developing Statement of Need
Ophthalmology Transfer – phase 2
Project group in place
Helipad
Interim helipad in place - final solution being assessed by CAA.
Step Down Unit
Discussion has commenced on Procurement Process
Key Issues
• Recruitment of Nursing staff – 31 beds closed
• Recognition of Budgetary performance
• Dependency on patient income
• 2016 Estimates
• Undergraduate Training costs - €6.5m per annum
• Management of Unscheduled Care
Implementation of Change Programme Initiatives
• Scheduled Care
Implementation of plan to meet waiting list targets –Hospital
Group approach to maximise capacity