Board of Directors Meeting in Public 30 October 2014 Board of Directors’ Meeting - In Public
30 October 2014 at 9:00am
Education Centre
AGENDA
Item
Item
No.
14.214
Outcome
Report type
Apologies for absence
Note
Verbal
14.215
Declarations of interest
Note
Verbal
14.216
Minutes of public Board meeting 30 September 2014
Approve
Enc 01
14.217
Matters arising from public Board meeting 30 September 2014
Note
Verbal
Quality Report
Note
Vin Diwakar, Chief Medical Officer and Michelle McLoughlin, Chief
Nursing Officer
Performance Report
Note
David Melbourne, Deputy Chief Executive & Chief Finance Officer
Resources Report
Note
David Melbourne Deputy Chief Executive & Chief Finance Officer
and Theresa Nelson, Chief Officer for Workforce Development
Strategy
Enc 02
Reflection and Review of our IT Strategy
Adam Carson, Associate Director, ICT & PMO
Transforming our Pathways of Care
David Melbourne, Deputy Chief Executive / Chief Officer for
Finance, Nick Barlow and Lucas Mol, Newton
Executive Update and Issues
Note
Presentation
Note
Enc 05
Presentation
Chief Executive’s Report
Sarah-Jane Marsh, Chief Executive
Chairman’s Report
Christine Braddock, Chair
Note
Verbal
Note
Verbal
Note
Verbal
Quality & Resources
14.218
14.219
14.220
14.221
14.222
14.223
14.224
Enc 03
Enc 04
AOB
14.225
Questions from members of the public
BREAK 10.25 – 10.40
Next meeting of the Board of Directors: 27 November 2014, TBC
UNCONFIRMED
Item 14.216 Enc 01
BOARD OF DIRECTORS MEETING
Minutes of the meeting held in public on 30 September 2014 at 09.00
in the Education Centre, Birmingham Children’s Hospital
Present
Attending
Ref.
14.188
Christine Braddock
Keith Lester
Sarah-Jane Marsh
Vin Diwakar
Jon Glasby
Colin Horwath
Michelle McLoughlin
Tim Atack
David Melbourne
Theresa Nelson
Judith Smith
Roger Peace
Elaine Simpson
Matthew Boazman
Deborah Bannister
Rebecca Alton
CB
KL
SJM
VD
JG
CH
MM
TA
DM
TN
JS
RP
ES
MB
DB
RA
Chairman – Chair for the meeting
Non-Executive
Chief Executive Officer
Chief Medical Officer
Non-Executive Director
Non-Executive Director
Chief Nursing Officer
Chief Operating Officer
Deputy CEO and Chief Finance Officer
Chief Officer for Workforce Development
Non-Executive Director
Non-Executive Director
Non-Executive Director
Director of Strategy and Planning
Interim Company Secretary
Executive Assistant to the Chairman, NEDs and Governors
Item
Action
Apologies for absence
No apologies for absence
14.189
Declarations of interest
There were no declarations of interest.
14.190
Minutes of the Board meeting held in public on 31 July 2014
The minutes of the meeting held in public on 31 July 2014 were agreed as an accurate record,
subject to removing Judith Smith from being in attendance.
14.191
Matters arising from the Board meeting held in public on 31 July 2014
There were no matters arising not covered by the agenda.
14.192
Chairman’s Report
CB reported verbally as follows:
•
Joint development with the Birmingham Women’s Hospital (BWH)
A number of meetings have been held looking at how the development will move forward
and a lot of progress has been made. The joint development will come up through the
business of the meeting today.
•
University Hospitals Birmingham NHS Foundation Trust (UHB)
We have also been engaged quite heavily with UHB and BWH, in terms of looking at interconnections and work we can do together. We are now involved in a transport
Page 1 of 10
UNCONFIRMED
Item 14.216 Enc 01
Ref.
14.193
Item
infrastructure development around the Edgbaston site. A lot of work has been undertaken,
particularly trying to get the LEPS involved in understanding the implications of the
transport infrastructure.
•
InTent
This event which focussed on ‘Caring for Team BCH’ was hugely successful and was well
attended by a good cross section of trust staff. SJM will discuss in more detail.
•
AGM
One of the outcomes from the AGM in July was that the governors identified they wanted
to host an informal session to look at their own development and their priorities going
forward. This informal session took place on 18 September 2014 and a list of priorities have
been identified. An Away Day is likely to be arranged for the governors before the end of
the year. The governors are keen to get involved as they still do not feel as involved as they
could be.
•
Well Led Board
Over the summer, the board have moved forward with the self-assessment process and
well led board development. Deloitte have now been appointed to work with us to
complete the full process. They are clear that we are looking for an innovative and
developmental review with the clear aim of improvement in the future. Once the review
starts in January, it will take about 8 weeks to complete, depending on Deloitte’s access to
the right people and documentation.
The Board noted the verbal report.
Chief Executive’s Report
SJM reported verbally as follows:
•
InTent week – ‘Caring for Team BCH’
The idea behind the theme for InTent week came from the fact that we know the hospital is
busier than ever before and this will continue into the future. We are reliant on staff
working very hard day in day out to deliver our services. We need to help to support our
staff to be as resilient as they possibly can, not just in the face of increased activity but also
in the face of the complexity of some of the children we look after. We wanted to do this in
practical ways so we; held focus groups for any members of staff, obtained input from an
organisation called Chimp Management, held a leaders day and human factors training.
The week was well received. 900 staff took part in the focus groups and 120 staff came to
the leaders day. There have been some lovely stories since of people putting the things
they had learnt into action, for example the theatre team are undertaking the 30 day
appreciation challenge.
The staff were challenged to think for themselves differently and not to wait for
Page 2 of 10
Action
UNCONFIRMED
Item 14.216 Enc 01
Ref.
Item
management before putting good ideas into action.
JS commented that she was encouraged by the next generation of consultant staff getting
enthused about human factors. JG commented on the atmosphere which was warm,
engaged and relaxed. People were talking about small things that were making a big
difference, which was quite humbling. TN added that there had been a real emphasis on
the staff taking care of themselves as a precursor to taking better care of patients.
A focus next year will be on trying to engage with the staff that did not attend InTent this
year to try and achieve even greater participation.
•
Internal Visits
Lord Warner attended InTent week to look at how we engage with our staff. He is currently
reviewing safeguarding and visited our Emergency Department and talked to staff there
about the Multi-Agency Safeguarding Hub and how we approach safeguarding in the
hospital. He spoke to MM and SJM about some of our ideas as to how we move the
governance around safeguarding forward. It was good opportunity to influence some of
things he might say around health in his review.
•
Una O'Brien, Permanent Secretary of the Department of Health, visited to look at staff
engagement and complaints. SJM was also able to discuss funding of the new hospital
project and how we have been able to identify alternative funding streams. She was able
to discuss what help and support the DoH might be able to provide.
•
Lord Willis is currently reviewing the shape of caring on behalf of NHS England, which is
particularly focused on nursing from education onwards. He is looking into how we get the
workforce we need for the future (the next 10 to 15 years). He met with a whole range of
staff and got to test out some of his ideas on them. His report will be published in February
2015.
•
•
External Visits
Vitality Partnership. DM and SJM visited the Vitality Partnership, a GP partnership
operating in the West Birmingham area to look at ways of delivering primary care. It
provided an opportunity to think about how we might develop some links, especially
around the new hospital development and CAMHS. It also allowed us to consider how the
shape of primary care might change across Birmingham.
Royal Orthopaedic Hospital (ROH). SJM went on a partnership visit to ROH to discuss
where they see themselves in 5 – 10 years time. The main players in specialised services in
Birmingham are endeavouring to strategically come together on the same campus site but
ROH are not part of that group. ROH have significant service overlap with us and UHB and
we need to consider how this can work best in the future.
Page 3 of 10
Action
UNCONFIRMED
Item 14.216 Enc 01
Ref.
Item
•
Events
•
National Conference on Paediatric Palliative Care Systems. People from all over the country
came to look at the systems and processes we use to plan around palliative care, and also
the emotional well being of staff who deliver that service. Over 100 people were involved
in this conference which took place last week.
•
Annual Memorial Walk and Picnic at the National Memorial Arboretum
•
KIDS 5th Birthday Party
•
‘All About Play’ launched
•
Opening of new Ward 9, which has been refurbished at a cost of around £350,000 over the
summer
•
Flu Campaign launched. Last year 86% off staff had the flu jab, which was one of the highest
percentages in the NHS. It is important for us to protect ourselves and the children who
cannot protect themselves. This campaign is going to be heavily pushed again this year and
we are aiming to beat the % of our staff who were immunised last year. It is not just about
the staff in patient facing roles, every member of staff is always two steps removed from a
patient.
The Board noted the verbal report.
STRATEGY
14.194
Monitoring Mortality at BCH
JM presented to the Board.
Mortality is monitored to:
• Enable us to measure the quality of care we deliver.
• Enable comparison between institutions.
• Help us to learn as individuals, as department and as an organisation.
There is no perfect way of monitoring mortality, particularly in a children’s hospital. There are
a relatively small number of deaths at BCH and we look at them in a number of different ways,
including:
•
•
•
•
•
Absolute number of deaths
Deaths per 1000 admissions
PICANet Data (PICU Deaths only)
Cumulative sum charts
Hospital Standardised Mortality Ratio (HSMR)
At BCH we investigate all deaths individually anyway. The figures above can act as triggers and
Page 4 of 10
Action
UNCONFIRMED
Item 14.216 Enc 01
Ref.
Item
allow us to be able to cross check / triangulate any potential difficulties.
Absolute number of deaths and Inpatient Deaths/1000 Admissions
This looks at crude mortality and is very basic. There are no adjustments to the data to take
into account specific factors such as co morbidities. The only adjustment that can be made is to
standardise the data to link the number of deaths per 1000 admisisons.
PICU Deaths
In PICU there is a more complicated way of looking at mortality. Data is collected on every
patient that is treated in PICU, using PIM2r. This data collected on first contact and includes:
• A number of clinical metrics, to give an idea of how sick the patient is when they arrive
• Reason for admission and whether it is elective
• High and low risk diagnoses
The data is submitted to PICANet to produce an annual report. This data is collated into charts
and graphs, which enables us to compare ourselves with other units.
In the most recent annual report, it is clear that we are the biggest single intensive care unit in
the UK. If the hospital is plotted on the graph below the line, this represents an excess of
survivors. If it sits above the line, there is an excess of deaths. With appropriate adjustment,
BCH sits within the funnel plot.
There are a number of problems:
• A report is only produced annually
• 30% of deaths occur on wards, so PICANet only looks at 70% of our deaths
• It only looks at the patient on first PICU contact. PIM data does not tell us if we managed
these patients appropriately before PICU admission.
Cumulative Sum Charts (CUSUM)
CUSUM charts provide real time data. These charts are replicated in the quality report. The
black line on the graph represents cumulative excess deaths and the purple line represents
cumulative excess survivors. If the black line starts to climb, this indicates that more patients
are dying then we would expect.
The risk adjusted models that we use change over time. PIM2r has been mentioned, but we are
now actually onto PIM3r, which has been risk adjusted to take into account the developments
and improvements in care. There are some patients that we would expect to survive today that
would not have survived five years ago.
This data is monitored in real time, so we have a much earlier warning if there are any
concerns. If there is a spike in the data, this can trigger an investigation but it may also mean
that the tool needs to be re-calibrated.
CB asked about palliative care and where the statistic sits if the patient dies at home or in a
hospice. MM commented that if the child or young person dies in their own home, it will come
under the community data although there will be a link through to us. VD commented that in
the individual reports of every patient who had died, we looked into whether the patient was
appropriately offered palliative care.
Cardiac Deaths
Page 5 of 10
Action
UNCONFIRMED
Item 14.216 Enc 01
Ref.
Item
Deaths from cardiac causes accounts for the largest number of deaths by speciality therefore
there is additional monitoring in place for this. The data only takes into account a specific
procedure only and does not take into account other co-morbidities.
The VLAD chart takes into account more variables. There are no control limits on this graph. If
the line on the graph goes up, this is good. If the line goes down, this is bad. There are a
number of downward moves recently and the cardiac department have confirmed from the
data that they do not think this is statistically significant. This has acted as a trigger and all of
these deaths will be reviewed at Cardiac M&M.
VD explained that the “gold standard” for looking at deaths is individual case review. This
happens in ICU and cardiac, and the two units do challenge each other. We have an overall
trust wide mortality system that looks for specific triggers and then there are the statistical
systems which compare ourselves to other units nationally. When there is no perfect statistic,
the best way to look at it is from as many different angles as you can.
HSMR
This has been around since 2001, allowing for comparison between institutions. It is based on
routinely collected administration data. It is the ratio of observed to expected deaths. This is
risk adjusted for diagnosis only. This index is based on adult data, so there is essentially no risk
adjustment for paediatrics. It is therefore largely meaningless.
JG asked why this data was reported to board every month if it is meaningless. JM said that
there was no value in reporting it to the Board, as even the institutions we try to compare
ourselves too are very different to ours. JG queried whether we are therefore getting false
assurance. VD commented that it would be difficult to defend taking this report out, as every
other Trust reports it. TA confirmed that the CQC and regulators review this chart. KL added
that this chart is in the public domain and he wants to see what everyone else sees.
VD advised that work is ongoing with Jacqueline Cornish, National Clinical Director for Children
and Young People. She has asked us to produce a national system for specialist children
hospitals to produce a standard system. She will work with Sir Bruce Keogh, Medical Director
for NHS England, so there is an agreement about what all of these Trust’s will actually use. All of
the children’s hospitals in the North of England have been looked at and we are gradually
working around the South trusts; this will be discussed at the Children’s Hospital Alliance on
Friday.
External Reviews
There are various external reviews which provide the hospital with reassurance:
• All BMT patients get discussed at a national level at an annual meeting
• GOSH are invited to look through our cases
• Coroner
• Child Death Overview Panel, which reviews all unexpected deaths
Way Forward
There is a need to develop something that can compare us to other organisations. Alder Hay
are keen to work with us on this. Using our MIST safety data collaborative we will be working
with them to take this forward.
CH commented that it is correct that we focus on survivability, however is the quality of life of
Page 6 of 10
Action
UNCONFIRMED
Item 14.216 Enc 01
Ref.
14.195
Item
the patient considered. Is the hospital assured that the patient has had the best possible
outcome? VD explained that this is a big challenge and we do have some information/data. In
terms of outcomes, there is work going on nationally. It is not at the level of maturity for Board
time to be dedicated to it yet; however the liver and cardiac unit have published work which
can be reported back to the Board if desired. From our work with the Children’s and Young
Persons Outcome Form we strongly believe that a child’s school number and NHS number
should be the same, so good work can be done in comparing educational outcomes with health
outcomes.
The Board noted and received the presentation.
Next Generation Project – Update on the Management Restructure
TN updated the Board.
There are four key streams to the Next Generation Project:
•
•
•
•
New facilities
Patient pathways
IT strategy
People
There are four main elements to the Next Generation – People Project:
•
•
•
•
Clinical Groupings and Leadership Structure
A revised Accountability & Leadership Culture
Transformation of pathways and therefore new roles required
Provision of more productive workforce for the new clinical block
The focus today will be on clinical groupings and leadership structure and a revised
accountability and leadership structure. The impact of changing a leadership structure can be
quite significant, it is therefore important as to how we engage and communicate with people
throughout the process.
Why change the leadership structure?
Operational
• Lack of seamless decision making across directorates causing delays in service improvement
e.g. play, pre-admission
• Devolution of decision making to the front line.
• Clinical synergies not exploited to manage resources better
Strategic
• Failing to develop future clinical leaders – current roles are too big and complex
• Executives involved in day to day operational issues too regularly, impacting on leadership
accountability and development
• Timing never perfect so important to make changes from a position of strength
What work has been done so far?
Before the consultation was launched at the end of June, we went through three months of
engaging with our people. TA added that during this pre consultation phase the initial set of
Page 7 of 10
Action
UNCONFIRMED
Item 14.216 Enc 01
Ref.
Item
clinical groupings was changed quite significantly to reflect conversations with the consultants.
TA felt confident the clinical body felt fully involved and part of the consultation.
We have worked hard on POC (programmes of care). These are pathways which cut across all
clinical groupings. VD and his team have developed a process to bring teams together to
manage the POC more efficiently. This was a fundamental principle from the critical care
summit.
Clinical Groupings
There are seven main groupings. Each group is led by a clinician. The POC will work across each
of these. A complexity tool has been designed to work out the leadership structure for each of
these groupings. The change in structure is cost neutral.
ES asked where ‘Play’ now sits as it used to be with Clinical Psychology. MM explained that in
the new structure it sits in surgery and MM will still have oversight.
VD explained that the groupings represent the key areas that the Board have identified as a
priority and achieves what clinicians have asked for.
Working Example
This surgical pathway follows the path of the majority of children who are admitted for elective
care.
Current Directorate Structure
Revised Clinical Groupings and Structure
Child admitted into SDC which is managed
by Clinical Support
Now all departments in the one
Child goes to Theatre which is managed by directorate making improvements to the
surgical pathway much clearer.
Specialised Services
Child is operated on by a surgeon who is
managed by Surgery
Return to ward either SDC or surgical ward
which is managed by CS or SS
Under the current structure the patient would be managed by a number of directorates and
where there is a blockage in the system, this is much more difficult to resolve. Under the new
structure the patient is treated by the same directorate throughout.
Operational Reporting Structure
The Deputy Chief Nursing Officer, Deputy Chief Medical Officer and the new Deputy Chief
Operating Officer, will be the three people involved in the daily operation of the organisation.
Their roles are focused on facilitating and unblocking pathways. They will report to TA on a dya
to day basis, but their professional accountability will remain with VD and MM.
One of the key pieces of feedback from our staff was a request not to implement these changes
during the winter which is a difficult time. Therefore, a decision has been made to fully
implement from April 2015, but staff will be moved into their new posts over the next few
weeks.
How do we map our governance through to the Board?
The Board need to consider:
Page 8 of 10
Action
UNCONFIRMED
Item 14.216 Enc 01
Ref.
Item
•
•
•
•
If we are going to empower local clinical decision making how do we need to be different
both at board and committee level – culture, challenge, assurance etc
How do we ensure quality remains our guiding principle throughout
How do we use information as a change agent
How does the scheme of delegation and accountability framework support growth of our
trust leaders
The scheme of delegation and accountability framework will be subject to scrutiny by the Audit
Committee next month.
CB commented that an enormous amount of time had obviously been invested into the
development of the restructure over a long period of time. There was discussion as to whether
the NEDs were as sighted on this work as the executive team or as sighted as they needed to be
at this stage. Overall, the development of this work has been through the correct processes but
as it is such an important piece of work CB will consider with the NEDs whether this subject
needed greater board time in the future. The issue will be considered by CB and the NEDs at
their NED meeting and they will feed back to TN if they would like the matter brought back to
board at this stage. It will inevitably come back as the implementation progresses in due
course.
The Board noted the presentation.
QUALITY & RESOURCES
14.196
Quality Report
JG commented that both quality reports were looked at in detail in Quality Committee last
week. There were a couple of items that the committee focused on:
• The changes in our position around mortality and the situation around cardiac, which JM
has today covered this already in great detail.
• The programme of work around breast feeding. This is a possible theme that Quality
Committee may want to look at in the coming year.
• Work around outliers. The Committee had been assured at the approach taken and that the
Trust had pro-actively spotted it as a potential theme/issue, without having any concrete
data. The Committee were also assured by the actions taken.
• SJM and JG are meeting with the Chair of the Safeguarding Children Board tomorrow to
discuss the role of the hospital in the broader city and the community.
14.197
The Board noted the report.
Performance Report
The Board noted the report.
14.198
Resources Report
The Board noted the report.
OTHER
14.199
Questions from the Public
Carl Harris (staff governor) commented that in terms of leadership development, allied health
professionals are keen to be part of the change. TN acknowledged this enthusiasm and
Page 9 of 10
Action
UNCONFIRMED
Item 14.216 Enc 01
Ref.
Item
explained that the changes will afford them the opportunity to lead a directorate.
Next Board Meeting: 30 October 2014, The Education Centre, BCH
Page 10 of 10
Action
Board of Directors
Item 14.218
Report Title
Sponsoring Directors
Contributors
Previously considered by
30th October 2014
Enc 02
Quality Report
Dr Vin Diwakar, Chief Medical Officer & Michelle McLoughlin,
Chief Nursing Officer
Governance Services, Corporate Nursing, Education, Infection
Prevention and Control, PICU & Cardiac Services
SLT & CRAQA
Situation
The enclosed report provides an update on key clinical safety and quality topics.
Background
The report is collated from a number of information sources and provides assurance that key
risks are being escalated and monitored until sufficient action has been taken to address the
concerns.
The report includes information on key risks, serious incidents, mortality data, cardiac arrest,
respiratory arrest, other acute life threatening events, infection control data, Safety
Thermometer data, Net Promoter Question results, and data from the PED database.
Information on Never Events and other safety information is included by exception.
The report now aligns information against Trust priorities and measures.
Assessment
Emerging trend on SDC with patients experiencing prolonged fasting times and perceptions
that the theatre times are not communicated effectively. We will explore the data and
provide a detailed analysis within the November Quality Report.
General Overview Information – Quality Report October 2014
•
2 new SIRIs
•
6 new complaints
•
9 Closed complaints
•
Zero new Never Events for 18 months
•
82% of Patient Experience Feedback is positive
•
Net promoter scores:
Parent /carer - 89
Children & Young People – 87
The young person in-patient score has increased from an unusually low score of 78 in
September.
Recommendations
•
Review the enclosed report
Risk Description
Failure to correctly identify the
greatest risks to the quality of care
and safety of our patients.
Key Risks
Controls
• Directorate Governance
systems
• Board Assurance
Framework
• Risk Register
• Safety Strategy
• Safety Dashboard
Key Impacts
Strategic Objective
Strategic Priorities
CQC Registration
NHS Constitution
Other Compliance
Equality, diversity & human
rights
Assurances
•
•
•
•
Monthly Board Safety Report
Mortality Review
Monitoring of incident trends
Monitoring of complaints
trends
Every child and young person cared for by Birmingham Children’s
Hospital will be provided with safe, high quality care, and a
fantastic patient and family experience
3. Further develop our approaches to gaining feedback from staff,
children, young people and families to ensure that their voice is
heard at every level of the organisation.
4. Further innovate our systems to promote and enhance patient
safety and reduce avoidable harm.
Standard 16 - Assessing & monitoring the quality of service
provision could be affected by a failure to manage risks
highlighted by the report. Risks to compliance with other
standards may be highlighted by the reports.
Patient Rights
• Quality of Care and Environment
•
Treatments, Drugs
•
Respect
•
Consent and Confidentiality
•
Informed Choices
•
Complaint and Redress
The report supports compliance with NHSLA and Monitor
requirements
Right to life
Quality Report:
Safety & Patient Experience
October 2014
Vin Diwakar, Chief Medical Officer
Michelle McLoughlin, Chief Nurse
1
New Events & Concerns
There have been no new Never Events since 15/4/13
There have been 2 new SIRIs
14/15:43 Patient attended the Emergency Department and was diagnosed with a suspected viral respiratory infection. This patient was
discharged after an hour in the department, then represented several hours later with severe sepsis requiring admission to PICU.
14/15:39 An incorrectly recorded weight was used to generate the patient’s prescription. The child’s mother had given the weight in pounds
and ounces and it had been recorded in kg. The patient received an overdose of gentamicin on two occasions.
Patient is attending Physiotherapy but Mother
claims they have "failed to provide her daughter
with a satisfactory pain management programme"
Father disagrees with Emergency Department
Clinical Lead response and the reasons his
daughter was discharged from ED.
There have been 6 new Formal Complaints
No. Complaints
25
20
15
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
10
Mum is concerned that there was a lack of
5
information about waiting times in ED, that they
0
experienced considerable delay which resulted in her
self-discharging her son, and there is a difference in
the pathway between referrals and walking straight
into ED.
Concerns about the quality of care on PICU and Ward 15.
Patient Experience database –
Father feels that he was not listened to and all treatment
options were not considered.
A vascuport port extension had
Family state that a Consultant was very
been left in for 2 weeks and 3 days,
dismissive.
without being changed, where is
The family state that the Consultant indicated should have been only 7 days, as per
that she would do a blood test but “it was
hospital policy. The child suffered
stupid as the results would come back normal
from a pseudomonas infection.
and she would be discharged in any event.”
The family were also asked if they wanted a
chromosome test without explanation.
Need to Improve comments
Emerging trend on SDC with patients experiencing prolonged fasting times and perceptions
that the theatre times are not communicated effectively. We will explore the data and
provide a detailed analysis within the November Quality Report.
Closed SIRIs
There were 4 closed SIRIs in
September
Summary
14/15: Failure to identify NAI before discharge resulting in a patient being
put at risk of further injury.
Findings
There were no clear systems failures which contributed to this incident.
The decision to rule out NAI was made by a competent person and there
was no information which should have been available to support this
decision which was not available.
14/15:21 Excoriation injury to buttock. This is believed to be a chemical
burn caused by the patient’s faeces. The patient is a very complex cardiac
patient and had been suffering with gut motility problems. Records show
that the patient was promptly cleaned after each episode of diarrhoea.
Findings
On balance the skin injury was caused by a septic embolus and that this
being such an unusual circumstance was not predictable or preventable.
14/15:07 Haematology handover sheet was found outside the entrance
to another hospital.
14/15:01 Burns Handover sheet containing some patient identifiable
details was found on the site of another organisation.
Key Actions
This case will be used as an example of how subtle NAI can be. This will be
built into safeguarding training and will be used as part of the ED and
General Paeds Peer review process to share the learning widely across the
teams.
We will highlight this case to a wide audience so that they are aware of this
potential risk.
• While we continue to work towards an electronic handover solution we
will develop the handover sheet to include a watermark and so that it is
printed on a specific colour which will act as visual cues to prompt staff
about the importance of keeping these documents safe. Posters have
been displayed across the Trust reminding staff about the importance of
document security.
• Specific guidance has been added to the Information Governance Policy
in relation to the practice of taking handover sheets off site. This
guidance has been publicised across the entire organisation via a joint
letter from the Chief Nurse and Chief Medical Officer.
• Each specialty must risk assess their handover sheet practice to ensure
that we are minimising the risks of confidentiality breaches. Awareness
of this risk will be raised across the Trust.
3
Closed Complaints
There were 9 Closed Complaints in September
Summary
Concerns about the lack of information provided by
Endocrinology. Mother believed her son has been prescribed
the incorrect emergency injection for adrenal crisis.
NHS England expressed concerns about a discharge summary
produced by the Emergency Department that was sent to a
Health Visitor.
Key Actions
•
•
Explanation provided in relation to prescribed medicine
Literature now available for families
•
•
ED Doctor to write a letter of clarification for the GP
New ED IT System has been purchased to allow free text to enable additional explanations, in addition
to automated text from codes, when formulating discharge letters
•
•
•
•
Concerns about length of wait for steroids and concerns that •
•
patient was provided with incorrect breast milk.
•
•
Concerns that a consultant had not arranged for MRI of brain •
and spine to be done under General Anaesthetic together
and for Lumbar Puncture to be done whilst under General
Anaesthetic - as discussed with parents previously.
Concerns about a delay in diagnosis including a delay with an •
•
MRI scan and obtaining the results of the scan.
•
•
•
Concerns that a Consultant Nephrologist did not listen to her •
and made assumptions when diagnosing.
The Contractor has held discussions with all drivers to remind them of the no smoking requirements
BCH and Contractor have created a Charter based on the Trust Values
Contract amended to ensure that 100% of journeys arrive on time with penalties in place
Amendment to contract to include Daily Communication between the contractor and the Trust
Guidelines on the roles and responsibilities of teams when care is shared between teams
Implementation of Safer Handover Toolkit
Refresh all nursing staff on handling, storing and administration of Expressed Breast Milk (EBM)
Undertake a review of Trust Policy and processes for handling, storing and administration of EBM
New system implemented to ensure that if a scan request is received from different specialties, each
request is reviewed in terms of specific requirements for the patient, and not just one request as had
happened in this case
Father received a Did Not Attend (DNA) letter although they •
had attended the appointment and have not received the
results of the MRI and CT scan.
Explanation and apology provided to family in relation to the DNA letter being incorrectly sent and
information provided in relation to the results.
Concerns about the taxi service from BCH. Observations
included rudeness, inefficiency and smoking on arrival.
Concerns about communication between Consultants and
G.P.s - appointment changed 3 times.
General concern that the hospital were not taking his
concerns about the patient's health seriously.
•
•
•
Extension of hours within the cross-sectional radiology team to encompass 6 day working
Additional MRI sessions instigated
Additional Consultant staff recruited to manage the increasing demand for imaging
Additional Radiographer staff are being recruited to allow for further extension to service
Mobile MRI scanners have been used to increase capacity
Explanation provided in relation to diagnosis.
Meeting arranged with the family and clinicians to discuss and resolve issues raised
Explanation provided about the information shared with the GP following clinic appointments
Apology provided for the delay in one of the clinic letters being sent to the GP
4
Complaints Quarter 2 2014/15
Key facts:
•23 Formal Complaints in Q2
•82 individual issues were identified within the 23 complaints received in Q2
•In Q2, there were no referrals to the Ombudsman
•111 Formal Complaints Received in 2011/12
•73 Formal Complaints Received in 2012/13
•110 Formal Complaints Received in 2013/14
Frequency of Complaints since 2005/06 to date
50
40
30
20
10
0
Complaints per 1000 admissions
Complaints According to Theme Q2
3
25
Waiting, delays, cancellations and
access to services
45
19
28
Staff Attitude
Quality of treatment
Communication
Other
50Pattern
since Q4 2010/11
40
Waiting, delays &
cancellations
Staff Attitude
30
20
Quality of Treatment
10
Communication
0
Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2
1011 1112 1112 1112 1112 1213 1213 1213 1213 1314 1314 1314 1314 1415 1415
Other
PALS Contacts – Quarterly Analysis – Q2
Waiting, delays & cancellations
Quality of Treatment
Quality of Medical Care
e.g. concerns about
treatment received to
include misdiagnosis
Staff Attitude
Communication
Oral Communication
e.g. lack of information about
delays, treatment, procedure and
conflicting information between
medics
Other
Outpatient/Inpatient delays and
cancellations
e.g. delays and cancellations of
appointments, cancellations of
surgery and difficulties in obtaining
surgery date
Enhancing Patient Experience
Prioritising person-centred care
The report presents information from different sources including, including feedback cards, e mail, ward walkabouts, verbal feedback; all
collated on the Patient experience Database (PED), the Friends and Family (F&F) Questionnaire, the Feedback App, Patient Opinion and
more qualitative feedback from patient experience and participation projects such as patient stories and quality walkabouts.
Each method brings its strengths and weaknesses and therefore utilising a toolkit approach enables the Trust to better understand the
patient and family experiences and helps prioritise where to focus efforts on action planning for improvements.
Ensuring responsiveness
• All feedback information from the PED, Friends & Family, the app and any other source are sent on a monthly basis to ward managers,
Lead Nurses and Heads of Nursing for analysis and action.
• We liaise immediately and directly with the relevant managers over any detractor or need to improve comments requiring action and
monitor action progress against the comments
……the top category of need to improve comments relate to
18%
• Patient feedback influences the quality walkabout choice of ward. a clean, comfortable and safe environment, including food –
Combined PED and Friends & Family data…..
82%
…overall satisfaction with staff, providing safe,
high quality care.
at BCH and Parkview; (a food survey and walkabout was
undertaken– see focus on food), noise at night, activities
for older children and breast feeding equipment.
Need to
improve
Positive
Staff nurse Dan was
fantastic – I don’t know
how we would have got
through this without
him - Parent (SDC)
There were some concerns about
being short staffed raised in a
number of areas.
A couple of comments specifically
mentioned a shortage at night and
weekends.
Provide a better service at
HDU seemed to be understaffed whereas in most
weekends E.g. have more doctors
hospitals it is seen that there is always a nurse
available for treatment. (Young
present, that is not the case at BCH.
person Ward 7)
More staff on shift especially the
night shift (young person Ward 10)
Friends and family questionnaire
Monthly adult scores (in-patient)
MSep-14
Overall Trust Discharges
1132
Total number of responses in period
261
Number of promoters
236
Number of passives
20
Number of detractors
5
Neither likely or unlikely
3
Unlikely
0
Extremely Unlikely
2
Net Promoter Score
Monthly young people scores (inpatient)
Overall Trust Discharges
215
Total number of responses in period
69
Number of promoters
60
Number of passives
9
Number of detractors
0
I Disagree a bit
0
I Disagree alot
0
Undecided
0
89
Response Score (20% Target)
23%
Net Promoter Score
Sep-14
Net promoter in-patient scores:
Parent /carer scores are improved but
Children & Young People scores are lower
again than last month. The number of
passive comments remains higher than
expected. We will continue to monitor this
Reasons for young people passive responses
More
food
choice
87
Response Score (20% Target)
Monthly adult ED scores
Sep-14
32%
Monthly Young people ED scores
Sep-14
Overall Trust Discharges
2937
Overall Trust Discharges
627
Total number of responses in period
502
Total number of responses in period
132
Number of promoters
430
Number of promoters
96
Number of passives
62
Number of passives
34
Number of detractors
10
Number of detractors
2
Neither likely or unlikely
6
I Disagree a bit
1
Unlikely
2
I Disagree alot
1
Extremely Unlikely
2
Undecided
0
Net Promoter Score
Response Score (15% Target)
84
17%
Net Promoter Score
Response Score (15% Target)
71
21%
More staff at night
needed
It would be better
if there were no
teachers and no
needles!
ED CQUIN target
responses met for
September,
reflecting the work
and focus by ED on
improving their
responses
More
TV’s
In-patient
CQUIN Target
responses
achieved for
both parent/
carer
&CYP
Feedback App & Social Media
Improving our reputation! - Update
Finalist
App comment ‘Too many staff from Birmingham children's hospital are walking around the
city or on public transport either in uniform and/or with ID badges on it is a disgrace.’
A staff uniform monitor rota is in place. A letter has been drafted to give out to all staff where
there has been non-compliance observed in relation to the uniform policy – including if the
uniform is partially visible. It is the job of the ward manager to then address the breach as they
will be informed . There are posters in the ward staff rooms for information about how to
ensure compliance with the uniform policy.
On the first day there were no staff to report and the staff who were entering or leaving were
complying with policy.
Social Media
Facebook & Twitter comments
continue to be predominantly
positive – 82 positive comments in
September
…2 need to improve - 1 FB and 1 twitter
Security issues raised….
After being here 12 months as a mum alone late at night I among
other parents feel intimidated by men daily asking for money
cigarettes etc as this is a hard enough time for us all and would
really appreciate security been around.
A response has been sent asking the parent to contact the Welcome
Desk and discuss their concerns with the Operational Security
Manager. Security staff are aware and will be extra vigilant about
the issue.
10
Focus on Food
Patient Experience and Participation
Food Survey Report - October 2014
Wards: 5, 7, 9, 10, 12, Participants: 24 (16 Parents/Carers, 8 Patients)
The survey was conducted on two separate occasions by a BCH patient experience volunteer.
Each time, the survey was conducted at 12:30pm, just after lunch. Each participant was asked the following 11
questions:
Patient response – 8 participants
The response on the surveys was overall a positive one, particularly around food choice, temperature of food and the
friendliness and helpfulness of staff:
•All 8 respondents said that they had been given a choice of food, that the food was at the right temperature and
that the serving staff were friendly and helpful.
•7 participants said that they were happy with the choice of food and 7 participants also said that they knew when
the meal times were.
Areas for improvement:
•The availability of snacks as only 4 patients said that snacks were available if they were hungry between meal times.
•The majority of patients also said that they had not been given choice over food if they were in need of it due to
religious or dietary reasons; 5 said they hadn’t been given a choice compared to 3 who felt they had.
In addition, the majority of patients (6 participants) had ordered their food using the MAPLE and said that they
would prefer to eat their meals in their bed rather than in a group on the ward.
The feedback on the appearance of the food was mixed:
•4 patients said their food looked ‘nice’, ‘good’ or ‘very good’
•2 patients said their food looked ‘alright’ or ‘OK’
•1 patient said their food looked ‘bad’
•1 patient said their food looked ‘sloppy’
The feedback on the taste of the food was overall positive:
•2 patients said their food tasted ‘really nice’ or ‘excellent’
•2 patients said their food tasted ‘good’ or ‘nice’
•2 patients said their food was ‘edible’ or ‘OK’
Parent/Carer response – 16 participants
•15 participants said that they were given a choice of food and that they were happy with that choice.
•14 participants said they felt they had been given a choice over food if they were in need of it due to religious or
dietary reasons. Only 1 parent/carer said they felt they hadn’t been given that choice.
•13 participants said they were happy with the food temperature compared to 1 participant who said they were not.
•13 participants said that they felt serving staff were friendly and helpful, compared to 1 participant who said they
were not.
Areas for improvement:
•The availability of snacks as 4 parents/carers said that their child had not been offered snacks in between meals if
they were hungry. However, 11 parents/carers said they had.
•5 parents/carers said that they were not aware of the times that the meals were due, compared to 11 parents/carers
who said they were.
Similarly to the patients, the parents/carers also thought that having meals served at the patient’s bed rather than on
the ward was better, as only 2 participants said they should be eaten in a group on the ward. One comment was that
eating on the ward was ‘not practical’. As well as this, 11 parents/carers had used the MAPLE system to order food,
whereas 4 hadn’t.
The feedback on the appearance of the food was overall positive:
•6 participants said that the food looked ‘good’
•4 participants said that the food looked ‘as expected’, ‘OK’ or ‘fine’
•3 participants said that the food looked ‘nice’, ‘tasty’ or ‘yummy’
•1 participant said that the food looked ‘very good’
The feedback on the taste of the food was also positive:
•9 participants said that food tasted ‘good’, ‘nice’ or ‘tasty’
•4 participants said that the food tasted ‘OK’
Overall, the one area to improve on that was highlighted by both patients and parents/carers was the availability of
snacks in between meal times. An additional comment that was mentioned was that one participant felt that long
term patients needed a greater variety of food.
Ward 7 – Quality Walkabout
Review noise at
night.
All staff reminded and plans
to raise as part of induction
of new staff.
Explore solutions to a lack of
ventilation in sluice.
Review role of Mental Health
Liaison Nurse.
Pending
Estates have been
asked to review.
Ensure nurse staffing board is
kept up to date.
Staff reminder
• Working with pharmacy to
continuously monitor
temperatures
• Recorded on the risk
register
Explore the
solution to
temperature
issues in the
treatment room.
Improve completion
of F&F
Questionnaires.
Questionnaire
now attached to
discharge
paperwork.
Monitoring Infection control
September 2014
Infection
No.
MRSA Bloodstream Infections (BSI)
0
MSSA BSI (pre 48 hour)
3
MSSA BSI (post 48 hour)
2
E. Coli bacteraemia (pre 48 hour)
1
E. Coli bacteraemia (post 48 hour)
2
Glycopeptide-resistant enterococci
0
C. Difficile
0
MSSA pre 48 Hours 2011/12
MSSA pre 48 Hours 2013/14
MSSA pre 48 Hours 2012/13
MSSA pre 48 Hours 2014/15
5
4
3
2
1
0
MSSA post 48 hours 2011/12
MSSA post 48 hours 2013/14
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
April May June
E-Coli - pre 48 hours 2011/12
E-Coli - pre 48 hours 2013/14
5
4
3
2
1
0
E-Coli - pre 48 hours 2012/13
E-Coli - pre 48 hours 2014/15
July
Aug
Sept
MSSA post 48 hours 2012/13
MSSA post 48 hours 2014/15
Oct
Nov
Dec
Jan
Feb March
E-Coli - post 48 hours 2011/12
E-Coli - post 48 hours 2012/13
E-Coli - post 48 hours 2013/14
E-Coli - post 48 hours 2014/15
5
4
3
2
1
0
14
Respiratory Arrests, ALTEs and
Unplanned Admissions to PICU
Explanation of Data
Unplanned admissions to PICU are a
measure of how well we are monitoring
patients on the wards. Good monitoring on
the wards means that we will pick up
deteriorating patients more quickly,
allowing us to admit them to PICU when
required. A combination of high levels of
unplanned admissions and low levels of
cardiac arrests, respiratory arrests and
acute life threatening events (ALTEs) means
that we are monitoring and escalating
clinical deterioration in a timely manner.
Details of Cardiac Arrests
In September there was 1 cardiac
arrests outside PICU in theatres.
It was not predictable or preventable.
There were 6 cardiac arrest on PICU
one of which was potentially
predictable and preventable which is
being reviewed through the M&M
process. None of the others were
predictable and preventable.
Number of Emergency Events
No of Cardiac Arrests (ex PIC)
No of Respiratory Arrests
No of Cardiac Arrests (PICU)
No of ALTEs
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14
15
Safeguarding
Key Figures
Child Protection Training
( includes Adults)
Level 1
98.4
Level 2
81.2
Level 3
81.6
There has been 0 Safeguarding SIRI
There has been 0 new Safeguarding Complaint
There has been 0 “Position of Trust’ case
There have been no new recommendations from Serious Case Reviews
100% of BSCB Meetings attended by BCH Executive lead or representative
90% of cases which require peer review /clinical supervision have had this
There has been 0 child deaths related to suspected physical abuse/neglect
There has been 0 reported cases for Female Genital Mutilation.
• Safeguarding CQUIN:
•We have completed 9 Qualitative Audit Proformas for Quarter 2 as agreed.
Care Quality Commission: Inspection for services for looked
after children and safeguarding in Birmingham Monday 29th
September 2014:
The Emergency Department and CAMHS Tier 3 and 4 were part of the inspection.
We are awaiting formal feedback via the Clinical Commissioning Group.
A child’s Journey through the Safeguarding Process:
•A 12 yr. old was admitted to the Burns Unit with injuries
consistent with an aerosol burn. However, concerns were
raised due to late presentation and inconsistencies.
•Detailed history taken by the Burns Consultant from the YP
on his own.
•This was discussed with the Consultant General
Paediatrician and the Trust Safeguarding Team.
•Liaison took place between the GP and School.
•A referral was made to Social Care and a Strategy Meeting
took place. This was attended by BCH professionals .
•A Child and Young Persons Assessment was opened which
would be completed by the Social Worker.
•YP was seen by the Consultant Paediatrician who listened
to his views. These were recorded in the referral. He wished
to be discharged home and agreed a CAMHS follow up on
discharge. His Social Care assessment ensured that his
needs were being met holistically and his safety assured
•This case was discussed in the Monthly Burns Peer Review:
Reflective Practice: It is important to speak to child / YP on
their own and they should be given this opportunity. All
staff were aware of the safeguarding procedures and were
satisfied with the outcome for the child.
Mortality
Past Harm
Mortality data is presented in a number of ways, and
an overall picture can only be gained by using a
number of indicators. These are:
•Absolute number of deaths per time period.
•Number of deaths per time period per 1000
admissions.
•Standardised mortality ratio (See next slide)
•Cumulative sum (CUSUM) charts.
•Review of individual deaths.
Inpatient deaths per 1000 admissions
This is a simple calculation to overcome any
variations in admission numbers over time (e.g.
the hospital may have more admissions in the
winter months) or between hospitals of different
sizes.
Data can be compared between
organisations by this method as it allows for
different admission numbers but it is limited as a
tool for comparison as there is no modification
for case mix. The graph on the right shows the
number of inpatient deaths per 1000 inpatient
admissions at BCH since June 2012. Please note
that the data does not include deaths which
occurred in the Emergency Department.
Absolute Number of Deaths
The simplest way to represent mortality is as an
absolute number of deaths in a particular time period;
however it does not take into consideration either the
number of admissions to the hospital or the case mix of
patients. It is useful only as a sense guide to other data
as it has not been modified in any way. Data cannot be
compared between organisations in this format.
16
Deaths
Deaths per 1000 Admissions
14
12
10
8
6
4
2
0
17
Standardised Mortality Ratio (SMR)
In order to account for differences in case mix for different organisations the idea of standardised
mortality ratios has been developed. This attempts to account for differences in patients, such as
diagnosis, age and pre-existing medical problems, and allows for comparisons between hospitals.
A standardised mortality ratio (SMR) is the ratio of the actual number of deaths in a hospital within a
given time period, to the number that might be expected if the hospital had the same death rates as a
larger reference population (e.g. all English Hospitals). The SMR scores can be presented in a number of
ways.
Run Chart
This shows how the standardised
mortality rate of a hospital changes
over time. If there are a small
number of deaths in each time
period then the month to month
variation can be quite wide (as is the
case with BCH where there are on
average 4-12 deaths a month).
18
Bar chart presenting data comparing a number
of hospitals:
This shows the position of an individual hospital in comparison
with its peer group. It is easy to understand but does not give
much information about whether our outcomes are unusual. The
graph presented below shows 6 months’ worth of data rather
than 12 as previously presented.
Our SMR has risen slightly from 161.67 to 159.92
Movement in last month
Funnel plot
This shows the standardised mortality ratio on the Y axis, and the
number of expected deaths on the X axis. Control limits can be
applied, so that it is possible to see how likely that the variation
from a score of 100 is by chance only. In the example below an
amber dot occurs if there is between a 0.3% (1 in 330) and 5% (1 in
20) likelihood that the score is different from 100 by chance and a
red dot if there is less than a 0.3% likelihood that the score is
different from 100 by chance. Such warnings should be investigated
as to cause. The funnel plot below is presented using 6 months’
worth of data.
We are in the red section of the funnel plot.
19
Deaths in the Paediatric Intensive Care Unit
(PICU)
CUSUM Charts
Another way of representing outcome
data is by cumulative sum charts.
These can be used where there is a
score available to give a risk of
mortality for each individual patient.
Currently this method is in use at BCH
for intensive care.
The charts use data from all patients,
not just deaths, so are more powerful
than SMR in detecting problems.
For BCH, the PICU CUSUM is a good
reflection of overall hospital mortality
as over 70% of deaths at the hospital
occur on PICU. There is no evidence of
systemic care failures which could have
contributed to deaths on PICU.
20
Deaths in Cardiac Services
CUSUM Chart
One of the Trust’s highest risk specialties is Cardiac Services. The nature of the activity means that proportionally
more of our mortality is related to that specialty than others. The team carefully monitors clinical outcomes to
ensure that that we are providing high quality care.
The CUSUM chart is a graphical representation of the outcome data
for the specific procedures which are nationally monitored (70-80% of
our patients fall into this group).
In addition, the team also monitors overall mortality for all surgical
patients.
An upward movement in
the chart means that the
outcome for a specific
patient was better than
expected. A large increase
means that the outcome
was significantly better
A downward movement
means that the outcome for a
specific patient was worse
than expected, again the size
of the decrease is a measure
of how much worse the
outcome was than expected
This series of 3 downward movements
represents 3 specific patients experiencing a
worse than expected outcome in a relatively
short period. This series of outcomes will be
reviewed as part of the Cardiac M&M
meeting and future data monitored closely.
Overall our outcomes are better than expected. However, please note
that the baseline will be reset on a regular basis, so we do not expect
to move further and further from the x-axis
21
Deaths in Liver Transplant
CUSUM Chart 7 month lag time
Another of the Trust’s higher risk activities is Liver transplantation.
Although we do not carry out a large number of these, the team monitors the outcome rates posttransplant. The graphs below show that our outcome rates are comfortably within acceptable limits.
Interpretation of the charts
The O-E chart is a useful tool for
observing performance over time.
A downward trend indicates a
lower than expected rate of
mortality compared with the
baseline period, whereas an
upward trend points to an
observed mortality rate that is
higher than expected.
To identify statistically significant
changes the tabular CUSUM chart is
used to complement the O-E chart.
A significant shift in the underlying
mortality rate is evident when the
chart crosses the limit and
generates a signal. The tabular
CUSUM chart can be used to
forewarn of possible future signals
as the chart approaches the limit.
Such ‘signals’ may be due to one of
a number of different reasons. A
signal may be due to
transplantation of patients of
higher risk than previously, a short
run of adverse events, or it may
occur just by chance with no
underlying cause (i.e. a false
positive result).
22
Item 14.219
Board of Directors
Thursday 30th October 2014
Enc 03
Strategic Objective/ Enabler
Every child and young person requiring access to
care at BCH will be admitted in a timely way, with no
unnecessary waiting along their pathway
Report Title
Performance – Sep 2014 Performance Report
Sponsoring Director
Deputy Chief Executive
Author(s)
Head of Health Informatics, Performance Manager
Previously considered by
Finance and Resources Committee
Situation
This report provides the September update on the Trust Performance supporting improving
our patient experience. The report highlights performance and in particular where
performance is not being met and any concerns and improvements planned.
The attachment provides further details on our current and comparative performance
Background
Performance to August 2014
As previously reported there have been four areas of particular concern regarding
operational performance in 2014/15 to date
•
Diagnostic waits including MRI, where we have been breaching the target of 99% of
patients to be seen in 6 weeks, although the actions taken had been starting to
improve the position, with total breaches reducing over the year.
•
18 weeks waiting times have been met, but by a narrow and diminishing margin, in
part due to increasing demand including from outside the Birmingham area. We have
reported that meeting this target in future would remain a challenge.
•
The hospital’s available physical capacity has been impacted upon by increasing
length of stay and delayed discharges, in turn leading to fewer available beds and
cancelled operations.
•
Total Trust cancelled operations and those nationally reportable are high. We have
been struggling to successfully re-schedule all children and young people within 28
days and have had breaches of the 28 day standard
We noted last month that the position in August had markedly improved, due to a
combination of factors including reduced demand for services through the holiday season
and management and clinical initiatives to address issues.
Assessment
Summary of Performance in September 2014
Performance in most areas remains steady this month, although we haven’t performed
against all of our targets as well as in August in part because the level of demand for our
care increased following the end of the school holidays. The key highlights include;
•
•
•
•
•
•
•
nationally reportable cancelled operations continued to decrease with 26 reported
this month (28 last month), and are now well below the recent BCH average;
there are no 28 day breaches regarding the rescheduling of cancelled operations for
the second month running;
all the key ED performance targets have been met;
the number of long stay ‘bed blocking’ patients have remained the same as last
month. For CAMHS there has been no movement in these patients since last month.
Bed availability issues have reduced and are no longer causing significant numbers
of cancelled operations;
only four tertiary and urgent patients were not found a bed;
only 2 KIDS patients could not be supported in our PICU; and
CAMHS continue to meet 18 weeks targets, although performance has fallen again
to 93.9%, and 11 patients could not be found a bed.
Regarding the target to see diagnostic tests in 6 weeks, performance has improved in
September with 22 breaches compared to 29 last month. We are projecting to carry 27
general anaesthetic (GA) breaches in October. This is higher than projected in the August
paper (15), the rise stems largely from a technical issue with the method for extracting data
from the Radiology Information System (RIS.) As a result the likely no.of breaches was
under-estimated. This has now been resolved. Plans are being put in place regarding
additional anaesthetic capacity, which if successful and with normal levels of demand
experienced the target should be met in November 2014.
RTT and 18 weeks continues to remain a concern, although we have again met our national
targets for the month by a small margin.
(a) Access to Services
Diagnostic waits including MRI
There were 22 patients (17 MRI and 5 CT) at the end of September who had been waiting
over 6 weeks for a diagnostic test. This amounts to 96.1% of all patients seen versus a
target of 99%. The breaches were all for general anaesthetic (GA) cases.
Non GA cases are being managed going forward with the help of additional capacity at
Aston Brain Centre using their 3T scanner and radiographers. Standard of image is good
and the staff are former BCH employees. Aston sessions are booked for 22nd and 29th
October and there will be 1 or 2 days a week available every week from November onwards.
Given reasonable levels of demand this should allow for the non GA list to be managed
within target.
Managing the GA cases within 6 weeks is our current difficulty. Scanner capacity is not the
issue, rather it is anaesthetic staffing that is in short supply. However an additional staff
member starts in November, and as we start to meet the non GA demand more successfully
thanks to Aston, we should be able to switch some capacity at BCH from non GA to GA
cases. In this manner it is planned to create an additional 11 GA sessions, which is circa 44
operating slots, in November. All other things being equal, this ought to be enough capacity
to bring our performance in line with the target. However currently we are projecting 35
breaches for November, and 32 for December, without this additional capacity factored in.
Of further interest is that demand (slide 8 of the Powerpoint attachment) has again shown
weeks where it is high and above the average. This will need to be monitored carefully in
terms of its impact on demand. Also clinical changes can have an impact, for example
regarding CT demand. The new CT scanner has allowed for better clinical practice eg the
ability for us to carry out advanced coronary scans, replacing the need for catheters. These
changes, though welcome, will create more demand on the Radiology service.
18 weeks waiting time
The 18-week standards were met in September with the non-admitted performance being
only just above the target at 95.02%. Performance for admitted patients was 90.3% and for
incomplete pathways 92.5%.
There has been significant emphasis placed in September 14 on reducing our backlog of
long waiters in the Trust. This has had an impact on our performance around the targets for
completed clocks, and the slide on page 5 of the Performance Report shows this. The
‘Patients Not Treated Within 18 Weeks’ chart shows many more non admitted clock stops
over 18 weeks than usual. As a result we only just met our target. However this will help us
with future positions once the backlog is cleared, and also fits in with the requirements of our
commissioners.
The chart on slide 6 of the Performance Report shows an increase in the numbers of
patients who have yet to receive a TCI date after 14 weeks on the list, or whose TCI will take
them over 18 weeks. This remains at historically high levels and is a key indicator of the
difficulty we will have to manage within 18 weeks over the next month.
Slide 7 shows that there are 73 patients either waiting over 30 weeks at the end of
September, or whose clock stopped after 30 weeks in month. Again the reduction since the
peak of May 2014 is indicative of our focus on reducing the number of long waiting children
and young people.
The total inpatient waiting list continues to be high with 4114 patients on the list at the end of
September (4168 at the end of last month). However we have seen a good reduction in the
size of the outpatient waiting list again partly as a result of our emphasis on bringing in long
waiters. This has fallen by 500 since its peak in July 14.
Nationally there is increased scrutiny on RTT and weekly reporting is now required to
Monitor and Commissioners on our backlog of RTT patients who are awaiting a clock stop.
It has been announced that ‘resilience’ funding will be made available to support
organisations to meet the targets and Commissioners have agreed monies to fund any
contract over-performance that occurs as a result of BCH clearing the current 18 week
backlog and continuing to meet the performance standards.
Based on our modeling work we project that we will continue to meet the standards for 18
week clock stops in the months of October and November, although addressing the ‘over 18
week and still waiting’ backlog means it will be tight. The backlog overall will come down to
around 480 by the end of November, approximately 94% of the list will then be within 18
weeks. We anticipate that Orthopaedics would have the most over 18 week waiters at that
point, followed by Plastics and ENT.
As noted last month the short term workload is about ensuring detailed planning and
scheduling are in place to make sure all existing capacity is used to its full potential wherever
possible. The surgical flow project with Newton’s will make a contribution to this. However
step changes in capacity are currently some time off, either via a mobile theatre (not until
Spring 2015 if implemented) and then eventually the building work associated with Next
Generation.
Therefore looking forward, based on current assumptions and forecasts meeting the 18
week standards will continue to be a challenge.
Access to services – other areas
Access to BCH has remained good during September for the other pathways into our
hospital.
Emergency Department
96.4% of patients were seen within 4 hours and there were 148 breaches. This is well above
the target of 95%, but it is the highest number of breaches for a month in 2014/15 so far,
even though overall activity for September was not particularly high.
Tertiary referrals and Home Referrals
Performance in this area remains good.
• Of the 163 referrals, only 2 were not found a bed in September.
• Only 16 patients waited over 24 hours for a bed (one more than last month) and is
the second lowest figure since February 2013.
• When comparing actual time of admission against recommended time for admission,
90.5% of requests were met in target time compared to 91.9% last month.
PICU (Paediatric Intensive Care Unit) referrals
The West Midlands PICU service is provided by BCH, University Hospitals of North
Staffordshire NHS (UHNS) Trust and the KIDS (Kids Intensive Care Decision Support)
service run by BCH.
Performance remains steady as only one West Midlands (WM) patient (compared to one last
month) and three non WM patient (compared to one last month) could not be supported due
to hospital reasons. This is much lower than the historical average.
CAMHS referrals
The CAMHS Tier-4 (Child & Adolescent Mental Health Service) West Midlands service is
provided by BCH and other providers (some private) with BCH providing the assessment of
all requests, ideally within 4 weeks. The time taken to undertake assessment now stands at
7.9 weeks (compared to 5.9 weeks last month and 4.3 weeks in 2013/14). Assessment of
CAMHS patients within four weeks has reduced to 46% from 54% last month, so that
performance is worse than for 2013/14 at 52%. This was a result of a shortfall in capacity. A
capacity planning exercise has been undertaken to ensure all job plan slots are being
delivered and CAMHS are about to trial telephone calls to patients failing to respond to their
first invitation letter to reduce the wait time to first appointment.
Due to capacity and urgency, eleven tier 4 patients could not be supported by BCH CAMHS
in September; (compared to six in August). There continues to be significant capacity
pressures across the West Midlands and nationally for Tier 4 beds.
(b) Utilisation of Facilities
Cancelled operations
In September, 26 patients or 1.13% of all operations were nationally reportable e.g.
cancelled on the day of operation or after admission by the hospital for a non-medical
reason. This is less than previous month (at 28) and September 2013 (at 54). More than
half these (14) were as a result of theatre capacity being lost to Trauma or other emergency
cases (including 5 due to liver transplants. Bed shortages accounted for only 6 cancellations
and are therefore not a significant concern this month. 22 of the 26 (85%) of cancellations
affected the Surgical directorate.
There were no breaches of the 28 day standard for the second month due to active
management of breaches. Bed shortages were not an issue that led to cancellations in
September, and this is indicative of there being slightly more scope to schedule patients and
this helps with achievement of this standard.
Regarding the Trauma cases, in mid month 2 elective lists were switched to Trauma, which
should have a positive effect on both cancellations and patient experience. A Trauma coordinator is now in place to assist in identifying lists and beds for these patients. Similarly we
have created a surgical flow co-ordinator post for 6 months to help ensure we utilise as
much capacity as possible in a time of growing demand for our services.
Bed Availability - Long stayers and delayed discharges
The overall numbers of long stay patients remained steady in September 2014. The six
CAMHS patients from last month were still awaiting placements and were delayed for 975
days in total.
In September, there were four children who were fit for discharge but waiting for non-hospital
related actions before they could be discharged (two for a care package, one for social care
and one to be discharged to DGH). The total number of bed days relating to these delays is
333 days compared to 418 last month.
Recommendations
The challenges going forward remain the same as last month and are;
- to continue to put in place the arrangements needed to meet the diagnostic wait target.
Latest plans suggest this will be met in November 2014 unless there are unanticipated
issues with demand and or capacity.
- explore all avenues to maintain elective throughput and continue to meet our 18 weeks
RTT performance;
- continue to maintain the other levels of access to services and utilisation of facilities seen in
September when demand for services continues to pick up further into the Autumn, aided by
the winter plan and associated funding. Regarding this to note the slight dips in performance
for the ED standards and for CAMHS access in September and review again in the October
report.
The Board is asked to note the performance and plans for further improvement.
Key Risks
Risk Description
Controls
Assurances
Escalating demand for our Discussions
with Maintaining
scrutiny
on
services, potential risk of commissioners to be held performance against various
failing access targets
about demand management RTT targets
Bids against operational
resilience moneys
Insufficient capacity in place Appropriate
escalation
to meet service demands
systems in place
Validation of waiting lists
stepped up
Daily, weekly and monthly
reporting in place.
MRI capacity being identified Revised capacity plans being
including mobile van and produced.
Aston for non GA and more
GA capacity on site
Specialty recovery plans and
plans for additional capacity
being put in place as part of
response to ‘Operational
Resilience’
Capacity
plans
being
renewed and developed.
This
includes
modelling
capacity/demand
between
now and 2020 (new hospital)
Key Impacts
Strategic Objectives
CQC Registration
outcome)
NHS Constitution
Other
Compliance
This reports covers progress against meeting the strategic
objectives linked to supporting improving our patient
experience.
(state 4: Care and welfare
Yes – treatment within 18-weeks is a requirement within the
NHS Constitution.
(e.g. Many of the indicators are local or national standards
NHSLA,
Information monitored by the Department of Health, Monitor and our
Commissioners.
Governance, Monitor)
Equality, diversity & human The report considers any particular impact on patients with
learning disabilities, and on different ethnic groups.
rights
Trust contracts
Non-delivery of NHS standards can result in financial
penalties
Other
Meeting the strategic objectives raises the profile of Trust
locally, regionally and nationally
Operational Performance Report
Month 6 2014/15
Performance for September 2014
David Melbourne
Paul Franklin
Pragati Raithatha
Deputy Chief Executive Officer and Chief Finance Officer
Head of Health Informatics
Performance Manager
1
Operational Performance Indicators
How our patients access care
ED - time in ED
18 weeks performance (incomplete)
PICU – non WM patients supported (6 patients)
ED – time to seen
18 weeks performance (admitted)
PICU – non WM patients not supported ( 3 patients)
ED – Time to triage (all)
18 weeks performance (non admitted)
PICU – WM patients not supported (only 1 patient)
ED – time to triage (ambulance)
Long waiters - patients not treated within 18 weeks
due to insufficient capacity
Diagnostic waits over 6 weeks
ED – Left without being seen
Long waiters - patients not treated within 30 weeks
In region Tertiary referrals sent elsewhere (2)
ED – Unplanned readmissions
Long Waiters - patients waiting over 52 weeks
Tertiary patients waiting over 24 hours for a BCH
bed (16)
Patient Deflectors
18 weeks performance - CAMHS
CAMHS Patients that requested a T4 bed and were
not admitted (11 patients)
Utilisation of our facilities
Cancelled operations – national definitions
Cancelled operations – breaches of 28 day standard
Cancelled operations – all hospital
cancellations
Cancelled operations - equipment failures or admin
errors
Cancelled operations - patients cancelled
more than twice
Long stay patients and patients with delays after
being declared fit for discharge
2
Operational Performance Report
Month 6 2014/15
Performance for September 2014
How our patients access care
3
Emergency Department
95th % time
in A&E:
3.97hrs
95th % time to
triage (all):
33 minutes
Median time to
be seen: 60
minutes
95th % time to
triage (ambulance):
13 minutes
0 Patients
Deflected
Left without being
seen:
2.31%
ED re-attenders
for related
condition 2.51%
ED overall position: The seasonal aspect of ED demand meant that as expected the August activity was low and is back to higher levels in September.
Consequently performance against most targets has deteriorated since last month, although all have been met except the triage target for all patients (not
just ambulance.) It is pleasing to note that ED re-attenders decreased from 3.39% last month to 2.51%. Overall therefore performance against our ED
standards remains good.
% Patients Who Left ED Without Being
Seen
Standard < 5%
Total Time Spent in A&E
Standard ≤ 4 hours (95th Percentile)
Time to be Seen
Standard ≤60 minutes (Median)
4.70
90
7.0
80
4.50
6.0
70
5.0
4.30
4.0
4.10
60
50
40
3.0
3.90
30
2.0
20
3.70
1.0
10
3.50
0.0
A
M
J
J
A
S
2012-13
2014-15
O
N
D
2013-14
Target
J
F
M
A M
J
J
A
S
O
N
D
2012-13
2013-14
2014-15
Target
J
F
M
0
A M J
J A S O N D J F M
2012-13
2013-14
2014-15
Target
4
18 week waits
Admitted
Non admitted
Incomplete
• 90.3%
• 95.02%
• 92.5%
18 weeks overall position: all targets were met in
September 2014 by a very slight margin for non admitted in particular, where
percentage achieved is less than last month. 73 patients were waiting over 30 weeks (compared to 92 last month) and also the number of
patients receiving TCIs late in their pathway remain relatively high, so the pressure on waiting times is likely to continue going forward.
Addressing our backlog of long waiters resulted in a large increase in non admitted clock stops over 18 weeks in September 14.
206 patients were not treated within 18 weeks due to insufficient capacity.
The non admitted clock stops have increased to 90.
18 weeks admitted performance
94.0%
93.0%
Patients not treated within 18 weeks due to insufficient capacity
92.0%
91.0%
90.0%
89.0%
90
88.0%
There are no patients waiting over 52 weeks. This
stems in part from agreed new admin and reporting
procedures around where patients request very
long pauses on their pathway. Previously we have
been reporting these as 52 week waiters
Feb-13
41
2
54
0
8
2
105
83
61 56 62 73
128 118
1
118
75
Admitted
97
112
Non admitted
8
90 87 90 97
112 116
Sep-14
3
3
4
Aug-14
2013/14
4
Jul-14
7
46
Jun-14
M
Mar-14
F
Jan-14
J
Dec-13
D
12
8
Oct-13
N
Sep-13
O
Aug-13
2012/13
S
Jul-13
A
Jun-13
J
May-13
J
Apr-13
M
Mar-13
A
10
May-14
11
Nov-13
86.0%
60
14
Apr-14
14
Feb-14
87.0%
5
18 week waits
% still waiting for clock stop (incomplete) under 18
weeks
Fig 2: 18 weeks Current problem, future problem
100.0%
700
98.0%
600
500
96.0%
400
94.0%
300
92.0%
04.10.14
Target
31.08.14
M
03.08.14
F
13.07.14
2014/15
J
22.06.14
D
25.05.14
N
27.04.14
O
06.04.14
2013/14
S
16.03.14
A
23.02.14
J
02.02.14
2012/13
J
12.01.14
M
15.12.13
A
24.11.13
0
03.11.13
88.0%
13.10.13
100
22.09.13
90.0%
01.09.13
200
Performance for patients still waiting for their initial treatment (either admitted or non admitted pathway) has increased slightly this month to
92.5% being within 18 weeks (Fig 1.), compared to 92.1 last month. This remains very close to the target of 92%.
Regarding patients waiting for an admission (Fig. 2), the green line, (which is the total of the red and blue lines) illustrates the overall potential
problems we have in managing our 18 weeks admitted demand; this has increased steadily since April 2014, with slight decline in July and August.
The blue line illustrates patients with a date to come in who are already over 18 weeks or whose TCI date is over 18 weeks. This has reduced
slightly.
The red line illustrates patients who are waiting 14 plus weeks and do not have a TCI date yet. This is starting to increase again. The challenge of
meeting 18 weeks for our patients continues to be significant and all Directorates are reviewing this to see if actions can be taken to help reduce
these waits.
6
Whole Inpatient waiting list and long waits
73 RTT patients either still waiting or
whose clock stopped after 30 weeks
Whole Waiting List Size (not just RTT
patients)
8000
All Patients Still Waiting or Whose Clock
Stopped Over 30 Weeks
160
7000
Specialty break down of the 59
patients still waiting over 30 weeks
140
6000
120
5000
100
80
140 140
60
40
20
Inpatients
Surg/Cardiac Inpatient
Outpatients
The overall waiting list for surgical and cardiac stands
at 2303, with the total inpatient list standing at 4114
and outpatients at 6695. Although there has been a
decrease in the lists this month, they remain
extremely high when compared with previous
periods. The reduction in the size if the inpatient list
is marginal, but actions to address outpatient
demand and long waiter backlog is now having a
good impact on the size of the outpatient list.
73
94
109
116
99 107
104
92
73
Sep-14
Aug-14
Jul-14
Jun-14
May-14
Mar-14
Feb-14
Dec-13
0
Nov-13
24/09/2014
24/08/2014
24/07/2014
24/06/2014
24/05/2014
24/04/2014
24/03/2014
24/02/2014
24/01/2014
24/12/2013
24/11/2013
24/10/2013
24/09/2013
24/08/2013
24/07/2013
24/06/2013
0
57 61
Oct-13
1000
Sep-13
2000
Jan-14
3000
Apr-14
4000
At end of September, there are still 73 patients waiting
over 30 weeks (either still waiting or who had their clock
stopped in the month), compared to 92 last month.
Paediatric
Cardiology
Paediatric Ear
Nose and Throat
Paediatric
Neurosurgery
Paediatric
respiratory
Paediatric Plastic
Surgery
Paediatric Surgery
Paediatric Trauma
and Orthopaedics
Paediatric Urology
Paediatrics
Grand Total
3
6
2
1
15
5
16
8
3
59
The action to address our long waiters is having a positive
impact here.
Of the 73 patients 14 had their clock stopped over 30
weeks and 59 are still waiting.
7
Diagnostic waiting lists
Diagnostic waits overall position: We continue to fail to meet our
key target for MRI, although breaches have reduced significantly
from the start of this year. There were 17 breaches in September
for MRI and also 5 CT breaches. All are GA related. Demand
continues to be high and capacity subject to some constraints and
therefore some breaches will continue into the future.
The chart below indicates that a reduction in demand and the additional capacity
created to address our six week wait problem has had an impact on the size of the
overall MRI waiting list over the last few months.
MRI Waiting list
Total WL
1400
GA WL
1200
Patients waiting >6 wks for diagnostic test - actual & forecast
1000
Patients
160
140
120
100
80
60
40
20
0
800
600
400
200
2012-03-…
2012-04-…
2012-05-…
2012-07-…
2012-08-…
2012-09-…
2012-10-…
2012-11-…
2012-12-…
2013-01-…
2013-03-…
2013-04-…
2013-05-…
2013-06-…
2013-07-…
2013-08-…
2013-09-…
2013-11-…
2013-12-…
2014-01-…
2014-02-…
2014-03-…
28/04/20…
29/05/20…
2014-06-…
2014-08-…
2014-09-…
Dec-14
Total waiting list additions by week
Total external referrals
UpperCI
Mean
TGT (10)
180
160
140
120
100
80
60
40
20
0
Total Additions by week
Lower CI
Linear (Total Additions by week)
07/09/2014
07/08/2014
07/07/2014
07/06/2014
07/05/2014
07/04/2014
07/03/2014
07/02/2014
07/01/2014
07/12/2013
07/11/2013
07/10/2013
07/09/2013
07/08/2013
07/07/2013
07/06/2013
07/05/2013
07/04/2013
07/03/2013
07/01/2013
The service continues to be under significant pressure, but actions to manage the
position are starting to show results, as breaches are significantly lower than at the
start of the year. 22 patients breached the 6 week target in September 2014 (17 are
MRI breaches and 5 were CT breaches). Breaches are predicted to continue due to
the high demand. Predicted breaches for the next three months are shown in the
graph above and are predicted to be 27, 35 and 32 breaches. These breaches are
all for GA cases and this is the area where we have the most capacity constraints
currently as the additional Aston capacity for the non GA cases is starting to come
on line. Prediction for Oct to Dec is slightly higher than reported in the August
paper as the figs there were under-reported due to a technical issue with the
method for extracting data from the RIS System. However work is in hand to
allocate additional GA sessions in November due to new anaesthetic capacity
coming on line. This would mean that with normal demand and without
unexpected capacity issues we should meet this target by then end of November
2014.
The SPC chart (right) on total waiting list additions shows that the high level of
additions fell in August (average of 120 per week). However this trend has reversed
in September with an average of 130 additions per week.
07/02/2013
Nov-14
Oct-14
Sep-14
Aug-14
Jul-14
Jun-14
May-14
Apr-14
CT
27 35 32
Patient numbers
MRI
Mar-14
Feb-14
Jan-14
Dec-13
Nov-13
Oct-13
0
8
Access to CAMHS
Community CAMHS - Waiting Time to Assessment
A:- 0-4 wks
CAMHS 18 Weeks Performance
100%
100
80%
362
709
95
60%
956
105
90
40%
85
20%
80
1475
B:- 4-8 wks
C:- 8-13 wks
43
367
354
233
1066
757
854
881
767
1125
884
2011/2012
2012/2013
D:- >13 wks
8
288
199
1211
430
2013/2014
2014/2015
0%
75
2010/2011
Apr May
Jun
Jul
2012/13
Aug
Sep
Oct
2013/14
Nov
Dec
Jan
2014/15
Feb
Mar
Target
CAMHS continue to achieve their 18 week target with 93.9% of patients
seen within target in September (and 97.8% year to date). However the
last 2 months have seen a decline in performance.
Financial Years
In September CAMHS assessment of their patients within four weeks has reduced to
46% from 54% last month, so that performance is worse than for 2013/14 at 52%. The
average wait is now 7.9 weeks from 4.3 weeks in 2013/14, and 8 in 2012/13. This is as a
result in shortfall in capacity and this is currently being reviewed to ensure all job slots
are being delivered. Also to reduce wait times to first appointment the department is
trialling telephone calls to patients not responding to their invitation letter.
CAMHS Patients that requested a T4 bed and were not
admitted (month trend)
18
16
14
12
10
8
6
4
2
0
Apr
May
Jun
Jul
2012/13
Aug
Sep
Oct
2013/14
Nov
Dec
Jan
2014/15
Feb
Mar
Tier 4 referrals (in blue) and gateway assessments (the red line) have increased in
September. The green line shows patients not able to access a bed and therefore
referred to the Specialised Commissioning Team. The number has increased to 11 in 9
September.
Urgent Tertiary and Home Referrals
163 referrals for
specialist beds,
148 admitted
2 in region
patients unable to
get a bed
0 out of region
patients unable to
get a bed
13 patients no
longer required a
BCH bed
14 in region patients
waited over 24 hours
to get a BCH bed
2 out of region waited over
24 hours to get a BCH bed
Overall position: Tertiary and home urgent referrals totalled 163 in September. Two patients were refused a bed (both in region) and 16
patients waited over 24 hours which continues to be lower than average. Overall 90.5% of requests were met within the required clinical
timescale.
Activity levels - The level of urgent referrals (163) continues to be relatively low in September.
Urgent Tertiary and Home Referrals
250
200
150
225
175
170
188
191
172
182
197
177
188
181
173
163
169
209
230
217
179
159
163
100
50
0
Feb-13 Mar-13 Apr-13 May-13 Jun-13
Waiting time vs. clinical
target time
Clinicians can request the patient to be
admitted in up to 48 hours, dependent
on their assessment. The graph shows
the timescales requested for
admittance and time of decision to
admit.
Overall 90.5% of requests were met in
September (compared to 91.9% in
August).
Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14
Home
Tertiary
Total
Jul-14 Aug-14 Sep-14
Performance vs clinical target time for patients provided a bed - home and tertiary referrals
70
100%
97%
89%
60
78%
50
80%
40
60%
30
40%
20
20%
10
0%
0
within 12 hours
Met
12-24 hours
Up to 48 hours
Target Time
Not met
% patients meeting tgt time
10
Urgent Tertiary and Home Referrals
Referrals Sent Elsewhere
Two referrals were sent elsewhere in September 14. Referrals sent elsewhere for
14/15 at 28 is now 78% of the entire 13/14 financial year total, indicating that the
management of these urgent referrals has been challenging. This has been due to
high overall demand for beds in early Summer 2014 in particular.
Referrals Waiting over 24 Hours
The number of children waiting over 24 hours for a bed after a
tertiary referral continues to be below average. 90.5% of referrals
were managed within the clinical target time which is lower than
last month (91.9%).
Tertiary and Home Urgent Referrals Sent Elsewhere
Paediatrics
T&O
Plastic
Surgery
Resp Med
Neurology
Nephrology
Medical Oncology
ENT
Clin Haem
Cardiology
Hepatology
YTD 14/15
Tot 13/14
Trend - Tertiary and Home Referrals Waiting Over 24
Hours for a Bed
50
45
0
5
10
15
20
Long Term Trend Tertiary Refusals
40
35
30
25
18
16
14
12
10
8
6
4
2
0
20
15
10
5
0
Aug-09
Nov-09
Feb-10
May-10
Aug-10
Nov-10
Feb-11
May-11
Aug-11
Nov-11
Feb-12
May-12
Aug-12
Nov-12
Feb-13
May-13
Aug-13
Nov-13
Feb-14
May-14
Aug-14
Aug-14
Jun-14
lower ci
Apr-14
Feb-14
Dec-13
Avge
Oct-13
Aug-13
Jun-13
Apr-13
Feb-13
Avge
Dec-12
Oct-12
Total
Over 24 Hr Waits
upper ci
11
PICU Demand and KIDS Service
1 West Midlands patient could
not be supported within
Region
3 non West Midlands
patients could not be
supported within Region
6 additional non West Midlands
patients were supported at BCH
PICU demand overall: Referrals
in September have increased compared to the low level in August. However only 4 patients not
be supported within the local network and had to be taken out of region.
250
There were 96 referrals to KIDS in September 2014 of which 33%
of referrals were avoided , 43% were admitted to BCH, 20% were
referred to other WM hospitals and 4% went out of the region
(compared to 3% in previous month when referrals were very
low).
Year on Year Comparison of Total Referrals to KIDS
200
150
100
Referrals to KIDS Service Taken Out of Region
(Leics or Other Non WM Provider)
50
0
Apr May
Jun
Jul
Aug
2012/13
Oct
2013/14
Nov
Dec
Jan
Feb
Mar
2014/15
Outcome of Referrals to KIDS - Trend
Aug-14
Jun-14
Apr-14
Feb-14
Dec-13
Total
Oct-13
40%
Aug-13
Jun-13
Apr-13
Feb-13
50%
Dec-12
Oct-12
60%
Sep
30
25
20
15
10
5
0
Avge
30%
20%
10%
0%
Avoided Admission
BCH
UHNS and Other WM
Out of Region
The red line shows that BCH
took fewer referrals in the first
part of Winter 2013, but is now
at more normal level. Despite
the increase in referrals in
September, more referrals
were
avoided.
Therefore
admissions taken OOR has not
increased significantly.
For the winter periods patients
are more likely to be taken out of
Region. However in June 14 in
particular, due to high demand for
beds, more patients were taken
out of region but this has now
returned to normal levels.
12
Operational Performance Report
Month 6 2014/15
Performance for September 2014
Utilisation of our facilities
13
Cancelled operations trends
Cancelled operations overall position: the number of cancelled operations flagged as nationally reportable in September 2014 is
26 and is below the monthly average and total for last month (28). Five of these cancellations were as a result of accommodating a liver
transplant. For the second month running there were no breaches of the 28 day standard. Hospital cancelled operations on the day as
percentage of elective operations has reduced again to 1.13%, (from 1.39% last month). The graph below shows this percentage is variable
each month.
Cancelled Operations On The Day - National Definition
As a % of Electives
Nationally Reported Cancelled Ops
Jul-14
Apr-14
Jan-14
Oct-13
Jul-13
Jan-13
Oct-12
Jul-12
Apr-12
Jan-12
Oct-11
Jul-11
Apr-13
4
2
2
0
0 0
Sep-14
Contract Trajectory
0
1
4
3
Aug-14
Avge % Cancelled
0
2
Jul-14
0.0
3
7
5
Jun-14
10
6
May-14
0.5
7
Apr-14
20
Mar-14
1.0
11
Feb-14
30
Jan-14
1.5
Cancelled
operations as a
percentage of
elective operations
was 1.13%, lower
than the last
month (1.39%)
The contract
trajectory shown is
for 1314, as one
has not been
agreed yet for
1415.
Dec-13
40
lci 2stdev
16
Nov-13
2.0
18
16
14
12
10
8
6
4
2
0
Oct-13
50
uci 2stdev
Breaches of 28 Day Cancelled Operations Standard
Sep-13
2.5
mean
Aug-13
% Cancelled
3.0
Data
Jul-13
3.5
Apr-11
Apr May Jun
2012/13
Jun-13
28
350
300
250
200
150
100
50
0
-50
-100
May-13
54
All Hospital Cancelled Operations
Apr-13
66
The total number of
nationally reportable
cancellations in September
was below average at 26. In
48
mid month 2 elective lists
were switched to Trauma,
which should have a
28 26
positive effect on both
cancellations and patient
experience. A Trauma coordinator is now in place to
Jul Aug Sep Oct Nov Dec Jan Feb Mar assist in identifying lists and
2013/14
2014/15
Avge for 3 years
beds for these patients.
Similarly we have created a
surgical flow co-ordinator
Percentage of Operations Cancelled on the Day
post for 6 months to help
80
ensure we utilise as much
capacity as possible in a
70
time of growing demand for
our services
60
Total Cancelled
80
70
60
50
40
30
20
10
14
All Hospital cancelled operations year to date by specialty
All Hospital cancelled operations year to date by reason
Admi nistrative
Error, 0.9%
All Hospital Cancelled Operations 2014/15 Year to Date
Other Dir 3, 0.6%
Other Dir 4, 9.7%
Ana esthetist
una vailable, 3.0%
Plastic Surgery,
13.0%
Other, 4.7%
Surgeon
una vailable, 3.6%
Other Dir 2,
6.5%
T&O, 6.4%
Hepatology, 4.0%
Urology, 6.3%
Haematology,
4.6%
Cardiology, 3.8%
La ck of theatre
ti me, 5.0%
Emergencies/Trau
ma , 24.9%
ICU/HDU beds
una vailable, 5.7%
Unfi t with acute
i l lnes (Hosp Ca nc),
5.7%
Cardiac Surgery,
8.8%
Radiology, 7.6%
Bed Shortage,
18.6%
Opera tion not
necessary (Hosp
Ca nc), 13.1%
Ophth, 4.3%
Paed Surgery,
12.5%
ENT, 11.8%
Pa ti ent not suitable
for OP, 14.8%
Nationally Reportable Cancellations by Reason – Sep 2014
The hospital has cancelled 1288 operations so far in 2014/15. The Surgical Directorate
has the most cancellations (825– 64.0%) with Plastics, Paediatric Surgery, ENT and
Cardiac Surgery being the largest single specialties. The biggest reason for the YTD
cancellations is Trauma and Emergencies (25%), bed shortages with 18%, patient not
suitable for operation (15%) and operation not necessary 13%. For September the biggest
reason is to accommodate emergencies and trauma (31%). Actions in place to try and
alleviate this are outlined in the previous slide.
Equipment failure
Bed shortage
Emergency/Trauma (of which 5 due to liver transplant)
List overrun
Admin Error
ICU bed shortage
Total
0
6
14
3
1
2
26
15
Multiple cancellations
Patients cancelled more than once in same specialty during
2014/15
90
35
Cancelled Operations Associated With Patients cancelled more than once in
same specialty during 2014/15
80
30
70
25
60
20
50
15
40
10
30
20
5
10
Twice
3 times
4 times
5 times
6 times
7 times
Sep-14
Aug-14
Jul-14
Jun-14
May-14
Apr-14
Mar-14
Feb-14
Jan-14
Dec-13
Nov-13
Oct-13
Sep-13
Aug-13
Jul-13
Jun-13
May-13
Apr-13
0
0
Twice
3 times
4 times
5 times
6 times
7 times
Strategic Objective – patients cancelled more than twice
(Hospital Cancellations Only)
In September 2014 27 patients had an operation
cancelled who had previously had an operation cancelled
at least once in the same specialty in the previous 12
months. These 27 patients had 62 cancellations
between them in total in the previous 12 months in the
relevant specialty.
Six patients had an operation cancelled in September 2014
for the third or more time (NB cancellations have to be in
the same specialty and in the previous 12 months to be
counted)
Strategic objective: Year to date hospital cancelled
operations are running 321% higher than the
equivalent year to date figure for 2013/14. (Target
10% reduction)
Classification changes account for this in part.
Strategic objective: For nationally
reportable, one operation was cancelled
due to admin error, and none due to
equipment failure or unavailability (Target
is zero)
16
Fit For Discharge Days
Long Stay Patients
From Summer 2013 to June 2014 there was an increasing number of
longer stay patients in the hospital, as can be seen by the trend lines
illustrating the numbers over 7, 30 and 90 days at any particular point in
time. This had a significant impact on bed availability and cancelled
elective operations. General Paediatric patients in particular were a
problem area.
In July and August 14 this cohort of long stay patients was significantly
reduced, freeing up capacity on the wards overall and reducing the
number of cancelled operations due to bed shortages. However this trend
has reversed in September for those staying over 7 days and slight
increase in those staying over 90 days
140
Inpatient Long Stayers by days
120
CAMHS - Long Stay Patients at end of September - Fit for
Discharge Days
Patient 5
Patient 3
Patient 1
0
100
200
300
Before fit for discharge
400
500
600
After fit for discharge
6 CAMHS patients were fit for discharge at end of September and are the same
patients reported last month. All were waiting for placements. In total these six cases
have been fit for discharge for 975 days. At time of writing this report one had been
discharged and another was due for discharge.
Long Stay patients at end of September - days fit for discharge
100
Patient 3
80
Patient 1
0
60
100
200
Before fit for discharge
40
20
03/10/2013
16/10/2013
29/10/2013
11/11/2013
24/11/2013
07/12/2013
20/12/2013
02/01/2014
15/01/2014
28/01/2014
10/02/2014
23/02/2014
08/03/2014
21/03/2014
03/04/2014
16/04/2014
29/04/2014
12/05/2014
25/05/2014
07/06/2014
20/06/2014
03/07/2014
16/07/2014
29/07/2014
11/08/2014
24/08/2014
06/09/2014
19/09/2014
02/10/2014
0
'GT7
' GT30
'GT90
300
400
500
After fit for discharge
4 patients were waiting for discharge at end of September. Two patients were
waiting for a care package (with one of these also having social issues), one
needs social care and the final patient is waiting transfer to DGH. In total these
4 patients have been fit for discharge for 333 days. Assuming an average
length of stay (excluding day cases) of 4 days, another 83 patients could have
been seen at the hospital if these patients had been discharged, as they
became fit. It is pleasing that delayed discharges have been decreasing over
the last couple of months.
17
Item 14.219
Surgical Directorate
Business case for a Mobile ‘Visiting Hospital’
1
SECTION
1
EXECUTIVE SUMMARY
NAME OF BUSINESS CASE:
Proposal for a temporary theatre and ward unit on site.
TYPE OF BUSINESS CASE:
This case proposes the placement of a mobile theatre and ward unit known as a ‘Visiting Hospital’
on site that provides additional capacity for elective surgical admissions which will support a
reduction in waiting times and achievement of the 18 week standard.
2
SECTION
2
BUSINESS NEED (WHY DO WE NEED TO CHANGE?)
The Business Need – why do we need to change?
The Trust has continued to be challenged with the size of the inpatient waiting list and there is a mismatch
between capacity and demand. Despite undertaking a series of actions to increase efficiency and capacity
the elective surgical waiting list has continued to grow. This is making it difficult to achieve access standards
and there have been a growing number of patients waiting beyond 18 weeks for their definitive treatment.
Recently due to National pressures to meet 18 weeks, commissioners have requested providers to submit
recovery plans to reduce backlogs and sustain 18 week performance. Whilst it is known that through the
Surgical Flow project further efficiency improvements can be made this case aims to provide a solution that
will respond to helping reduce the backlog and put us in a much stronger position for changes to be made.
The purpose of this business case is to propose the positioning of a temporary Visiting Hospital, which is a
combination of a modular operating theatre and a modular ward at the front of the hospital.
The next generation project will see the development of a clinical build which will accommodate additional
theatres and associated bed capacity. However, once agreed this will take 2 years for it to become
operational.
BACKGROUND
Work was undertaken with IMAS in 2013 to refresh the capacity and demand modelling undertaken in 2012,
which continued to demonstrate a mismatch. Furthermore there has been a growing year on year demand in
the majority of surgical specialties. To support this increase in demand additional weekend lists have been
accommodated and in week capacity secured at the Birmingham Treatment Centre. Whilst this additional
capacity has been accommodated it has significantly stretched resources and often fluctuates dependent on
the availability of staff. Equally the utilisation of BTC is variable due to the limitations of case mix and age
restriction.
The current situation and existing arrangements
Activity
The following table provides the last 3 years elective Surgical (D4) activity which demonstrates the year on
year increase, which has been delivered through a combination of new ways of working, additional weekend
lists and capacity at the Birmingham Treatment Centre.
11/12
11,267
12/13
11,804
13/14
12,418
Demand
A review of referrals and source has been undertaken. The below charts show the growth in referrals across
3
the high volume surgical specialties (Figure 1) and by CCG (Figure 2), comparing 2013/14 monthly average
against Q1 2014/15 average.
Figure 1
Figure 2
Capacity & Demand Gap
Modelling of the ideal waiting list size to sustain and comfortably meet the 18 week standard was undertaken
in November 2013 and Table 1 below highlights the challenges faced.
Table 1
Ideal OPWL
Size
Actual
OPWL Size
Variance
Ideal IPWL
Size
Actual
IPWL Size
Variance
Urology
181
525
-344
153
277
-124
ENT
247
755
-508
300
412
-112
Paed Surgery
139
257
-118
222
243
-21
Plastics
202
328
-126
204
251
-47
Orthopaedics
210
386
-176
75
246
-171
Specialty
It has been calculated that to reduce our backlog to our ideal WL size this would require 1 theatre operating
for 6 months. To close our demand and capacity gap there is a requirement for an additional theatre. This is
demonstrated in table 2 overleaf.
4
Table 2
Specialty
Ideal WL Size to
achieve 18 weeks
Current RTT WL Size
(excluding Planned)
Backlog
Additional Capacity
Required to meet
current Demand and
18 weeks (excl dealing
with Backlog)
5 Sessions *
Paediatric Surgery
200
264
64 = 32 theatre
sessions
Urology
153
272
2 sessions
ENT
290
424
Plastics (inc CLEFT)
204
284(exc Laser)
119 = 40 theatre
sessions
134 = 45 theatre
sessions
80 = 40 theatre
sessions
Orthopaedics
75
239
0
Total
922
1483
164 = 82 theatre
sessions
239 sessions
Comments/Actions
* Major /Minor split of
cases needs further
work as this could
change the additional
capacity required.
2 sessions
1 session
Further work to review
this by sub-specialty to
understand where we
need to focus the
capacity.
10 sessions
Cancelled Operations
The Trust experienced significant pressure during the spring/summer months in terms of bed capacity and a
number of elective admissions were cancelled across many specialties, particularly in April, where the highest
numbers of on the day cancellations were reported (Figure 3). To avoid further cancellations on the day
throughout May and June the surgical directorate were regularly cancelling patients the day before to avoid
further disruption and anxiety (Figure 4).
Figure 3
Figure 4
These cancelled operations have added further pressure onto the inpatient waiting list that is shown in Figure
5 overleaf. The specialties where there has been the largest increase are within ENT and Orthopaedics.
5
Figure 5
Whilst the Trust has achieved 18 weeks since April 2013 this continues to be challenged. Figure 6 below
shows the 18 week performance of the surgical specialties (D4) since April 2013.
Figure 6
92
90
88
Performance %
86
Target %
84
82
80
6
Figure 7 below shows the growth in the number of patients waiting 18+ weeks (dated & undated) since
August 2012 to Sept 2014.
Figure 7
There is currently no flexibility in the existing theatre plan with all theatres utilised to their full capacity
Monday to Friday. There are a couple of exceptions where there are treatment rooms available but the types
of cases are limited due to the size, specification and location of these. This means that when there is staff
shortage, increase in emergencies or liver transplants, elective activity is often cancelled.
Trauma demand has also increased year on year and when there are peaks in demand elective cases will be
cancelled as trauma lists overrun into elective afternoon sessions. Figure 8 below shows the trauma demand
for the past 3 years.
Figure 8
New Ways of Working
The surgical flow project will undoubtedly provide efficiencies with theatre scheduling and utilisation.
However, it is recognised that the outputs of this will take time to be realised. The introduction of preassessment for all elective admissions and an admissions lounge will all help to improve flow of patients and
utilisation of capacity. The mobile unit will provide an option for these changes to take place and provide the
capacity needed to get us into a better position.
7
Fit with the Trust’s Strategic Objectives
Our Vision
The surgical directorate have a shared vision to provide excellent care that is nationally and internationally
recognised with services that are innovative and which strive for improved patient outcomes through
research and development. This involves strengthening partnerships with colleagues and stakeholders
internally and externally within the health economy, wider community and our networks. We will place
babies, children, young people and their families at the heart of what we do in a Directorate where
performance stands out with high quality cost effective care. We wish to develop a new hospital with
appropriate facilities for the local population and beyond, retaining and attracting the best calibre of
consultants, nurses and other health professionals wanting to share in our success and vision.
We have 4 strategic aims to
•
•
•
•
Build the profile and reputation of services through listening and engaging with key stakeholders
Enhance access and care with coordinated patient journeys
Ensure that the services have the required resources, capabilities and capacity to meet demands and
deliver high quality care
To achieve a sustainable financial position
Our vision and aims underpin the Trust’s Strategic objectives.
We will have made year on year reductions in avoidable waiting at all stages of care
The additional capacity this case will provide will ensure that we can improve on our 18 week performance
and provide timely care for our patients.
We will work with our partners to establish a range of mature clinical networks
We wish to develop further hub and spoke arrangements for a number of our high volume specialties. This
will compliment this case and ensure we can continue to meet the demand to our services.
We will be able to demonstrate that no child has experienced avoidable harm
Supporting this case will reduce waiting time for patients.
We will admit children and young when they need us to and deliver services which are safe, effective,
compassionate, innovative and child-centred in a healing environment
In addition this proposal would fit with the long term goals of delivery of safe and effective services and
delivering the best outcomes for children young people and their families.
8
SECTION
3
OPTIONS ANALYSIS
Long list of options
Option 1 – Do nothing – Continue to operate WLI and use of BTC
Option 2 – Mobile Ward & Theatre Unit ‘Visiting Hospital’ with a link corridor into the main hospital
Option 3 – Mobile Ward & Theatre Unit ‘Visiting Hospital’ without link corridor to the main hospital
Option 4 – Increase provision off site, utilising other NHS or private provider facilities.
Option 5 – Management of Demand
Excluded Options
Option
Reason for Exclusion
Option 3
Excluded based on reputational and safety factors
Option 4
This already happens with the BTC but case mix and age restrictions limit
utilisation.
Option 5
Demand data has been shared with Commissioners and discussions are ongoing. However, the unit is to help manage patients currently waiting and
therefore this option would not have the immediate impact.
Short list of options
Option 1 – Do nothing – Continue to operate WLI and at BTC
Option 2 – Mobile Ward & Theatre Unit ‘Visiting Hospital’ with a link corridor into the main hospital
9
Options Analysis
The analysis below appraises the mobile unit over a 26 month period starting February 2015 to March 2017
in line with the opening of the new clinical build in April 2017.
FINANCIAL ANALYSIS £'000
Yr 0
Yr 1
Yr 2
14/15
15/16
16/17
2 months 12 months 12 months
BENEFITS
TOTAL
working
ref
Income
1
311
1,635
466
2,412
Loss of car park
2
-31
-98
-98
-228
280
1,536
367
2,184
Total Benefits
COSTS
0
Revenue
0
Pay
3
171
1,024
1,024
2,218
Hire of unit
4
894
0
406
1,300
Consumables
5
18
98
38
155
B Braun
6
3
14
6
22
Facilities
7
6
35
35
75
Utilities
8
1
4
4
9
Reduction in premia pay
9
-8
-47
-591
-645
Reduction in BTC hire
10
-34
-202
-202
-437
One off costs:
0
Theatre Trays
11
153
0
0
153
Framework registration
4
6
0
0
6
Cleaning equipment
12
5
0
0
5
Capital:
0
Works - corridor
13
21
124
145
289
Works - MDC door
14
0
1
1
1
CCTV
15
0
2
2
4
1,235
1,053
867
3,155
-955
484
-500
-971
Total Costs
Net (Costs) / Benefits
10
Notes
1. Income
An options appraisal has been undertaken that has evaluated how the unit could be used and the proposed
case mix. These are shown in Appendix 1. This case mix takes account of current demands, including backlog
and risks to RTT delivery.
The growth in terms of demographics and market share have been assessed in conjunction with the planned
efficiencies through Newton, which are shown below:
Activity
Specialty
Urology
ENT
T&O
Plastics
Paed Surg
Maxfac
Ophthalmology
Target
improvement
7%
13%
8%
9%
9%
7%
8%
Additional
98
92
81
79
0
0
22
Repatriation of
BTC
0
93
Weekend
activity
0
196
0
66
43
12
17
The impact of this has necessitated evaluation of further specialities to ensure that there is sufficient activity
demand to maximise utilisation of the mobile unit. Once all backlog and unmet demand is absorbed then the
activity will be an in week repatriation of premium weekend activity and urology activity currently delivered
at Birmingham Treatment Centre (BTC).
The income has been calculated using the average tariff by speciality for new activity only. The financial
impact of repatriating activity is reflected in a reduction in costs.
2.
The loss of car park income relates to the 27 car park spaces which will be removed at the front of
the site.
Expenditure
3.
Pay
The unit will operate 5 days a week between 8am and 6pm. Nursing and operating department practitioners
can be supplied directly from Vanguard. It is recommended that at least one member of Vanguard personnel
is hired to maintain an onsite presence and be responsible for the day to day functioning of the unit, which
includes daily stock keeping. If this service is purchased then the unit can be deemed a healthcare facility and
VAT payable on the hiring of the unit and staffing can be recovered, which is a significant financial advantage.
Recruiting the remaining staff will provide in house capability and a phased approach which will maximise
development and service delivery. This will also mean that a trained and embedded theatre team will be
available in readiness for the new theatres contained within the Next Generation project.
a.
Consultants and Juniors: An increase of 10 sessions per week will require 2 Anaesthetists which have
been costed at mid-point. Although the additional ENT sessions can be met through existing
consultant workforce, locum consultants will be required for Urology, Trauma and T&O. These are
included in the financial analysis with further junior support for Trauma and T&O.
11
b.
Theatre and recovery/ward staff: Theatre staff will work a 4 day week, 8am – 6pm through a
standard 10 session week rota. It is recognised that recruitment to posts will require an
implementation and training programme with potential reliance on bank and agency in the interim.
Bank and agency pay costs have therefore been used in the financial analysis for the following
manpower:
Theatre Team:
Surgical Nurse
ODP – hired from Vanguard
Anaesthetic nurse
Nurse
Nurse
Recovery staff:
Recovery practitioner
Recovery Nurse
CSW – Ward
CSW - Ward
Band
6
5
5
3
2
Number
1
1
1
1
1
5
2
5
3
2
1
1
1
c. Administration: A full time band 3 ward clerk has been included at mid-point and will act in a coordinator role, managing all referrals to the mobile unit.
d. The increase in activity will require additional clinical support services, which has been estimated as:
Department
Labs
Labs
Labs
Imaging
Ambulatory Care
Ambulatory Care
Ambulatory Care
Ambulatory Care
Service
Histopathology
Microbiology
Blood Science
Radiology
Phlebotomy
Pharmacy
Technician
Physio
WTE
0.2
0.5
0.3
0.6
0.25
0.2
0.5
0.5
e. Cleaning and portering pay costs have also been incorporated in the financial analysis.
Non-Pay
4.
Hire of unit: A reduced weekly hire charge for the combined operating theatre and ward unit has
been negotiated which presents better value for money the longer the unit is on site. The maximum
reduction to £11,000 per week is available when hired for 18 months or longer. A further 10% reduction can
also be guaranteed when procured through the North of England NHS Commercial Procurement
Collaborative. BCH does not currently have access to this framework so a £6k registration fee will apply.
The financial analysis assumes full payment of 18 months hire on arrival of the unit with the hire charges
after this period paid in respective months.
As detailed above, VAT is recoverable if the unit is deemed a healthcare facility. This requires certain criteria
to be met which include Vanguard staff stocking the unit daily. Sourcing the ODP through the contract will
achieve this however the final contract will need to be reviewed by the Trust’s VAT advisors before this can
be guaranteed (initial discussions have already taken place which we have acted upon in deciding how the
unit will operate). The risk of not recovering VAT is low as this is adopted at other providers accommodating
12
a Vanguard unit. The charges in the financial analysis and in the table below are therefore excluding VAT.
Framework
Fee
Cost Saving
(from original
quote) over
duration
Per week
Per week
Price via
Procurement
Framework
6 months
£15,000
£15,000
£13,500
£6,000
£33,000
12 months
£15,000
£14,000
£12,600
£6,000
£118,800
18 months or
longer
£15,000
£13,000
£11,700
£6,000
£251,400
Original quote Revised quote
Duration
5.
Consumables are estimated at £3k per week for one theatre plus £30 per patient for drugs which is
the average cost year to date. This applies to new activity only as the consumables for current weekend and
BTC activity are already within baseline.
6.
The sterilisation of theatre trays has been calculated using suggested case mix, volume, tray category
and current contract price. These costs apply to new activity only as already in place for current BTC and
weekend activity.
7.
Facilities: costs include linen, waste, post, catering, patient transport, disposables and post.
8.
Utilities: Additional charges for electric and water
9.
Reduction in premium pay: The analysis assumes 23 weekend sessions are transferred in week
during 15/16 with a further 300 sessions being transferred in 16/17. The associated saving in premium rates
are therefore included.
10.
Reduction in BTC hire: Repatriating 72 sessions per year of urology activity from BTC will eliminate
hire charges of £2,800 per session. No formal SLA is in place for this service hence no notice period exists.
One-off costs
11.
Theatre trays: The case mix in option 2 has been reviewed and extra trays identified. Expansion of
specialities may lead to further trays being required, however this is dependent on speciality and timing of
the additional sessions. Although the full cost has been included in the financial analysis, trays have a useful
estimated life in excess of 2 years and can therefore be used in the new theatres contained within the next
generation project
12.
A cleaning machine will be required as the current machines cannot be used due to mobility
restrictions.
Capital
13.
A corridor is required to link the operating theatre to the ward unit and full connection to the main
hospital. The design and construction fees have been depreciated against a 26 month duration and cover:
a.
Fees for the design, planning application and building regulations.
b.
Site set up costs and building work for an enclosed corridor and fire exit ramps. This includes
all mechanical and engineering required.
c.
Water connection from the hospital boundary to MDC.
13
d.
e.
5% contingency.
Provision of £5,000 for removal of the corridor
14.
The outside door at MDC will need to be widened to provide an emergency route or transfer patients
who may not recover as anticipated and need to stay overnight. This will also make the door compliant with
DDA regulations. The current width presents a risk as it is not wide enough to allow a standard bed trolley to
pass through it.
15.
Additional CCTV provision is recommended and has been factored into the analysis and depreciated
over the life of the current system.
Further considerations:
In the first 12 months, over 80% of activity relates to current backlog or growth after Newton efficiencies.
During this period the deficit reduces month by month as additional income is received. As repatriation of
current activity replaces backlog activity the income reduces without cost reductions only partially offsetting
this. At this point the deficit begins to increase and continues over the remaining period.
Although an 18 month contract is needed to guarantee the full reduction in hire charges a review of activity
will be required at the 12 month point to assess growth assumptions and any potential opportunities. At this
stage a decision will be made on whether the Mobile Unit will be required through to April 2017.
Affordability:
The Trust has been successful in negotiating additional monies for Winter and RTT. These will be received
during 2014/15 and will have to be used in that timeframe. This affords us the opportunity to utilise part of
these monies to fund the 2014/15 deficit.
The impact of this decision and the resultant I&E positions in 2015/16 and 2016/17 are outlined in the table
below.
Year 0
Year 1
Year 2
Overall
2014/15 2015/16 2016/17
£000
£000
£000
£000
Original Position
-955
484
-500
-971
Confirmed RTT and Winter Funding
955
955
Total Impact on Existing Planned Surplus
0
484
-500
-16
Original Surplus
4761
4008
4221
Revised Surplus
4761
4492
3721
The case will provide a further benefit to the Trust’s finances in 2015/16 and as a result the planned surplus
increases to £4.492m. As the case presently stands there is a reduction in the planned surplus in 2016/17 to
£3.721m. However, with the review at 12 months a further assessment of the impact on 2016/17 will be
undertaken so this is the worst case scenario.
Overall, with the utilisation of the RTT and Winter monies the case has a net deficit of £16k.
In cash terms this case essentially has a nil impact (an overall reduction of £16k) so does not impact upon the
affordability of the Trust’s strategic ambitions around Next Generation.
A further consideration, although not factored into the case is the positive impact this will have on the
potential for the Trust to incur contract penalties. This unit will provide greater resilience and lessen the risk
of this being incurred.
14
Evaluate how well each option meets the evaluation criteria using the table below.
Option description
Option 1 – Do
nothing
Option 2
Evaluation Criterion
Raw Score (1-5)
Raw Score (1-5)
1
3
Achievability (See table below)
2
4
Risk of doing (See RISK
ASSESSMENT SCORING)
3
1
Financial Viability (See table
below)
1
5
OVERALL SCORE (SUM TOTAL)
7
13
Strategic fit (See STRATEGY
SCORING table below)
15
STRATEGY SCORING
Rank the options against each of the below objectives of the Trust. A score of 5 for example would
mean that the option has a high strategic fit, whilst a 1 is a low strategic fit.
Short term objectives
All children referred for inpatient
care will be admitted within 24h
of referral
We will have made year on year
reductions in avoidable waiting at
all stages of care
All children presenting at our
Emergency Department requiring
inpatient admission will be
admitted within 4 hours
We will be able to demonstrate
that no child has experienced
avoidable harm
We will work with our partners to
establish a range of mature
clinical networks
We will develop at least one
annual campaign at local, regional
and national levels centred on
children’s rights, health and wellbeing issues
Long Term Objectives
Option 1 – Do
nothing
Option 2
0
3
1
4
0
2
1
3
0
0
0
0
Option 1
Option 2
We will admit children and young
when they need us to and deliver
services which are safe, effective,
compassionate, innovative and
child-centred in a healing
environment
We will work with our partners to
deliver care as close to home as
possible
Our intentions will be delivered by
advocacy for the best outcomes
for children, young people and
their families
TOTAL SCORE
1
3
0
0
3
3
6
18
SCORE FOR INSERTION IN
SUMMARY TABLE (DIVIDE TOTAL
BY 8 AND ROUND TO NEAREST
WHOLE NUMBER)
1
2
16
Criteria
Achievability
Financial Viability (See EXCEL
WORKBOOK)
Score of 1 (Low)
Score of 5 (High)
The investment requires
significant change management,
reorganisation and additional
capacity and resources. There is
no / limited evidence of similar
projects delivering success.
There is existing capacity and capability
within the organisation and the
timescales and scope are realistic and
achievable.
Costs significantly outweigh
benefits (additional income and
efficiency savings) and the
required investment exceeds
available resources.
Benefits outweigh costs and the
required resource is available to deliver
the whole proposal.
17
RISK ASSESSMENT SCORING
Results
Option 1
Option 2
Measurement of Consequence (1 to 5)
4
2
Measurement of Likelihood (1 to 5)
4
3
Raw Risk Assessment (i.e. Consequence x
Likelihood)
16
6
Overall score from above divided by 5 and
rounded to nearest whole number
3
1
Taking the scores from total score from the now completed first table, the options can be evaluated
against each other.
OPTIONS EVALUATION
Options Evaluation Score
Ranking
Proposed Solution? (Yes
/ No)
An explanation should be
provided here where the
proposed solution is not
the option with the
highest score.
Option 1 Do
Nothing
Option 2
7
2
No
13
1
Yes
18
SECTION
4
PROPOSED SOLUTION
Project Scope
Visiting Hospital providing mobile theatre and 8 bedded ward area with a link corridor
to the main hospital for 18 months
In Scope:
Providing additional capacity for Urology, ENT, Orthopaedics and Trauma
Out of Scope:
A Task & Finish Group was set up to develop this case. An options appraisal was undertaken to review how
the unit could be used and the case mix. As previously described the preferred option is Option 2 which is
shown below:Monday
Tuesday
Wednesday
Thursday
Friday
Mobile
Urology
Plastics
ENT
MaxFac/Dental
ENT
Theatre 8
Plastics
All-day Trauma
Spinal
All-day
Trauma
Plastics/Maxfac
Theatre 6
Trauma/T & O
El Ortho
Trauma/T & O
El Ortho
Trauma/T & O
Theatre 2
Cardiac
Cardiac
Emergency
Plastics
Cardiac
A standard operational procedure is currently being developed that will provide a process for patient
admission into the unit. The unit will be linked to Medical Day Care which will provide an entrance for
patients/parents on admission. The link corridor to the main hospital provides an emergency route or a
transfer route for patients who may not recover as anticipated and need to stay overnight.
The benefits of this mobile unit are:•
•
•
•
•
•
•
•
Provide additional capacity for Trauma, Orthopaedics, ENT & Urology
Reduction in cancelled operations due to trauma
Provides associated bed capacity to compliment additional theatre activity
Reduction in waiting times for patients
Support achievement of 18 week standard
Reduction in backlog (patient waiting over 18 weeks)
Will bridge the gap between demand and capacity
Will enable flexibility for the management of liver and trauma activity
19
•
Enables new ways of working through the surgical flow to be embedded
STAKEHOLDER MAPPING TEMPLATE
Stakeholder
Group
Patients
GP’s
Consultant staff
Parents / carers
Perceived
Benefits
Improved
Access
Improved
Access
Manageable
work load
Better access
and treatment
for patients
Changes
Needed
Increase
capacity
Increase
capacity
Improve
theatre and
clinic utilisation
Increase
capacity
Perceived
Resistance
None
Negative
None
None
None
Neutral
Positive
C
R
C
R
C
R
C
R
C= CURRENT COMMITMENT
R= REQUIRED COMMITMENT
Stakeholder Analysis
Patients: Patients are key and at the centre of all that the Trust does. This business case would improve
patient access and reduce waiting times.
GPs: Will experience easier referral streams into the service due to an increase in capacity.
Parents / Carers: Although they are not the patient, parents and carers are key to the success of the Trust.
This project will improve the treatment of patients and in turn the experience of parents and carers.
20
SECTION
5
RISK ASSESSMENT
Summary Risk Table
Risk Description
Score
Responsible
Individual
Cost* (£)
Locum/Agency
Recruitment of theatre
& anaesthetic staff
VAT applied to the
hiring of the mobile
unit is not recoverable
Mitigation Strategy
Use of Vanguard staff
4
Use of Vanguard staff to
stock unit
£260K
(over 26 years)
Final contract to be
reviewed by VAT advisor
Unknown
Risk of council tax
increasing as use and
income generation of
land will change
*Cost of dealing with the risk if it were to materialise.
21
SECTION
6
BENEFITS ANALYSIS
Summary Benefits Table
Ref
Critical Benefits
C1
Increase in weekday and job planned
theatre time delivering required
activity at a lower cost
C2
Improved capacity and reduction in
13 week outpatient, 18 week RTT
and 26 week inpatient targets
C3
Provide additional trauma capacity
Measurement
Basis
Base /
current
Value
Target
Value
Target
Date
Improved
performance against
target
13 weeks –
100%
100%
December
2013
26 weeks –
99.6%
100%
Base
Value /
current
Target
Value
Reduced overruns
Reduced cancelled operations
Ref
A1
A2
Additional Benefits
Improved reputation of the Trust
due to improved access targets
Provides flexibility in theatre plan to
undertake additional weekend lists
reduce backlog and/or provide
private capacity
A3
Maintains market share
A4
Fits with Trust Strategy and Medium
Term Estate projections
A5
Minimises risk of contractual
penalties enforced by the
commissioners in term of cancelled
A6
Recruitment and training of
Anaesthetists and theatre team will
result in an embedded team being
A7
Measurement
Basis
-
-
One off costs which include theatre
trays and cleaning machine can be
utilised in the next generation
-
-
-
-
-
-
Residual value
after 2 years
of £122k
22
Target
Date
SECTION
7
PROJECT DELIVERY
Project Plan Table
Milestone Activity
Responsible
Individual
Start
Date
CSD, ASD and CFM approval
LC
Sept 14
Operational Leadership Team
(OLT) Approval (if required)
Investment Committee
Approval (if required)
Capital Planning Group (CPG)
Approval (if required)
Finance and Investment
Committee (FIC) Approval (if
required)
Completion Date
LC
7/10/14
LC
16/10/14
End of
Oct 2014
Post Implementation Review 1
23
End Date
6/10/14
14/10/14
Time
Requirement
SECTION
8
FUNDING
Funding Table
Total Funding
Required
Funding
for
Capital or
Revenue
Spend?
Source of Funding
Funding
constraints
£0.35m
Capital
Winter/RTT monies
Commissioner
support
£0.016m
Over 3 years
Revenue
Growth/Backlog
Repatriation
Winter/RTT
Commissioner
support
The FRC is asked to approve the funding requirements above.
24
Approvals required
and / or date
obtained
APPENDIX 1
OPTION 1
Monday
Tuesday
Wednesday
Thursday
Friday
Plastics
Plastics
Urology
Plastics
Plastics/MaxFac
Theatre 8
ENT/Urology
(?alternate)
All Day Trauma
Spinal
All-Day Trauma
ENT
Theatre 6
Trauma/T & O
El Ortho
Trauma/T & O
El Ortho
Trauma/T & O
Cleft
Cleft
Cleft
Cleft
Cleft
Mobile
Theatre 9
pm session
OPTION 2
Monday
Tuesday
Wednesday
Thursday
Friday
Mobile
Urology
Plastics
ENT
MaxFac/Dental
ENT
Theatre 8
Plastics
All-day Trauma
Spinal
All-day
Trauma
Plastics/Maxfac
Theatre 6
Trauma/T & O
El Ortho
Trauma/T & O
El Ortho
Trauma/T & O
Theatre 2
Cardiac
Cardiac
Emergency
Plastics
Cardiac
OPTION 3 (with Existing Theatre Plan)
Mobile
Monday
Tuesday
Wednesday
Thursday
Friday
Urology
Ortho/PS&U
ENT
Plastics
ENT
OPTION 4
Mobile
Theatre 8
Theatre 6
Theatre 7
Monday
Tuesday
Wednesday
Thursday
Friday
AM
ENT
ENT
Urology
ENT
ENT
PM
ENT
Plastics
Urology
Plastics
ENT
AM
Plastics
Trauma
Spinal
PM
Plastics
Plastics
Spinal
Plastics
Plastics/Maxfax
AM
Trauma
EL Ortho
Trauma
EL Ortho
Trauma
PM
Ortho
EL Ortho
Ortho
EL Ortho
Ortho
AM
ENT
Trauma
ENT
Trauma
ENT
PM
ENT
ENT
ENT
ENT
ENT
25
Trauma
Plastics/Maxfac
Board of Directors
Item 14.220
Thursday 30 October 2014
Enc 04
Strategic Objective/ Enabler
Every child and young person requiring access to
care at BCH will be admitted in a timely way, with no
unnecessary waiting along their pathway
Report Title
Resources report period 1st April 2014 – 30th September
2014
Sponsoring Director
Chief Finance Officer
Author(s)
Director of Finance and Procurement, Chief Officer for
Workforce, Head of Informatics
Previously considered by
Finance and Resource Committee
Situation
This report is to communicate the various aspects of Trust performance in the financial
year to date, period ending 30 September 2014, and to identify any key risks that are
evident within the organisation.
The contents of this report will form the basis of the Trust’s Quarter 2 (Q2) Return to
Monitor.
The Trust is also required to report its predicted status for Governance and Mandatory
Services.
Background
The Trust is required to comply with the finance related legal issues contained within our
Terms of Authorisation as well as other key financial targets. This includes:
•
•
•
•
Not breaching the Private Patient Cap (a legal requirement);
Performing at plan for Monitor’s Continuity of Service Risk Rating leading to an overall
CoSRR of 4;
Minimising triggering the additional financial indicators; and the
Risk Assessment Framework, which may result in formal discussions with Monitor.
Delivery against these targets is driven by:
•
•
The volume and mix of demand experienced by the Trust; and
How the Trust uses its most valuable resource, its staff, in responding to that
demand.
The report explores each of these areas in turn and the impact on the financial position
and performance.
Assessment
Monitor Declarations
The key ongoing governance issue which impacts upon the Trust’s Monitor Governance
rating is the performance against the 18 week target for admitted patients. Performance
in month was, at 90.3%, above the 90% threshold. This, and the continuing level of
performance of the other metrics, enable the Trust to forecast a Green Governance
rating.
From a financial perspective the ratings will be a 4 under the Continuity of Service Risk
Rating. Under the old Compliance Framework a FRR of 4 would also have been
reported. These remain strong performances.
Activity
Activity performance in the year to date against plan and compared to 2013/14 is as
follows:
Activity Type
Against Plan
Against 2013/14
Emergency Department
+5.0%
+4.8%
Emergency/Non-Elective
-4.8%
-8.2%
Planned Care
+3.2%
+4.4%
Outpatients
+5.0%
+8.9%
From a financial perspective income has overperformed by £0.6m in the month. This is
the second month of above plan performance some of which was a result of the
discharge of some long stay patients. These discharges and the increasing level of drug
and device recharges are masking the financial impact of the level of cancelled
operations and the causes of these cancellations as reported in the Performance Report.
Workforce
Demand remains high and this has brought into sharp focus the short to medium term
capacity issues faced by the Trust. Sickness levels increased in the month and stood at
3.06%. The cumulative rate remained at 3.44% meaning both measures are above the
Trust’s 3% target albeit fractionally in the in-month case.
The combined substantive and bank staff level increased by 16wte in September. Bank
use decreased by 12wte whilst substantive staffing increased by 28wte. Compared to
September 2013 substantive wte have increased by over 5%.
Engaging with staff, especially during periods of pressure, is important and appraisals are
one indication of how well this is working in the Trust. The reported appraisal rate is now
82%, an increase of 3% on the position reported in August.
Finance
The end of the second quarter sees the Trust continuing to perform below plan. An inyear surplus of £2.7m sounds strong. However, it falls short of the plan submitted to
Monitor, and is well below the levels reported in the final 6 months of 2013/14 and we
have to be mindful that the plan we set was at the lower-end of expectations. September
is traditionally a transition month where income increases from the lows of the summer
months into October and November when financial performance is usually strong.
Controlling the costs of care that we provide remains central to our financial success as
downward pressure continues on the tariffs we are paid. Our savings levels are below
target in September. The key areas of shortfall include trust-wide schemes (contract
penalties, future fit and drugs) and it is vital that all trust-wide schemes are delivered
given that these constitute 50% of the plan this year. We have to secure the level of
savings that we anticipate this financial year to ensure affordability of the Next
Generation project and having plans exceeding 100% of our target is a positive move to
achieving this. The delivery of Directorate CIP savings has reduced significantly in
September and October sees a large increase in month on month targets.
The key issue financially in Quarter 1, which has continued into Quarter 2, has been the
impact of cancelled operations on clinical income, which is £0.2m under target. This is an
improvement in month due to the discharge of long stay patients and increasing levels of
drug and device expenditure.
Our cash balances are above plan. The September position was the Trust’s largest ever
closing cash balance although this has been partly assisted by an underspend on the
capital programme.
The Capital Programme was ratified by the Finance and Resource Committee in July.
Expenditure levels in Quarter Two are lower than expected due to delays on several key
schemes. The overall forecast is to meet the revised target of £12.8m.
Forecast
The revised forecast at year end is now a surplus of £4.8 million. This is the first time this
year that the original plan has been uplifted. The driver behind this £0.4m increase is the
receipt of additional winter and RTT monies. Although the majority of these are covered
by an offsetting revenue cost, there is a need to commit £0.4m of the cash received to
capital. This funding cannot be spent twice so it has to be recorded against I&E.
Monitor Month Data Collection
On September 15th all FTs were written to outlining a new monthly data collection
exercise predicated on the emerging signs of pressure on NHS finances. This requires a
return to the DH confirming the Trust’s Forecast Outturn positions on revenue and the
overall level of capital expenditure. This is again included within the Resource Report.
Recommendations
The Board review, discuss and approve the Resources Report.
The Board of Directors is asked to approve a forecast Governance (Green) and
Continuity of Service Risk Rating (“4”) for inclusion in the Monitor Q2 Return, which must
be submitted by October 31.
Key Impacts
Strategic Objectives
Staff and finance are key enablers to meeting the Trust’s strategic
objectives.
CQC Registration (state
outcome)
N/A
NHS Constitution
NHS Constitution has a pledge regarding 18-week waits.
Other Compliance (e.g.
NHSLA, Information
Governance, Monitor)
Monitor metrics are considered in the report.
Equality, diversity & human
rights
N/A
Trust contracts
N/A
Other
N/A
Resources Report
October 2014
Phil Foster
Theresa Nelson
Paul Franklin
Director of Finance and Procurement
Chief Officer for Workforce
Head of Informatics
1
Reporting on resources use.
1. Summary
2. Governance - Monitor Assessments and Declarations
3. Financial Performance
4. Income and Expenditure
5. Efficiency
6. Liquidity
7. Workforce
2
Summary.
September 2014
The second quarter has concluded with the Trust continuing to perform slightly below financial plan. The year to date
surplus of £2.7m is a relatively strong position but it does fall short of the plan submitted to Monitor and is also below
the average monthly surplus reported in the second half of 2013/14.
Achievement of the Trust’s planned £4.4m surplus is expected and this is confirmed by the forecast outturn assessment,
but this will use some of the reserves set aside. With the receipt of additional winter and RTT monies some of which will
have to fund capital expenditure the overall forecast has been increased by £0.4m to £4.8m. However, the plan was
widely accepted as being a downside case which makes the combination of continued underperformance and
Directorate positions a worrying scenario.
The operational difficulties at the Trust with regards to PICU and acute bed capacity and numbers of long stay patients,
are leading to high levels of total cancelled operations. This is having a direct impact on clinical income which remains
below plan. October is a month of expected higher activity and the financial target for that month reflects that.
Controlling the costs of care that we provide remains central to our financial success as downward pressure continues on
the tariffs we are paid. Our savings levels are below target in September despite starting the year more strongly than in
2013/14. It is crucial that the trust-wide schemes are delivered but these too are being impacted by the operational
difficulties being experienced. We have to secure the level of savings that we anticipate this financial year to ensure
affordability of the Next Generation project and having plans exceeding 100% of our target is a positive move to
achieving this. September has seen a smaller fall in savings delivery than previous months but the in-month targets rise
from October onwards and this is reflected in a reduced achievement percentage.
Bank usage in September was 17% lower than the equivalent period last year although substantive staffing levels are
5.2% higher. Appraisal rates are at 82%, which is 3% higher than the level reported in the August report. In-month
sickness increased by 0.08% to 3.06%. Year to date sickness has remain static at 3.44%.
Our cash balances remain strong although their performance has been assisted by a lower than planned capital spend
due to delays in key schemes.
3
2. Governance –
Monitor Assessments and Declarations
4
Our Month 6 regulatory position remains strong.
Quarter 1 - 2014/15
The ratings for Quarter 1 have been confirmed by
Monitor.
Monitor Quarter 1 2014/15 (Confirmed)
Finance risk rating - Continuity of Service Risk Rating
Governance risk rating
Finance risk rating - Compliance Framework
Month 6 – Quarter 2
Based on this performance the predicted measureable
Month 6 performance is Green.
Plan
Actual
G (4)
G (4)
G
G
G(4)
G(4)
Monitor Quarter 2 2014/15 (Predicted)
Finance risk rating - Continuity of Service Risk Rating
Governance risk rating
Finance risk rating - Compliance Framework
Plan
Actual
G (4)
G (4)
G
G
G(4)
G(4)
The Continuity of Service Risk Rating for September is
a 4 (the highest level).
For information under the old Compliance Framework
regime a FRR of 4 would have been reported in Month
4.
A continuation of the above will result in the Trust
achieving its planned Risk Ratings for 2014/15.
Forecast ratings for the year are included in Section 2 –
Financial Performance.
5
Monthly Reporting Collection Data.
On 15 September Monitor wrote to all FTs outlining the requirement for a new monthly data collection
process.
For October (and therefore reporting of September’s figures) the information requested is required to be
returned by October 24th. The requirements and the September figures are outlined below.
DH monthly reporting data from Birmingham Children's Hospital NHS FT as at 30 Sep 2014
Question
No
Question text
1
What is the trust's Surplus / (deficit) before impairments and transfers by absorption
2
What is the trust's Capital Expenditure, net of disposals, on an accruals basis
Plan value from 14-15 APR
or latest re-planned value
in £m
at 30 Sep 2014
Actual Value
in £m
at 30 Sep 2014
Forecast value
in £m as at
31 March 2015
only enter numbers below
only enter numbers below
only enter numbers below
2.825
2.710
4.761
12.579
4.017
12.834
6
2. Financial Performance
7
Financial Summary.
Governance
The Monitor Financial Risk rating is 4 per plan, with liquidity remaining strong.
This 4 is per the Continuity of Service Risk Rating (CoSRR) and also the former Compliance Framework.
Income and Expenditure
The I&E position is below the Monitor plan and the revised plan at £2.710m.
The Forecast position for the Trust has increased to £4.761m. This includes the I&E benefit of the proportion of
additional winter and RTT monies that will be used to finance capital expenditure to enable the use of a mobile
theatre at the Trust.
Efficiency
The EBITDA and Income Surplus margins are 5.2% and 4.2% , respectively. Both of these are marginally below
plan.
CIP at a Directorate level and Trust-wide level is below plan. This remains the primary financial focus and will be
a key component of Directorate recovery plans. Performance is at 81% and is forecast to drop to 76%.
Productivity measures associated with income are mixed with income per wte above plan for the second month
in succession.
Liquidity
Cash balances are above plan in September mainly as a result of a shortfall in capital expenditure.
8
Financial Balanced Scorecard.
FINANCIAL BALANCED SCORECARD - SEPTEMBER 2014
Plan
Governance Continuity of Service Risk Rating *
I&E
Liquidity
Efficiency
Actual
Variance
YTD
4
4
0
Continuity of Service Risk Rating *
Forecast
4
4
0
Governance Risk Rating
YTD
Green
Green
Governance Risk Rating
Forecast
Green
Green
I&E Position (£m)
In-Month
0.66
0.58
-0.09
I&E Position (£m)
YTD
2.82
2.71
-0.11
I&E Position (£m)
Forecast
4.38
4.76
0.38
Profitability - EBITDA (£m)
YTD
6.55
6.33
-0.22
Profitability - EBITDA (£m)
Forecast
11.82
12.16
0.34
Debt Service Cover Rating *
YTD
4
4
0
Debt Service Cover Rating *
Forecast
4
4
0
Cash (£m)
YTD
49.20
51.00
1.80
Cash (£m)
Forecast
45.49
46.49
1.00
Capital Expenditure (£m)
YTD
5.70
4.00
-1.70
Capital Expenditure (£m)
Forecast
12.74
12.84
0.10
Liquidity Rating *
YTD
4
4
0
Liquidity Rating *
Forecast
4
4
0
CIP Achievement (£m)
In-Month
0.72
0.69
95%
CIP Achievement (£m)
YTD
3.61
2.92
81%
CIP Achievement (£m)
Forecast
9.46
7.14
76%
Income per £1 Pay Expenditure (£)
YTD
1.61
1.58
98%
Income per wte (£)
In-Month
72.78
73.19
101%
Contract Penalties/CQUIN Loss (£m)
YTD
0.00
-0.21
-0.21
Contract Penalties/CQUIN Loss (£m)
Forecast
0.00
-0.38
-0.38
RAG
* Note - for those Monitor Ratings - 4 is the Highest Rating
9
3. Income and Expenditure
10
Income and Expenditure against Plan.
The Trust’s I&E position has improved slightly in September
with an overall deficit against plan of £0.15m now being
reported. This is an improvement of £0.15m.
Headlines are:
• The Trust is reporting a reducing (£0.2m from £0.8m)
deficit against Clinical Income. This is a third month of
improvement and reflective of the increased clinical
activity throughout the Trust;
• Part of the clinical improvement is associated with drugs
and devices income for which there is a direct offsetting
cost;
• Pressures continue to be felt in Directorates and mainly
arise from operational performance issues around
cancelled operations and previously high levels of long
stay patients. The impact of this clinical income
performance is being particularly felt in Specialised
Services and Surgery.
• Activity performance is covered in further slides within
this section;
• Additional Directorate pressures are experienced through
the phasing and delivery of CIP targets and the costs of
agency staffing. CIP performance is detailed in 4.
Efficiency section.
• CIP performance is causing operational financial
difficulties with the majority of Directorates overspent;
• The continued use of temporary staffing is adding
unfunded costs into system. The spend in this area over
the first 6 months exceeds £3.9m and equates to 5.1% of
the overall pay bill for the first half of the year (7.6% for
the equivalent period last year);
2014/15 I&E to September 2014
Income from activities
Other Income
Operating Expenses
EBITDA
Interest Receivable
Depreciation
Profit/(Loss) on Asset Disposal
Impairment
PDC Dividend
Interest Paid
Net Surplus/(Deficit)
Annual
Revised
YTD Plan
Plan per Annual Plan per LTFM
LTFM
£'000
£'000
£'000
217,995
217,517
109,864
19,666
22,949
9,603
-225,841
-228,684
-112,921
11,820
11,782
6,546
243
247
122
-4,624
-4,559
-2,312
0
0
0
0
0
0
-2,762
-2,762
-1,381
-300
-326
-150
4,377
4,381
2,825
Revised
YTD Plan
£'000
109,760
11,570
-114,770
6,561
124
-2,280
0
0
-1,381
-163
2,861
YTD Actual
£'000
109,518
11,927
-115,114
6,331
86
-2,302
0
0
-1,263
-141
2,710
Variance
£'000
-242
356
-345
-230
-38
-22
0
0
118
22
-151
• A detailed I&E breakdown is included as Appendix One.
• A detailed breakdown of expenditure by cost category is included as
Appendix Two.
11
Income and Expenditure Forecast.
The half-way point of the year has generated a more
detailed forecast. This is included as Appendix Three.
The forecast has been generated through a detailed
assessment of clinical income derived through the SLAM
system followed by a thorough review and assessment at
Directorate level.
This position is predicated on a number of assumptions and
these will continue to be developed in the coming months.
The revised forecast at year end is now a surplus of £4.8
million. This is the first time this year that the original plan
has been uplifted. The driver behind this £0.4m increase is
the receipt of additional winter and RTT monies. Although
the majority of these are covered by an offsetting revenue
cost, there is a need to commit £0.4m of the cash received to
capital. This funding cannot be spent twice so it has to be
recorded against I&E.
This is based on the following factors:
• The second half of the year has a greater level of CIP
schemes to be delivered;
• Achievement of the Newton efficiencies;
• A continuation of contract penalties and provision for
CQUIN shortfalls;
• A reduced level of donated asset benefit due to scheme
delays;
• Impact of reduced PICU income as a result of less than 31
beds being open;
• Reduced income associated with partially completed
spells;
2014/15 Forecast
Income from activities
Other Income
Operating Expenses
EBITDA
Non-Operating Inc & Expenses
Net Surplus/(Deficit)
•
•
•
•
•
Annual
Revised
Year-End
Plan per Annual Plan Forecast
LTFM
£'000
£'000
£'000
217,995
217,517
218,585
19,666
22,949
24,968
-225,841
-228,684
-231,392
11,820
11,782
12,162
-7,443
-7,400
-7,400
4,377
4,381
4,761
Variance
£'000
1,068
2,019
-2,708
380
0
380
Continued premium rate expenditure;
No benefit of any provisions made during 2013/14;
The receipt of, but no gain from, additional winter monies;
Impact of ED Observation changes;
Next Generation costs.
The forecast position will be updated on a monthly basis with review by
the CFO on the 10th working day as part of the monthly reporting
schedule.
12
Emergency activity profile.
Emergency Department (ED) attendances in
September have increased following the
expected August reduction in activity. The
September level is 7.6% above last year
however so this is higher than would be
anticipated as we start to move towards
Winter. Overall activity has increased by 4.8%
year to date compared with last year.
ED attendances
6000
5000
4000
3000
Regarding performance vs plan, Activity is
7.4% above plan for the month and 5.0%
above plan in 14/15 so far.
2000
1000
0
A
M
J
2011/12
J
A
S
O
2012/13
N
D
J
2013/14
F M
2014/15
2014/15 Emergency department
activity against plan
5000
4500
4000
3500
3000
2500
2000
1500
1000
500
0
A M
J
J
A
S
2014/15 actual
O
N
D
J
F M
2014/15 plan
Emergency inpatient FCE activity in month has
increased by 4.6% compared with September
2013. This is the first month this financial year
where activity has been higher than for the
same month last year. Overall there has
been a decrease of 8.2% in YTD figures
compared to the same period last year.
When compared to plan, emergency FCE
activity is 4.8% behind plan YTD, but with
September activity levels being 7.6% above
the planned level.
Both Paediatric Surgery (11%) and
Orthopedics (28%) are significantly above plan
in both month 6 and year to date. In month 6
Paediatrics also shows a large increase. We
have previously referred to the reduction in
the zero day length of stay patients being
admitted from the ED Department and
assigned to the A&E specialty as an admission.
If these are excluded activity is 4% above last
years levels.
However in Sep 14 these are higher than in
previous months, and this has contributed to
the first overall monthly increase vs plan for
emergency inpatient activity in 2014/15.
Emergency /Non Elective FCEs
2000
1500
1000
500
0
A
M
J
J
2011/12
2000
A
S
2012/13
O
N
D
J
2013/14
F M
2014/15
2014/15 Emergency/non
elective FCEs activity against
plan
1500
1000
500
0
A M
J
J
A
2014/15 actual
S
O
N
D
J
F M
2014/15 plan
13
Planned activity profile.
2014/15 All Elective FCE activity against
plan (incl Reg Day Admissions)
All elective FCEs
3000
3000
2500
2500
2000
2000
1500
1500
1000
1000
500
500
0
0
A
M
J
2011/12
J
A
2012/13
S
O
N
2013/14
D
J
F
2014/15
M
A
M
J
J
A
2014/15 actual
S
O
N
D
J
F
M
2014/15 plan
Elective activity in September was 12% higher than in September 2013 and YTD activity also shows a 4.4% increase over 2013/14.
Elective activity is now 3.2% above plan YTD, with activity being 9.4% above plan in September 2014. Paediatric Surgery, ENT and
Gastroenterology all had high levels of activity in month.
In the year to date, combined Haematology/Haemoglobinopathy/Oncology activity is 307 FCEs or 12% above plan with Plastic Surgery 116
FCEs or 12% below plan.
Neurology (48%) and Neurosurgery (24%) are significantly over plan with 601 FCEs having been carried out year to date versus a plan of
448.
14
Outpatient activity profile .
There is a 13.4% increase for
new attendances in September
and 11.0% increase for follow
up patients when compared
with September 2013.
New OP attendance
4000
3500
3000
YTD activity shows that new
attendances have increased by
0.6% and follow ups YTD have
increased by 6.7% when
compared to 2013/14.
2500
2000
1500
1000
500
0
A
M
J
J
2011/12
A
S
O
2012/13
N
D
J
F
2013/14
M
2014/15
Follow up OP attendance
12000
Against plan, all outpatient
activity was 10.9% above plan in
September 2014 and overall
5.0% ahead of plan YTD. Areas
with the biggest absolute
growth are T&O, Cardiology,
Paediatric Surgery, Respiratory
Medicine and ENT.
Outpatient
procedures
performed in September are
34.4%
higher
than
for
September 13 and 39.6% higher
YTD than in 2013/14. In terms
of HRGs this relates to minor Ear
Procedures,
minor dental
procedures
and
Electrocardiograms
10000
8000
6000
4000
2000
Outpatient Procedures
1400
1200
1000
800
600
400
200
0
A M
J
2011/12
J
A
S
2012/13
O
N
D
J
F M
2013/14
2014/15
2014/15 outpatient activity
against plan (excl AHP CNS and Phone)
16000
14000
12000
10000
8000
6000
4000
2000
0
0
A
M
2011/12
J
J
A
2012/13
S
O
N
2013/14
D
J
F
M
2014/15
A M
J
J
A
2014/15 actual
S
O N
D
J
F M
2014/15 plan
15
4. Efficiency
16
Profitability against Target.
The EBITDA (Earnings Before Interest, Taxation, Depreciation and
Amortisation) Margin remains below target (5.2% compared with
5.5%). This is a narrowing of the gap experienced in Month 5
(5.1% actual compared with 5.6% plan) with the actual EBITDA
margin having improved. In monetary terms EBITDA was also
below the YTD Monitor Plan, with a small in-month movement.
The coming 2 months will see an increase EBITDA margin
requirement as these are historically strong months.
EBITDA Margin
8.0%
7.5%
6.8%
7.0%
6.5%
6.0%
6.0%
5.8%
6.2%
5.5%
Actual
5.1% 5.2%
Plan for
Year
5.0%
4.5%
4.0%
Apr May Jun
The I&E Surplus Margin also continues to be below plan (2.2%
compared with 2.4%) which reflects the EBITDA margin. This too
is an improved % position and a narrower gap from plan
compared with Month 5.
As with the EBITDA margin the next 2 months sees an expected
increase in the margin.
Jul
Aug Sep Oct Nov Dec
Jan
Feb Mar
I&E Surplus Margin
5.0%
4.5%
4.0%
3.5%
3.0%
2.5%
2.0%
1.5%
1.0%
0.5%
0.0%
3.9%
2.7%
3.0%
3.2%
2.1% 2.2%
Actual
Plan for
Year
Apr May Jun
Jul
Aug Sep
Oct Nov Dec
Jan
Feb Mar
17
Productivity.
Income Generated per £1 of Pay Expenditure
Two productivity metrics have been produced for the first time in
September. These assess the:
• Income Generated per £1 of Pay Expenditure; and
• Monthly income per wte.
With staff costs equating to over two thirds of the Trust’s
operating expenditure the return on pay expenditure is vital to
the Trust’s productivity and profitability. Cumulative income per
£ of pay expenditure is performing ahead of the 2013/14 but
remains below plan in 2014/15. The September performance was
the nearest performance to plan in the year to date.
1.75
1.70
1.65
£
1.60
1.55
1.50
Apr
The monthly income per wte has, having commenced the year
with 4 consecutive months of sub-plan performance, recovered
since August and has delivered above plan performance.
May
Jun
Jul
Aug
Sep
Oct
Nov
#REF!
Inc/£1 Pay In-Month 2014/15
Inc/£1 Pay - Cumulative 2014/15
Inc/£1 Pay - Cumulative Plan 2014/15
Dec
Jan
Feb
Mar
Inc/£1 Pay - Cumulative 2013/14
Monthly Income per wte since April 2013
85
83
81
79
77
£ 75
73
71
69
67
65
Income per wte - actual
Income per wte - plan
18
CIP.
This is the CIP position at the halfway point of the year. The overall target reflects the following:
• Directorate targets;
• Trust-wide scheme targets; and
• Residual balance of the underlying legacy position from 2013/14.
Headlines from Month 6 are as follows:
• Overall schemes identified exceed the annual target – this is an improved position compared to 2013/14;
• The majority of schemes have been risk assessed within Directorates;
• Quality Impact Assessments are behind schedule but with the PMO’s involvement increasing this will improve in future months;
• Corporate and CSS are the areas furthest from target for overall schemes;
• The September performance in Surgery has deteriorated due to a revision of previous periods’ savings;
• The shortfall on the trust-wide schemes is within Contract Penalties (where pressures are evident for Diagnostics, 18 weeks and CQUIN),
Drugs (although this has improved in September) and Future Fit where workforce savings are not materialising in line with the plan;
• Phasing throughout the year remains back-ended.
CIP Information provided for the first time this month includes:
• Forecast actual position in monetary and % terms; and
• The level of recurrent plans (per recent KPMG audit recommendation).
Directorate Annual Target
CAMHS
Corporate
CSS
Medicine
SSD
Surgery
Trustwide
Totals
£389,526
£723,251
£666,136
£1,324,237
£1,390,984
£725,583
£4,240,000
£9,459,716
Identified
Plans
£388,640
£568,985
£633,716
£1,533,625
£1,420,330
£740,282
£4,240,000
£9,525,578
YTD Plan
YTD Actual
£194,311
£256,434
£250,312
£763,733
£709,009
£257,647
£1,181,000
£3,612,446
£190,546
£161,979
£342,519
£680,126
£540,234
£141,502
£864,489
£2,921,396
YTD Variance % Plan To Date % Annual Target
-£3,765
-£94,455
£92,207
-£83,607
-£168,775
-£116,145
-£316,511
-£691,050
98%
63%
137%
89%
76%
55%
73%
81%
49%
22%
51%
51%
39%
20%
20%
31%
Forecast
Actual £
£343,454
£371,164
£574,645
£1,356,624
£997,900
£291,668
£3,225,000
£7,160,455
Forecast
Actual %
88%
51%
86%
102%
72%
40%
76%
76%
Recurrent Plans
£350,050
£359,726
£451,101
£992,784
£937,792
£220,938
£3,110,000
£6,422,392
19
5. Liquidity
20
Cash and Capital.
The Capital performance in September was £1.6m behind plan.
The forecast spend for the year is £12.8m. However, scheme
delivery in a number of areas is behind plan with catch-up
unlikely to be until Quarter 4. Key categories of deficit at
Month 6 are:
•
Estates (£0.3m);
•
Parkview Development (£0.3m);
•
Medical Equipment (£0.7m); and
Patient Experience (£0.1m).
•
Further detail on this is included as Appendix Five.
Mar-16
Jan-16
Feb-16
Dec-15
Oct-15
Nov-15
Sep-15
Jul-15
Aug-15
Jun-15
Apr-15
2014/15 Plan
May-15
Mar-15
Jan-15
Feb-15
Dec-14
Oct-14
Actual
Nov-14
Sep-14
Jul-14
Aug-14
Jun-14
The cash position is included within the Balance Sheet which is
included as Appendix Four.
Apr-14
The graphical analysis includes a cash forecast through to
March 2016. This period sees a reduced cash balance as the
Parkview development continues along with the first year of
the clinical block.
55,000
50,000
45,000
40,000
35,000
30,000
£k 25,000
20,000
15,000
10,000
5,000
0
May-14
The Trust’s Liquidity remains significantly above the Continuity
of Service threshold of 4.
2014/15 Cash Position and Rolling Forecast
Mar-14
Cash is now 3.7% above plan at Month 6. This equates to
£1.8m and is primarily a result of reduced capex (see below).
Rolling Forecast
2014/15 Cumulative and Forecast Capital Expenditure against Plan and Monitor Margins
16,000
14,000
12,000
10,000
£k
8,000
6,000
4,000
2,000
Apr
May
14/15 Actual
Jun
Jul
14/15 Forecast
Aug
Sep
14/15 85%
Oct
Nov
14/15 115%
Dec
Jan
Feb
Mar
14/15 Plan - Original
21
6. Workforce
22
Workforce Report Summary September 2014
Sickness Summary – In month sickness is 3.06%, which is lower than this time last year and in line with our 3% target. Long term sickness
(%) has decreased to 1.58%, these staff are being supported through our processes. Short term sickness has increased slightly between July
and August 2014 and is at 1.48%.
The top 3 reasons for sickness during August are), Anxiety/Stress (608.89 WTE days lost) Musculoskeletal (526.71 WTE days lost and
Gastrointestinal (319.91 WTE days lost). We will be launching our new staff confidential support service in early November which provides
staff and manager support in the managing of stress related sickness.
Bank/Agency Usage – There has been an decrease of 16.23WTE during September 2014 to 178.13 WTE, compared to August. Admin usage
has decreased to 84.22 WTE and it continues to be high in the Medical Secretary profession (13.94 WTE) and also in Health Records (12.90
WTE).
Top 3 Clinical departments using bank are:
•PICU (16.98 WTE) – due to overall increase in acuity and gaps in establishment. Job advertised during September – 6 (4.80WTE) 4 New
posts and 2 replacements.
•Theatres (9.67 WTE) – Due to double running costs due to new staff who are supernumerary on rotation and vacancies filled but not yet in
post. No recruitment activity during September.
• Ward 7 (7.44 WTE) – Increased bank usage due to 2 long term patients needing 1:1 care, until new staff have started bank cover is needed.
No recruitment activity during August.
PDR Summary - PDR % has seen an increase this months and is now at 82%. Directorates are continuing to identifying hotspot areas,
sending out email reminders to managers and supplying their DMT’s with monthly figures.
Turnover Summary -12 month Turnover % for the Trust has decreased slightly for the 12 month period ending September 2014 but
remains above the Trust KPI (9%) at 11.10%. All Directorates with the exception of Clinical Support and Surgical have a 12 month turnover
% above the Trust 9% KPI target. The main reasons for leaving during September are voluntary resignation due to Relocation (10.80 WTE),
to undertake further education (4.76 WTE) and due to work life balance (2.80 WTE).
23
Workforce Dashboard
Trust
Target
CSS
Medical
Specialised
Surgical
CAMHS
Corporate
Trust (Previous
Month)
Trust (Current
Month)
Sickness % (YTD)
<3.00%
3.18%
4.46%
3.32%
3.13%
2.84%
3.16%
3.44%
3.44%
▬
Sickness % (Month)
<3.00%
2.22%
3.44%
2.73%
3.24%
3.20%
3.66%
2.98%
3.06%
▲
Indicator
Trend
79
102
110
61
34
75
451
461
▲
LT Sickness %
0.70%
2.18%
1.42%
1.71%
1.25%
1.99%
1.73%
1.58%
▼
ST Sickness %
1.52%
1.26%
1.31%
1.53%
1.96%
1.67%
1.25%
1.48%
▲
£27,828.51
£57,851.37
£41,856.94
£29,503.89
£19,014.22
£39,929.77
£214,023.55
£215,984.70
£168,755.55
£32,775.92
£198,350.36
£155,715.28
£91,513.43
£186,633.41
£912,739.25
£1,128,723.95
346.37
702.26
645.43
437.58
281.93
601.72
2922.90
3015.29
▲
86.34%
84.26%
86.31%
83.69%
78.07%
71.37%
82.34%
82.00%
▼
Starters FTE
12.15
26.28
19.00
12.60
2.41
29.55
90.21
101.99
▲
Leavers FTE
8.33
27.94
14.91
11.25
2.50
5.93
91.16
70.86
▼
8.74%
11.68%
11.45%
9.88%
13.11%
12.16%
11.64%
11.10%
▼
▼
Episodes
Cost of sickness
Cost of sickness
YTD
FTE days lost
sickness
PDR's %
Rolling Turnover %
90%
<9%
In Month Turnover
%
Headcount
WTE in post
1.53%
1.00%
0.60%
1.00%
0.61%
0.70%
1.07%
0.91%
574
511.07
725
658.74
841
770.29
474
436.01
316
284.93
610
561.11
3509
3194.47
3540
3222.15
Active Recruitment
7
7
12
4
3
10
72
43
▼
5.20
42.92
43.64
28.93
4.22
53.22
194.36
178.13
▼
3.58%
5.11%
4.63%
5.05%
4.00%
1.89%
3.92%
4.09%
▲
4
14
12
5
40
45
▲
0
1
n/a
Bank Usage
Maternity Leave %
Staff in Difficulty
6
4
Org Change
Please note that sickness is still one month behind so we are currently reporting on Augusts data
Current months WTE may be slightly lower due to new starters from the 2nd induction still being inputted onto ESR.
Employee Relations - On going or started during reporting month
Consultant Appraisals % is now a rolling 12 month figure
Turnover % is based on permanent staff leavers only
0
1
0
0
0
0
24
Sickness Absence
BCH Monthly Sickness %
Long and Short Term Sickness %
4.00%
3.50%
3.00%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
2.50%
2.00%
1.50%
1.00%
0.50%
0.00%
0.70%
1.58%
14/15
1.71%
1.31%
1.53%
284 Dir 3
Specialised
Services
284 Dir 4
Surgical
Directorate
1.25%
1.52%
1.48%
BCH Trust
Sickness
13/14
1.42%
2.18%
1.26%
284 Dir 1
Clinical Support
Services
284 Dir 2
Medical
Directorate
Short Term Sickness
Trust Target
1.99%
1.96%
284 Dir 5
CAMHS Services
1.67%
284 Dir 6
Corporate
Long Term Sickness
BCH Sickness Comparison
13/14
April
May
June
July
August
September
October
November
December
January
February
March
2.85%
3.13%
3.39%
3.58%
3.22%
3.36%
3.74%
3.65%
3.43%
3.73%
3.76%
3.69%
3.67%
3.23%
2.98%
2.98%
3.06%
Number of
Episodes
Monthly
Sickness %
Cumulative 12
Month Sickness
%
461
3.06%
3.44%
79
2.22%
3.18%
102
3.44%
4.46%
110
2.73%
3.32%
61
3.24%
3.13%
34
3.20%
2.84%
75
3.63%
3.16%
14/15
BCH Sickness Absence - August 2014
BCH Total
Clinical Support Services
Medical Directorate
Specialised Services
Surgical Directorate
CAMHS Services
Corporate
Sickness remains steady at 3.44%, this is due to a number of long term sickness cases, this will further
reduce as there are two stage 3 meetings to be held.
Anxiety/stress/depression still remains the main reason for sickness but this is due to one long term
case due to an employee relation case.
Challenge and confirm meetings are held on a quarterly basis and a number of audits in hot spot
areas have been undertaken by the HR Compliance Manager.
This has reduced from last month’s figures; this is shared evenly over long and short term
episodes. The hot spot areas are Neonatal Surgical Ward and Wards 9 and 10, again with a number
of gastrointestinal problems.
Support and Challenge meetings have been arranged for the directorate with hotspot as a priority.
Two long term sickness cases, one due to family bereavement.
There are a number of short term sickness cases and majority are due to gastrointestinal problems.
HR Advisor attends the ward managers meeting at Parkview on a monthly basis and sickness
percentages are discussed at the Senior Management Team Meeting monthly.
25
Bank/Agency Usage
Apr 14
May 14
June 14
July 14
Aug 14
Sept 14
CSS
4.66
6.01
6.50
7.22
5.96
5.20
Medical
39.14
42.61
53.40
49.18
49.53
42.92
Specialised
44.95
47.57
44.09
44.79
42.32
43.64
250
Surgical
26.57
26.80
22.32
35.96
32.41
28.93
200
CAMHS
9.07
8.65
10.21
7.87
14.69
4.22
Corporate
46.05
44.09
48.10
53.98
49.45
53.22
Total
170.44
175.73
184.63
199.00
194.36
178.13
Trust Bank/Agency Usage (WTE) Yearly Comparison
214.52
178.13
WTE
150
100
2013/14
2014/15
50
* The latest month is an indicative figure and about 95% accurate. The previous month figure will be updated
each month
0
Top 3 reasons for Bank/Agency usage
1. Vacancy – 125.94 WTE
2. Sickness – 21.91 WTE
3. Specialist Skills Required – 8.73 WTE
Admin bank and agency usage = 84.22 WTE.
Bank/Agency Usage September 2014
Top 3 reasons for Admin usage are Vacancy, Backlog and Teaching/Training.
Directorate Admin bank and agency is as follows:
1.06
CSS - 2.26 WTE - Labs, Diabetes and Surgical Day Care
37.25
Priority
7
47.28
Medical – 6.14 WTE - Primarily Medical Secretary Areas (4.94 WTE)
Specialised – 6.16 WTE – Cardiac Service, PICU and Liver
Surgical - 18.49 WTE - Primarily Medical Secretary Areas (9.00 WTE)
14.41
A&C
Non Reg
CAMHS – 3.71 WTE - East Locality and Tertiary Psychology
Reg
Medical
Corporate – 47.46 WTE – Health Records (12.90), Finance (5.23) and Patient Access Call
Centre (4.34)
26
PDR - AFC Staff
CSS
The Directorate continues to focus on
PDRs. Completion rates are regularly
discussed at the weekly Directorate
Executive Team meetings and
departmental managers discuss their
plans for adhering to the Trust’s PDR
completion target at their regular
business meetings which HR now
attends. A monthly workforce report,
including PDRs, is now produced for
the Directorate and this is discussed in
detail at a weekly Directorate
Management Team meeting.
Medical
The medical directorate has prioritised
this area as an area of focus. Each
service has presented their plans to
ensure all outstanding staff have a
completed PDR before the end of
September. It is projected the
directorate will meet the 90% target at
latest, the end of October. Any areas
that have not made progress by the
end of September, will receive support
to facilitate the proposed achievement.
Priority
3
Apr
May
June
July
August
Sept
BCH
82.93%
82.58% 83.58% 83.31% 82.34% 82.00%
Clinical Support Services
88.81%
84.74% 88.08% 89.49% 85.58% 86.34%
Medical Directorate
83.77%
82.97% 86.34% 82.97% 83.08% 84.26%
Specialised Services
83.66%
85.38% 86.54% 86.62% 88.00% 86.31%
Surgical Directorate
86.60%
87.24% 84.78% 85.42% 83.62% 83.69%
CAMHS Services
86.40%
84.42% 76.52% 74.79% 71.00% 78.07%
71.68%
72.41% 75.51% 76.55% 78.56% 71.37%
Corporate
Apr-14 May-14 Jun-14
Jul-14
Aug-14
Sep-14
Add Prof Scientific & Technical 88.60% 85.57% 83.59%
86.04% 79.03% 87.66%
Additional Clinical Services
83.50%
76.50%
81.68%
85.85%
85.26%
85.06%
Estates & Anciliary
79.71% 77.66% 76.97%
88.29% 82.30% 84.87%
77.69% 80.00% 89.23%
76.75%
88.24%
84.50%
76.11%
82.79%
85.82%
72.98%
84.80%
83.94%
Healthcare Scientists
77.24% 78.05% 83.87%
90.32%
88.71%
88.33%
Nursing
83.45% 83.33% 85.04%
84.45%
84.73%
84.78%
Table 1
Admin & Clerical
AHP's
Table 1 shows via staff group the Appraisal compliance. Compared to last months data
all staff groups with the exception of Admin and Estates have seen an increase in their
PDR. Admin & Clerical now have a % less than 75%.
Specialised
Specialised are the only directorate to have seen an increase in their PDR % this month.
Theatres PDR rate is now at 92% and PICU 91%. PICU has been working to improve their PDR
rates by introducing the following:
• With the introduction of PICU now working in three staff teams, the band 7 leaders have
more
responsibility for their teams and their development .
• In the local PICU band 6 leadership days they have introduced a session on importance of
appraisals.
• Senior band 5 staff are now developing skills to support/undertake PDR’s for a specified
group of staff
Corporate
HR will continue to email Corporate
HODs and copying in chief officers
requesting that appraisals are
undertaken. Letters have recently
been sent out from the Director of
Workforce requesting recovery
plans.
CAMHS
The CAMHS SLT have discussed this
% during their meeting in August.
The action from the meeting was
that managers will be emailed about
their PDR and mandatory training %
and new PDR dates will be emailed
to the directorate PA so that ESR can
be updated. The CAHMS % should
see an increase over the coming
months.
The directorate will be undertaking a
forward look approach to ensure
dates are scheduled for PDR’s until
end of March 2015.
Surgical
PDR rates for the Surgical directorate have been at 83% for the last 3
months; there are 3 key areas within the directorate where rates are
low, one of the main reasons is the spikes in sickness absence and
extra support is being given to these areas. There is a directorate
focus to improve the PDR rates using the following tools: Monthly HR
PDR reports sent to the departments, introduction of confirm and
challenge sessions, review by DMT Managers of PDR data
inputting. The wards discuss PDR;s rates at weekly band 7 meetings,
and in August one of the wards reached 97% PDR compliance.
27
Staff in Difficulty
Staff in Difficulty Cases (January 14 to September 14)
70
Number of Cases
60
61
53
54
50
40
37
35
52
40
38
44
30
20
10
0
January
February
March
April
May
June
July
August
Sept
Breakdown of Cases September 14
A large proportion of the staff in difficulty cases
continue to be due to conduct and performance
issues. Managers are becoming more effective at
dealing with inappropriate behaviour and measuring
against the Trust values.
44 Cases
31%
40%
Disciplinary
Grievance
Managers are identifying and managing staff in
difficulty more effectively. This is supported by
bespoke development in managing performance.
Harassment
Performance
22%
7%
28
BCH Nursing Staffing:
•
•
Physical Environment: September saw the reopening of Ward 9 after the refurbishment in time for the predicted increase in surgical activity. Ward
15 managed the scheduled closure of HDU bed spaces.
•
Staffing: Traditionally September is traditionally a low point in head count for Registered Nurses working for the trust as we await the autumn NQN
cohort to start. This year we have experience an increase in retention. These combined that we expect to be in a strong position by the year end. In
the next two months it will remain challenging as we both continue to deliver our activity levels whilst supporting and training the new intake. The
second cohort of CSW Development Trainees commenced in Sept whilst the successful candidates in cohort one have been placed into positions.
•
Temporary Staffing: We have seen a correlating reduction in nurse bank expenditure linked to the reduction in activity levels.
•
No Red shifts were recorded for the second month in a row as the enclosed national data set demonstrates.
Nursing Workforce Summary
Monthly Ave:
Jul-14
Aug-14
Sept-14
Act vs. Plan
Acuity
Skill Mix
Vacancy
Annual Leave
Mat Leave
Sickness
Bank
100.9%
95.5%
102.95
91.9%
97.1%
92.05
79.6%
79.9%
79.7%
3.5%
4.7%
4.8%
16.9%
18.8%
14.4%
7.3%
7.9%
8.1%
4.6%
4.5%
4.0%
7.7%
8.7%
8.1%
29
Nursing Workforce September 2014
Nursing Workforce
Dashboard:
Ward79.13
Nursing Staffing Actual vs Planned
Patient Acuity Level
Registered
Care Staff
Registered
Care Staff
Day
Day
Night
Night
Burns
Actual vs
Planned %
138.6%
Actual vs
Planned %
121.4%
Actual vs
Planned %
137.7%
Actual vs
Planned %
81.8%
Actual vs
Planned %
132.4%
Neonatal Surgical
134.2%
121.2%
131.3%
133.3%
131.5%
Sept-14
Total
Planned Resources
Unplanned: Actual & Response
No of
Times
Raised to
HoN
No of
Green
shifts
No of
Amber
shifts
No of
Red
shifts
88
2
0
81.5
10.9
0.84
11.1
7.6
1.6
52.8
2.2%
0
85
5
0
77.6
7.3
-0.41
10.8
9
3.3
72.4
5.6%
0
0
Unfilled
Registered
Vacanc Leave
Mat
Roster
Skill Mix%
y WTE
%
Leave %
%
Sicknes Bank Fill Bank
s
%
Used
Ward 1
95.7%
90.2%
98.8%
N/A
96.1%
73
17
0
81.5
2.7
-1.6
17.1
11.4
1.6
71.2
9.0%
Ward 5
100.5%
140.0%
101.7%
92.6%
107.1%
73
17
0
74.3
14.1
2.6
13.8
9.1
0.9
58.5
9.4%
0
Ward 9
102.3%
100.3%
103.6%
110.7%
103.2%
86
4
0
78.4
12.4
-1
16.5
8
1.2
66.3
8.8%
0
Ward 10
98.1%
91.5%
100.9%
103.2%
98.5%
88
2
0
77.2
3.3
-1.3
12.4
11.7
3.9
81.8
3.2%
0
ED
104.2%
99.4%
95.3%
100.0%
99.8%
80
10
0
78.5
7.9
9.8
20.7
4.5
7.2
81.5
17.5%
0
PAU
95.7%
103.3%
101.8%
95.6%
98.6%
87
3
0
83.4
9.3
-1.7
16.9
9.4
5.4
58.7
9.0%
0
Ward 2
90.1%
92.5%
96.3%
92.3%
92.7%
75
15
0
84.3
8.9
1.8
17.6
15.4
7.1
75.9
23.1%
0
Ward 7
98.2%
105.4%
96.5%
108.0%
99.8%
87
3
0
77.3
5.8
-4.2
13.2
3.9
1.4
77.9
18.4%
0
MHDU
103.5%
N/A
105.8%
N/A
104.6%
86
4
0
100
3.4
-3
11.8
9
0.8
23.1
1.3%
0
Ward 15
100.8%
99.5%
107.9%
133.3%
103.7%
79
10
0
84.1
23.5
6.6
18.7
5.9
5.5
41.7
10.5%
0
ODC*
103.2%
86.9%
N/A
N/A
97.8%
44
0
0
74.6
10.8
-1.62
7.7
17.2
1.2
63.9
13.5%
0
Ward 8
102.2%
86.9%
100.8%
150.6%
104.1%
81
9
0
85.9
14
0.8
11.4
18.4
4.2
74.0
2.5%
0
Ward 11
98.7%
104.7%
102.3%
111.1%
100.7%
83
7
0
92.6
6.8
-1
14.5
2.1
5.5
59.4
7.5%
0
Ward 12
103.4%
123.1%
101.8%
150.0%
105.5%
82
8
0
83.8
8.4
1.2
17.8
4.9
5.3
68.5
2.3%
PICU
96.1%
86.7%
95.6%
106.5%
95.9%
80
10
0
90.2
45.9
45.71
13.7
6.1
4.8
0
0
0
MDC*
159.0%
136.5%
N/A
N/A
156.0%
44
0
0
87.8
21.1
-0.3
14.8
4.8
3.1
SDC*
125.3%
110.5%
N/A
N/A
121.45
44
0
0
74.3
28.9
-6.6
15.6
4
6.0
Ashfield
109.7%
94.2%
94.8%
91.4%
99.4%
90
0
0
68.0
20.1
-1.6
16.2
5.7
1.5
52.5
1.0%
0
Heathlands
92.8%
97.3%
111.9%
155.5%
104.4%
74
16
0
36.0
-7
15.8
6.5
7.5
18.8
1.2%
0
97.8%
103.6%
114.3%
119.0%
106.3%
88
2
0
58.1
60.7
30.0
5.1
9.5
4.2
8.1
102.8%
102.5%
101.4%
110.3%
102.7%
1697
144
0
79.73
15.1
2.0
14.4
8.1
4
Irwin
Trust Average:
0
93.9
62.8
8.3%
8.1
0
0
•Excluded from National Upload
30
Nursing, Midwifery and Care Staff Staffing
September 2014 Submission to NHS England
Main 2 Specialties on each ward
Registered midwives/nurses
Ward name
Specialty 1
Burns
Neonatal Surgical
Ward 1
Ward 5
Ward 9
Ward 10
ED
PAU
Ward 2
Ward 7
MHDU
Ward 15
Ward 8
Ward 11
Ward 12
PICU
Ashfield
Heathlands
Irwin
171 - PAEDIATRIC
SURGERY
171 - PAEDIATRIC
SURGERY
171 - PAEDIATRIC
SURGERY
171 - PAEDIATRIC
SURGERY
171 - PAEDIATRIC
SURGERY
171 - PAEDIATRIC
SURGERY
420 PAEDIATRICS
420 PAEDIATRICS
420 PAEDIATRICS
420 PAEDIATRICS
420 PAEDIATRICS
420 PAEDIATRICS
420 PAEDIATRICS
Specialty 2
160 - PLASTIC
SURGERY
171 - PAEDIATRIC
SURGERY
361 NEPHROLOGY
100 - GENERAL
SURGERY
100 - GENERAL
SURGERY
150 NEUROSURGERY
180 - ACCIDENT &
EMERGENCY
300 - GENERAL
MEDICINE
300 - GENERAL
MEDICINE
300 - GENERAL
MEDICINE
192 - CRITICAL
CARE MEDICINE
303 - CLINICAL
HAEMATOLOGY
171 - PAEDIATRIC
SURGERY
170 321 - PAEDIATRIC
CARDIOTHORACIC
CARDIOLOGY
SURGERY
170 321 - PAEDIATRIC
CARDIOTHORACIC
CARDIOLOGY
SURGERY
420 192 - CRITICAL
PAEDIATRICS
CARE MEDICINE
711- CHILD and 711- CHILD and
ADOLESCENT
ADOLESCENT
PSYCHIATRY
PSYCHIATRY
711- CHILD and 711- CHILD and
ADOLESCENT
ADOLESCENT
PSYCHIATRY
PSYCHIATRY
711- CHILD and 711- CHILD and
ADOLESCENT
ADOLESCENT
PSYCHIATRY
PSYCHIATRY
Total monthly
planned staff
hours
Total
monthly
actual staff
hours
Registered
midwives/nurses
Care Staff
Care Staff
Average fill
Average fill
rate Average fill
rate Average fill
registered
rate - care
registered rate - care
Total
Total
Total
Total
Total
Total
nurses/midwi staff (%) nurses/midwi staff (%)
monthly
monthly
monthly
monthly
monthly
monthly
ves (%)
ves (%)
planned actual staff planned actual staff planned actual staff
staff hours
hours
staff hours
hours
staff hours
hours
975
1352
319
387
671
924
121
99
1352
1814
384
465
1056
1386
396
528
1151
1100
402
363
1034
1022
0
0
1580
1587
657
919
1265
1287
297
275
1872
1916
475
476
1210
1254
308
341
1833
1799
572
524
1199
1210
341
352
2353
2451
936
931
2244
2138
330
330
1781
1705
423
437
1210
1232
286
274
2002
1803
533
493
1485
1430
429
396
1417
1391
780
822
1254
1210
275
297
1138
1178
0
0
946
1001
0
0
2945
2967
1053
1048
2365
2552
99
132
1885
1926
286
249
1309
1319
275
414
2054
2027
182
191
1452
1485
99
110
1866
1930
351
432
1199
1221
44
66
11876
11407
566
491
9889
9456
506
539
1313
1441
780
735
1182
1121
495
453
988
917
819
797
671
751
242
376
852
833
624
647
561
641
352
419
138.6%
121.4%
137.7%
81.8%
134.2%
121.2%
131.3%
133.3%
95.7%
90.2%
98.8%
-
100.5%
140.0%
101.7%
92.6%
102.3%
100.3%
103.6%
110.7%
98.1%
91.5%
100.9%
103.2%
104.2%
99.4%
95.3%
100.0%
95.7%
103.3%
101.8%
95.6%
90.1%
92.5%
96.3%
92.3%
98.2%
105.4%
96.5%
108.0%
103.5%
-
105.8%
-
100.8%
99.5%
107.9%
133.3%
102.2%
86.9%
100.8%
150.6%
98.7%
104.7%
102.3%
111.1%
103.4%
123.1%
101.8%
150.0%
96.1%
86.7%
95.6%
106.5%
109.7%
94.2%
94.8%
91.4%
92.8%
97.3%
111.9%
155.5%
97.8%
103.6%
114.3%
119.0%
31
Mandatory Training Update
Mandatory training compliance at BCH is currently averaging at 80.36% (Vesper: 7/10/14) representing 0.18% decrease since last month. Table 1 below shows the
Trust Level Breakdown as at 7th October 2014 and the trajectory since Mar 2014. In terms of capacity and mandatory training updates, the amount of face to face
places planned for 2014 has been over and above requirements however as reported previously, there is low engagement with staff. Please see Table 2 for further
information. Despite 66% of training now being available on Moodle and numbers increasing month on month through Moodle training, it is not resulting in a positive
trajectory at present. A more detailed review of the mandatory training data across the Trust suggests there are key staff groups that are impacting heavily on
compliance. The Admin and Clerical group have now moved up the table sitting second only to Nursing and Midwifery which is disappointing as this staff group can
update all mandatory training topics online. See Table 3 for information.
Plan to Improve
To improve compliance we have implemented a number of improvements including reminder emails, processes for data query handling and register tracking and audit
to ensure data is entered in a timely manner. Data queries do exist however, not in sufficient numbers to impact significantly on the downward trend displayed in
Table 1. The targeted approach for Child Protection L2 back in June 2014 saw a significant increase with compliance reaching circa 89%. This approach along with
great support from managers enabled this to be achieved so we will be completing a more detailed analysis of data to deliver this targeted approach to weaker areas
and groups. This will form part of the wider recovery plan.
Table 1
Table 2
Table 3
32
BIRMINGHAM CHILDREN'S HOSPITAL NHS FOUNDATION TRUST
Income and Expenditure Summary (Working Document)
For the Period Ended:
30/09/2013
Annual
Plan
to Monitor
£'000
Appendix One
Revised
Annual
Plan
£'000
In
Month
Budget
£'000
In
Month
Actual
£'000
In
Month
Variance
£'000
YTD
Plan
to Monitor
£'000
Revised
YTD
Budget
£'000
Year
To Date
Actual
£'000
Year
To Date
Variance
£'000
Income
NHS Clinical Income
Elective Inpatients
Elective Day Cases
Non-Elective
Outpatients
ED
Other
Royal Orthopaedic
Total NHS Clinical Income
25,894
16,964
33,478
23,029
4,843
113,102
475
217,785
25,685
16,705
32,831
22,281
4,868
114,461
475
217,306
2,125
1,382
2,651
1,837
390
9,808
40
18,233
2,115
1,426
2,717
1,914
408
10,060
40
18,680
(10)
44
66
76
18
252
0
447
13,257
8,685
17,023
11,576
2,429
56,789
0
109,759
12,750
8,291
15,908
11,024
2,340
59,104
238
109,655
12,691
8,555
16,305
11,482
2,448
57,431
238
109,150
(60)
264
397
458
108
(1,672)
0
(505)
211
211
211
211
18
18
110
110
92
92
106
106
105
105
369
369
263
263
7,038
2,300
(2,081)
2,546
1,696
1,843
1,021
1,049
4,254
0
0
19,666
7,038
2,300
0
2,938
1,951
1,944
735
1,310
4,733
0
0
22,949
587
230
0
464
162
206
66
101
315
0
0
2,131
304
(7)
0
510
150
199
76
113
603
0
0
1,947
(283)
(237)
0
46
(12)
(7)
10
11
287
0
0
(184)
3,519
1,150
(1,041)
1,273
848
922
510
525
2,127
0
(230)
9,603
3,519
920
0
1,572
978
1,168
373
694
2,346
0
0
11,570
3,238
683
0
1,775
923
1,049
407
673
3,180
0
0
11,927
(282)
(237)
0
203
(55)
(119)
33
(21)
833
0
0
356
237,663
240,466
20,381
20,737
356
119,468
121,331
121,445
114
Pay
Clinical Support Services Directorate
Medical Directorate
Directorate of Specialised Services
Surgical Directorate
CAMHs
Corporate
Pay Inflation Reserve
Other Pay Reserves
Phasing Adjustment
Total Pay
20,381
31,397
40,377
22,854
14,605
19,154
4,158
0
0
152,926
21,075
32,892
40,500
23,162
14,152
20,329
0
1,723
0
153,833
1,832
2,728
3,356
2,116
1,172
1,599
0
0
0
12,803
1,802
2,845
3,378
2,041
1,171
1,682
0
0
0
12,920
30
(117)
(22)
74
1
(83)
0
0
0
(117)
10,191
15,699
20,189
11,427
7,302
9,577
2,079
0
(2,331)
74,132
10,472
16,400
20,131
11,851
7,112
9,938
0
(8)
0
75,896
10,536
16,681
20,351
12,297
6,941
10,124
0
0
0
76,930
(64)
(281)
(220)
(445)
171
(186)
0
(8)
0
(1,034)
Non-Pay
Clinical Support Services Directorate
Medical Directorate
Directorate of Specialised Services
Surgical Directorate
CAMHs
Corporate
Leases
Non-Pay Reserves and Developments
Bad Debts
Total Non-Pay
7,892
19,781
12,760
5,628
1,365
13,586
244
11,659
0
72,915
9,230
21,346
12,624
5,950
1,674
16,785
218
7,025
0
74,851
1,199
1,768
958
592
135
1,377
20
252
0
6,301
1,253
1,750
1,242
620
154
1,622
5
0
0
6,646
(54)
18
(284)
(27)
(19)
(245)
15
251
0
(346)
3,946
9,891
6,380
2,814
683
6,793
122
8,161
0
38,789
5,621
10,997
5,932
3,176
833
8,525
98
3,693
0
38,874
5,807
11,073
7,419
3,276
897
9,493
221
(1)
0
38,184
(186)
(76)
(1,488)
(100)
(64)
(968)
(123)
3,694
0
689
225,841
228,684
19,104
19,566
(462)
112,921
114,770
115,114
(345)
11,822
Non NHS Clinical Income
Road Traffic Act (RTA) Income
Total Non NHS Clinical Income
Other Income
Teaching and Research
Donated Assets
Other Central Income
Clinical Support Services Directorate
Medical Directorate
Directorate of Specialised Services
Surgical Directorate
CAMHs
Corporate
Other Income Reserves
Other
Total Other Income
Total Income
Central income only
Operational Expenditure
Total Operational Expenditure
EBITDA
11,782
1,277
1,171
(107)
6,547
0
4,624
2,762
(243)
300
4,559
2,762
(247)
326
0
380
230
(21)
27
0
376
211
(15)
23
0
4
19
(6)
4
0
2,312
1,381
(122)
150
6,561
5.4%
0
2,280
1,381
(124)
163
6,331
5.2%
0
2,302
1,263
(86)
141
(230)
Loss on Disposal of Fixed Assets
Depreciation
Dividends on PDC
Interest Receivable
Interest Payable
Retained Surplus/(Deficit) For Period
4,379
4,382
661
575
(85)
2,825
2,861
2,711
(151)
0
(22)
118
(38)
22
Appendix Two
Analysis of Expenditure by Cost Category
Plan
Actual
Variance
Variance
£m
£m
£m
%
YTD
YTD
YTD
YTD
YTD
YTD
3.82
16.21
8.09
27.89
9.27
10.40
3.64
15.55
7.85
26.59
9.52
9.88
-0.18
-0.66
-0.25
-1.30
0.24
-0.53
-4.7%
-4.1%
-3.0%
-4.7%
2.6%
-5.1%
YTD
YTD
YTD
YTD
YTD
YTD
0.00
0.03
0.04
0.07
0.05
0.02
75.90
0.00
0.80
0.36
2.07
0.55
0.12
76.93
0.00
0.77
0.32
2.00
0.51
0.10
1.03
1.4%
Total Non-Pay
13.84
10.18
14.86
38.87
14.19
10.96
13.04
38.18
0.35
0.77
-1.82
-0.69
2.6%
7.6%
-12.2%
-1.8%
Total Operating Expenses
114.77
115.11
0.34
0.3%
2.28
1.38
0.16
2.30
1.26
0.14
0.02
-0.12
-0.02
1.0%
-8.5%
-13.7%
118.59
118.82
0.23
0.2%
Pay
Substantive Staffing
Senior Management (including Board)
Medical Consultants
Other Medical Staffing
Nursing
Admin, Maintenance and Support Workers
Professional/Technical and AHPs
Bank, Agency and Locum Staffing
Senior Management (including Board)
Medical Consultants
Other Medical Staffing
Nursing
Admin, Maintenance and Support Workers
Professional/Technical and AHPs
Total Pay
Non Pay
Below the
Line
Drugs
Clinical Supplies
Other Operating Expenses
Depreciation and Amortisation
PDC Dividend Expense
Interest Expense on PFI
Total Expenditure
YTD
YTD
YTD
YTD
YTD
YTD
Appendix Three
Trust-Wide Forecasts
2014/15 Forecast
Income from activities
Elective Inpatients
Elective Day Cases
Non-Elective
Outpatients
ED
Other
ROH
Total Income from Activities
Other Income
Operating Expenses
EBITDA
Interest Receivable
Depreciation
Profit/(Loss) on Asset Disposal
Impairment
PDC Dividend
Interest Paid
Net Surplus/(Deficit)
Trust-Wide Forecasts
Directorate summary:
Clinical Support Services
Medicine
Specialised Services
CAMHS
Surgery
Corporate
R&D
Total
Annual Plan per
Monitor
£'000
Revised Annual
Plan
£'000
Year-End Forecast
Variance
£'000
£'000
25,894
16,964
33,478
23,029
4,843
113,102
475
217,785
19,877
-225,841
11,822
243
-4,624
0
0
-2,762
-300
4,379
25,685
16,705
32,831
22,281
4,868
114,461
475
217,306
23,160
-228,684
11,782
247
-4,559
0
0
-2,762
-326
4,382
26,135
17,237
33,688
23,211
5,093
112,746
475
218,585
24,968
-231,392
12,162
247
-4,559
0
0
-2,762
-326
4,761
450
532
857
930
225
-1,715
0
1,279
1,808
-2,708
380
0
0
0
0
0
0
380
Pay
-208
-98
-196
260
-1,655
-62
0
-1,960
Non-Pay
53
-291
-3,627
-79
-213
-1,356
0
-5,515
Income
158
-94
-203
-103
96
1,180
0
1,032
Total
3
-484
-4,026
77
-1,773
-239
0
-6,442
Appendix Four
Balance Sheet as at 30th September 2014
30th September 2014
£000
Non-Current Assets
PPE - owned
PPE - PFI
Intangible Assets
Non-Current Financial Assets
Other Receivables Non-Current
Total Non-Current Assets
101,870
1,019
253
550
1,698
105,391
Current Assets
Inventories
NHS Trade Debtors
Non NHS Trade Debtors
Debtor re Capital Receipts
Provision for irrecoverable debts
Prepayments
Accrued Income
Cash at GBS
Cash And Cash Equivalents - non-GBS
Total Current Assets
3,659
3,285
3,627
(1,707)
2,880
3,489
50,916
99
66,247
Current Liabilities
Deferred Income
NHS (Trade) Creditors
Non-NHS (Other) Creditors
Other creditors
Capital Creditor
Tax and Social Security
Provisions<12 Months
PDC Creditors
Accruals
(5,145)
(4,875)
(6,107)
(2,788)
(865)
(3,102)
(1,370)
(11,225)
Total Current Liabilities
(35,476)
Net Current Assets
30,771
Total Assets Less Current Liabilities
Accr&Def Incm Non-Current
Provisions for Liabilities and Charges
PFI Liability
Total Assets Employed
136,162
(667)
(3,587)
(1,676)
130,231
Financed by:
Taxpayers' Equity
Retained earnings
Public Dividend Capital
Revaluation Reserve
(29,588)
(87,723)
(12,920)
Total Taxpayers Equity
(130,231)
Appendix Five
Capital Programme - Year to Date and Forecast Positions
Area
Pre-Commitments Including
Parkview
CT Scanner
Gamma Camera
Electrical Infrastructure
Estates
Building
IT
Medical Equipment
Strategic Development
Other
Patient Experience
Facilities
Central Function
Other
Contingency
Total BCH Spending
Externally funded schemes
Respiratory Services
Sensory Garden
Theatre Project
Transnasal navigation system
ePMA
Cryoconsole
FibroScan
Total BCH Charity Funded
Total Capital Spending
Monitor Plan Resubmitted
Plan
Annual
Forecast
Forecast
Variance
YTD Plan
YTD Actual % of Scheme
Total
YTD
Variance
£000's
5,818
2,098
866
754
800
1,500
360
3,395
1,650
0
848
170
150
300
0
228
13,571
£000's
5,985
2,098
866
754
800
1,501
250
1,406
1,675
0
965
280
150
307
0
228
11,782
£000's
6,317
0
0
0
0
1,461
267
1,533
1,634
0
825
173
148
329
0
176
12,037
£000's
332
(2,098)
(866)
(754)
(800)
(41)
17
127
(41)
0
(140)
(107)
(2)
22
0
(52)
255
£000's
3,118
712
866
0
390
513
40
472
990
0
332
113
60
158
0
0
5,465
£000's
2,551
363
855
0
392
252
0
461
292
0
282
28
16
238
0
0
3,838
£000's
43%
17%
99%
0%
49%
17%
0%
33%
17%
#VALUE!
29%
10%
11%
77%
n/a
0%
33%
£000's
567
349
11
0
(1)
261
40
12
698
0
50
86
44
(80)
0
0
1,627
0
0
0
0
1,469
0
0
1,469
15,040
1
9
0
0
786
0
0
796
12,577
(2)
8
0
24
638
20
100
787
12,824
(4)
(0)
0
24
(148)
20
100
(8)
247
#VALUE!
9
0
0
153
0
0
#VALUE!
#VALUE!
#VALUE!
8
0
24
136
0
0
#VALUE!
#VALUE!
#VALUE!
97%
n/a
n/a
17%
n/a
n/a
#VALUE!
#VALUE!
#VALUE!
0
0
(24)
17
0
0
#VALUE!
#VALUE!
Item 14.222
Strategic Objectives
Applicable
Trust Board
30th October 2014
Enc 05
2. Every child and young person requiring access to
care at BCH will be admitted in a timely way, with no
unnecessary waiting along their pathway.
3. Every member of staff working for BCH will be
looking for, and delivering better ways of providing
outstanding care, at better value.
Report Title
Discussion document to inform the September 2014
Finance and Resources Committee: interim review of
the Next Generation Patient Pathways Programme
Sponsoring Director
David Melbourne
Authors
Phil Foster, Nick Barlow, David Melbourne
Previously considered by
Original business case to Board of Directors February
2014, following Finance and Resources Committee
Purpose
A business case was approved by the Board in February 2013 to appoint Newton to support
the Trust in this work. Newton have presented to the Finance & Resources Committee on
progress (September). This discussion document has been prepared to inform the Board of
progress, risks and opportunities to maximise the value delivered by the Next Generation
Patient Pathways Programme, specifically the outpatients and surgical flow projects.
Appendices:
- Introduction to the outpatient and surgery projects from January 2014
- One page project health summaries for outpatients and surgery
- Earned value management reports showing activity progress against plan
- Benefits tracking – financial opportunity, target and actual by service and project
- ‘HEIDI’ examples
Background
The outpatient and surgical flow projects started in April 2014 as major components of the
Next Generation Patient Pathways Programme. The core operational work in surgical flow
will be complete by the end of October, with the outpatient project running until the new year.
David Melbourne is the executive sponsor, Claire Burden is the operational lead. The
combined financial targets for these projects are:
- Part year effect for the financial year 14/15 of £960k
1
-
Full year target of £1.6m with a stretch of £2.5m assuming a 3.5 hour clinical session,
or
Full year target of £3.0m with a stretch of £4.0m assuming a 4 hour clinical session
Clinical teams are engaging well in both areas and significant operational improvements
continue to be made (5% increase in theatre productivity to date, reduced waiting times in
main outpatients for example, see below for more highlights). The projects are now
progressing towards the benefits realisation phase, where services will make use of the
capacity that is being released to turn it into cashable improvements (“dark green dollars” as
described by the Health Institute). With this in mind, services currently have firm plans
through these projects for:
- Part year effect for the financial year 14/15 of between £0.6m and £1.1m
- Full year effect of between £1.6m and £2.1m
These numbers are closer to the target level than stretch. The ambition is clearly to deliver
improvements at the upper end of the range. This document outlines the levers (with
supporting information for discussion) to increase the savings levels towards the stretch
values.
Key Points to Note
Operational Highlights
-
Trust-wide theatre utilisation at record levels in July
and August for the last 12 months
-
With some specialties showing even greater
improvement (see Urology graph for example)
-
Percentage of outpatients who have to wait less than 15 minutes from arrival to being
ready to see the clinician is up from one-third to two-thirds
Only 1 clinic per month starting late due to delays in the flow through main outpatients
Clinic start and end times now being captured for more than 64 clinics/week (and
increasing) using the clinic tracking tool. This information is crucial to the complete
redesign of all templates. This is the first time this kind of data has been captured in
outpatients to drive improvement as a matter of course
Service redesign process being run with 27 specialties – capacity & demand
modelling complete with 20, service redesign meetings run with 16, workshops run
with 9 and agreement of changes with 6 (covering ~90 templates and 50,000 slots
p.a.)
New slot availability based booking tool trialled for two specialties leading to extra
new attendances. Now rolling out across all
specialties
Launch of the ‘HEIDI’ system (‘Hospital Efficiency
Improvements Driven by Information’) – provides
transparency of performance and opportunities for
improvement by area, team and clinician. Used to
drive scheduling processes across surgery and
outpatients
-
-
-
-
2
Financial Overview
The table below presents the current financial overview of the programme. The row labelled
‘current plans’ represents the improvements which services have firm, declared plans for in
relation to these projects.
FY14/15
Target
Full Year Effect
Surgery
£700k-1.3m for 3.5hr sessions
£1.6-2.3m for 4hr sessions
Outpatients
£900k-1.2m for 3.5hr sessions
£1.4-1.7m for 4hr sessions
Total
£1.6-2.5m for 3.5hr sessions
£3.0-4.0m for 4hr sessions
£960k
£0.7m - £1.0m
(would jump up if session
length change can be agreed)
Surgery
Current
plans
Outpatients
Total
£0.9m - £1.1m
£579k - 1.1m
£1.6m - 2.1m and climbing
Governance Structure
The projects report to the Next Generation Programme Board (TLT) through the following
structure:
Monthly to coordinate and drive the programme, escalate risks & opportunities
Chair: Sarah-Jane Marsh, attendees: Executive team, Clinical Directors,
programme leads
Next Generation Programme Board
(extends across Facilities, People, Technology)
Provides clinical challenge & assurance
Every 6 weeks
Lead: Claire Burden
Attendees: Stream leads for OP and
surgery plus ~10 clinicians
EQuIP
Clinical Panel
Weekly to drive project
Clinical lead: rotates
(Tony Lander, Ingo Jester, Suren Arul, Neil Bugg)
Ops lead: split (TBC for on the day efficiencies,
Tom Adamson for scheduling, Keely McDougall for
data quality, Claire Morgan for pre-op)
Finance lead: Adele Struebig
Multiple attendees clinical and ops
Exec CIP
Meeting
BCH/Newton
Contract Review
Surgical Flow
Group
Outpatient
Mgmt. Group
Task and
Task
and
finish
groups
Task
and
finish
groups
finish groups
Task and
Task
and
finish
groups
Task
and
finish
groups
finish groups
Weekly to drive delivery of CIP, to escalate areas/services for challenge
Chair: Phil Foster, attendees: Michelle McLoughlin, Vin Diwakar,
Matthew Boazman, Kevin Sample, Tim Atack, Lukas Mol
Every 6 weeks to review earned value, benefits tracking,
feedback and BCH/Newton partnership
Attendees: Phil Foster, Claire Burden, Nick Barlow, Lukas Mol
Weekly to drive project
Clinical lead: Gill Derrick
Ops lead: Neil Barnett
Finance lead: Adele Struebig
Multiple attendees clinical and ops
Legacy and Sustainability
The benefits which these projects are delivering include:
- For patients and families:
o Shorter, more effective and efficient pathways
o Improved experience in clinics
o Shorter waiting times, greater access to our services
o Improved clarity of communication, “the BCH way”
o Smoothing and matching of demand to capacity
- For staff:
o Reward from successful delivery of a major change programme, building
momentum and confidence for Trust wide transformation
o Greater satisfaction, reduced frustration from efficient processes
3
Less time spent being reactive, more time proactively looking forward
Building Team BCH – in terms of cross functional teamwork, values, sense of
belonging, capacity, capability
o Transparency and data quality – access to and value of information about
your own service delivery
Operational:
o Shorter, more effective and efficient pathways
o Reduced waiting times and improved access to care
o More efficient processes to manage capacity and demand
o Development of a model for change
o Improved data quality for reporting, measurement and driving improvement
Financial:
o An improved service delivered in a more cost effective way
o Enabling opportunities for growth
o Maximise market opportunities and value for money
o See above for numbers
o
o
-
-
These benefits are being embedded to leave a legacy through a number of methods,
including:
- High levels of clinical engagement throughout the identification, design and
implementation phases to provide guidance, build a sense of pride and ownership
- Implementation of daily, weekly and monthly improvement cycles to embed
changes as part of business as usual with clear accountability. To ensure that all
changes are monitored, reviewed and actions taken as required to drive continuous
improvement.
- Information tools which provide a high degree of insight into the service being
provided by every team. This is achieved through the ‘HEIDI’ tools (‘Hospital
Efficiency Improvements Driven by Information’). The information presented is
personalised, highly relevant and drives actions.
- Learning and development – the core team have been trained in basic
improvement techniques and been able to put these into practice through these
projects. This team are now becoming trainers themselves to ensure that this
knowledge and skill set grows within the organisation. The wider project teams have
been involved in workshops and have used techniques which can be applied to a
wide range of challenges.
The biggest sustainability risk is within the surgery project. Early results look good and there
are some brilliant people involved, but the team does not have a consistent enough core
team (refer to governance structure above) to give total confidence that the improvements
will go from strength to strength after the main part of the implementation. This project needs
a strong clinical lead (one name, not split ownership) to finish delivery, manage the transition
to business as usual and drive even more improvement.
Risks & Opportunities to Maximise Value Delivered
With the current setup, this programme will deliver at target levels and it will be remembered
as a good programme. With the right ambition, there is an opportunity at this point to
increase value delivered to well in excess of target levels, closer to the stretch values. If we
can do this, this work will be remembered as a great programme which delivered an amazing
set of outcomes and set BCH up for Trust wide transformation in the years to come. The
changes will require difficult conversations and moral courage to make them happen.
The top opportunities to maximise value delivered by this programme are below (extracted
from the project risk register):
4
-
Surgical flow team strength and consistency. Operational strength poses a risk to
sustainability, clinical leadership poses a risk to total value delivered.
Absolute clarity around session length in surgery. Enabling this change will unlock
hundreds of thousands of pounds worth of additional opportunity
Acknowledgement that bed constraints will become a bottleneck for flow through the
pathway again in the future, identify how to ease this constraint
A forum to escalate opportunities to (for example outpatient template changes) when
services need to be more ambitious with their plans
Recommendations
Note the project successes in combination with the financial overview. Explore and discuss
the levers to maximise the value delivered by this programme, challenge and support the
core team to enable these changes to happen.
5
Appendices to Patient Pathways Interim Review
Trust Board
October 2014
Page 1
Appendices
1.
2.
3.
4.
5.
Introduction to the outpatient and surgery projects from January 2014
One page project health summaries for outpatients and surgery
Earned value management reports showing activity progress against plan
Benefits tracking – financial opportunity, target and actual by service and project
‘HEIDI’ examples
Page 2
Appendix 1 – Introduction to the outpatient and
surgery projects from January 2014
•
Outpatients
–
–
•
Surgical Flow
–
–
•
Executive summary introduction
Outline project plan
Executive summary introduction
Outline project plan
Key deliverables and benefits
Page 3
 Executive Summary – Outpatients
Understanding opportunities through studies and data analysis
•
•
•
Approach
Q-matic and Attendance data for Apr-12 to Oct-13
Clinic Tracker to capture live start and finish times
Clinic studies across departments and sites
Clinic
Templates
Patient Waits &
Flow in Department
Booking &
Capacity and Demand
Findings
•
•
48% of clinic time is spent face
to face with patients – <2hrs
Opportunity to better utilise
clinic time & reduce waits
through full template review
•
•
Flow in department reduced by
inconsistent template structure
Existing process not optimised
to ensure short wait times &
productivity
•
•
Poor visibility on un-used slots,
difficulties to drive a pro-actively
driven booking process
OP Room capacity on specialty
level doesn’t match demand
Benefits
Patient: Improved access to care, reduced waiting lists, fewer DNAs and on-the-day cancellations
Staff: Fewer over-runs, reduced demand and more even work load through the day, reduced delays
Operational: Greater visibility to better plan resources, ability to flexibly match capacity to demand
Financial: £1.2M - £1.4M pa through income and WLI cost avoidance due to fewer sessions to meet demand
Delivery
6-8 months to setup a data driven clinic template review process with the specialty CDs / DMs, optimise existing
booking process and improve visibility of booking through PASplus+ booking and reporting systems, capacity &
demand modelling, optimise flow in OP department and set-up a Trust-Wide performance review structure.
Page 4
 Project Plan – Outpatients
M1
M2
M3
M4
M5
M6
M7
M8
M9
M10
Kick-off sessions
Establish project team and project board
Project Setup & Governance
PID
Delivery plan, project milestones, results glidepath
KPI Dashboard
Change, risk, and issue logs
PASplus+ OP Module
PASplus+ OP Module
Improvement Project - Outpatients
Booking Efficiency, Templates, Vacant Slots, Utilisation
Provide visibility of opportunity
Trust-Wide Standardisation of
Outpatient Service
Support standardisation of Clinic Session length to match Job-Plan
Clinic Utilisation Tracker
Template Visibility
Matching Capacity and Demand
Template review training
Training Trust Team
Consultant Review and Objection Handling
Outpatient Improvement Cycle Process training
Vacant slot booking tools
Drive Booking Efficiency
Review Process
Removing Over Capacity Clinics
Newton Led: Clinic studies
Specialty engagement meetings
Phase 1 Specialties
Template reviews
On-the-day problem fixes
Ensure appropriate resource seeing patients to maximise capacity
• Specialtiy group 2
• Newton-led with greater support from DM
Phase 2 Specialties
• Ongoing work lead internally by the trust team with appropriate
support from Newton
Phase 3 Specialties
Page 5
 Executive Summary – Surgery
In session studies
-
48hrs of live studies
Approach
Historical data
analysis
Time with Team
•
- ORMIS and iPM
Apr 12 to Oct13
•
Booking Visibility
Schedule Mismatch
Operational & clinical
(surgeons, nursing,
theatres, anaesthetics)
Bookings team
On-the-day Delays
Findings
• 74% of session time spent
operating
• Lack of visibility of lists and
anticipated performance
• No data driven review process
Benefits
Delivery
• Mismatch between Capacity &
Demand
• Lack of clarity over start-times and
Finish Times
• Delays in starting lists and
turnarounds lead to over-runs and
cancellations
• Poor staff and patient experience
• OTD cancellations
Patient: Improved access to care, reduced waiting lists and fewer on-the-day cancellations
Staff: Fewer over-runs, increased accountability from all in team for performance, reduced delays
Operational: Greater visibility to better plan resources, continuous review of performance and causes of lost time
Financial: £1.3M - £1.6M pa through income and WLI cost avoidance due to fewer sessions to meet demand
5-7 months to optimise existing booking process and improve visibility of booking through PASplus+ booking and
reporting systems, capacity & demand modelling, optimise morning start procedures and set-up a performance
review structure to value, prioritise and tackle the greatest sources of lost time and causes for over-runs.
Page 6
 Project Plan – Surgery
M1
Project Governance
•
•
•
•
•
M2
M3
M4
M5
Kick-of f sessions
Establish project team and project board
PID
Deliv ery plan, project milestones, results glidepath
Change, risk, and issue logs
Improvement Project - Theatres
• Finalise installation requirements
Performance Reporting Development
- Booking
- Live View (24hr) of Theatres
- Performance Reporting
• DB/Serv er procurement & setup
• Hardware lead time
• Installation & conf iguration
• Test
• Acceptance
• Workshops, training
• Setup action meetings
• Start steering using
perf ormance reporting
Support improvement cycle
• Dev elop,agree, and implement theatre SOPs
• Challenge and lost time, sy nchronise theatre sessions and MDTs, etc.; capacity balancing
• Focus on start time and issues
Drive Theatre On-the-Day Efficiencies
Drive Booking Efficiency & Implement
Improvement Cycle
Capacity and Demand Planning
- Elective, Emergency & Trauma lists
•
•
•
•
•
Improv e v isibility of waiting list, perf ormance, and booking ef f iciency
Driv e appropriate booking rev iews, daily , weekly , monthly
Improv e clarity on cancellation of sessions and improv e uptake
Implement perf ormance reports
Driv e improv ement cy cle with local team
• Capacity and demand modelling f or
electiv e lists
• Optimise capacity to Emergency &
Trauma demand
• Improv e v isibility of waiting list, utilisation of sessions and in-session utilisation to driv e
capcacity and demand planning on a regular basis
Page 7
M6
M7
 Key Deliverables & Benefits
Financial Opportunity (p.a.)
Project
Outpatients
Surgical Flow
Key Workstreams
Key Benefits
3.5 hours
4 hours
• Improve flow through
department
• Booking performance
• Prioritised template review
• Capacity & demand matching
• Patients: Improved access to
care, reduced waiting lists, fewer
DNAs and on-the-day
cancellations
• Staff: Fewer over-runs, reduced
demand and more even work load
through the day, reduced delays
• Operational: Greater visibility to
better plan resources, ability to
flexibly match capacity to demand
£900k £1.2M p.a.
£1.4M £1.7M p.a.
•
•
•
•
• Patients: Improved access to
care, reduced waiting lists and
fewer on-the-day cancellations
• Staff: Fewer over-runs, increased
accountability from all in team for
performance, reduced delays
• Operational: Greater visibility to
better plan resources, continuous
review of performance and causes
of lost time
£700k £1.3M p.a.
£1.6M £2.3M p.a.
£1.6M £2.5M p.a.
£3.0M £4.0M p.a.
Reduce on-the-day delays
Improve start procedure
Improve booking process
Capacity & demand matching
Opportunity
Page 8
Appendix 2 – One page project health summaries
•
•
Outpatients one page project health summary as of 18 September 2014
Surgical Flow one page project health summary as of 18 September 2014
Page 9
Next Generation – Patient Pathways – Outpatients - Status
“Improving the experience of moving through our hospital systems to help children get home quicker”
Project Sponsor: David Melbourne
Patient Pathways clinical panel:
Operational owner: Claire Burden
Reporting to: Patient Pathways (Clinical Panel), and in turn to (TLT)
Gill Derrick, Fiona Reynolds, Oliver Gee, Ian Wacogne, Phil Debenham, Bryan Healy, Gary Williams, Marion Harris, ASD rep
Outpatient Management Group:
Phil Debenham, Andrea Jester, Gill Derrick, Neil Barnett, Yvonne Millard, Angie Hall, Alex Borg, Liz Meredith, Sue Hobday,
Debra Fitzgerald, Sian Holmes, Charlotte Reynolds, Tom Adamson/Lacey Bennett, Bo Dury, Shahab Raza, Georgina Mann
Work
stream
Problem
No visibility of clinic
1. Measures
utilisation and poor
& Visibility
visibility of unused slots
2. Service
Redesign
Average patient-facing
time is <70% of 3.5hr
clinic time
Objectives
-
Install and implement clinic tracking tool
Install and implement booking visibility tool
-
Redesign clinics & templates to ensure
resources are fully utilised while improving
patient and staff experience
PLAN
Apr May Jun
Jul
Aug
Sep
Oct
Nov
RAG
Update
-
Clinic tracker rolled out
Booking tool installed,providing slotcentric view of short term available
capacity
-
Agreed demand and WLI numbers
through target forms
Redesign of clinic templates in progress
(specialty by specialty)
-
3. Patient
Flow
Long patient waiting
times and ~9% of clinician time waiting for patients -
-
Eliminate clinic late starts due to flow issues
Reduce average & max patient wait times
Improve patient non-wait experience
-
4. Booking
Efficiency
~15% of slots unbooked
-
Improve booking efficiency by driving a proactive booking process
-
Process improvements in main OP
implemented
Reduced patient pre-clinic time to 14min
30sec
Eliminated late starting clinics due to
patient hold ups
Roll out of best practice to other OP
locations
Successful trial of booking tool use in call
centre to avoid unfilled slots for new
appointments
Improved booking process drafted to
integrate all parties involved
Roll out to other specialties
Risks and Issues:
•
•
Current template design and booking processes very show
large inconsistencies. This reduces transparency of the clinic
redesign impact. Risk of keeping status quo or reduced
capacity if not enough challenge is provided
Potential capacity not being considered in areas where no
pressure in service
•
Page 10
Sustainability of service redesign process is hard to ensure.
Slow cycle means it is hard to trial. Lack of template change
process governance poses risk to stability.
Next Generation – Patient Pathways – Surgical Flow - Status
Ensuring the best use of theatre resource whilst improving patient experience and maximising flow
Work
stream
Problem
Data Quality
Theatre reports
inconsistent, with limited
understanding of the
data source
Scheduling
processes
Manual and inefficient
process of ensuring lists
are correctly booked
On-the-day
efficiencies
Over 1000 hrs. per year
of theatre time lost to
late starts
-
-
Improving flow and
Realising the
scheduling alone may not
value
realise financial benefit
Preassessment
No consistent preassessment service
across the trust
PLAN
Objectives
-
Apr May Jun
Integrate HEIDI surgery software to give new
and accurate reports
Make ORMIS complete and correct
Use HEIDI booking tool for automatic visibility
of over- and under-booked lists
Redesign theatre scheduling processes to
ensure the best use of lists
Reduce late starts and turnarounds, giving
confidence to book lists fully
Use new reports to continually improve
Aug
Sep
Oct
RAG
Update
-
http://Heidi-surgery is live
Ophthalmology, gastro and IR clinicians already
using HEIDI to look at how they run their lists
-
HEIDI booking tool now used to coordinate D4
scheduling with theatres – directly drives
booking efficiency
-
Identifying 1st and 2nd patient on list before the
day of surgery to fix list start
Structured ‘morning flow procedure’ drawn up
and being shared with all involved departments
-
Convert productivity improvements into
financial value
-
To provide pre-assessment service for every
child requiring GA or sedation
Trust-wide theatre list productivity – last 10 weeks
Jul
Clarity by specialty through target forms on
activity trends and WLI usage
Need to setup actions against % improvements
Progress working with specialties to define their
pre-assessment needs and identify current
practice
Risks & issues:
•
Lack of project and change management skills with the trust team members on this
work stream could lead to poorly sustained results. Currently heavily supported by
Newton workstream owner
•
Theatre lists are bookable for 7 hours per day – yet we staff for 9.5 hours, which
typically endable 8 hours of bookable list time. Clinical ownership is needed to challenge
the current working practice and plan how to improve this.
•
Bed constraints could limit theatre productivity gains – work planned to look at how
scheduling changes could affect long term demand on beds
Page 11
1. Appendix 4 – Benefits tracking – financial opportunity, target
and actual by service and project
•
•
•
Outpatients benefits tracking
Surgical Flow benefits tracking
Combined programme cash flow forecast
Page 13
Outpatients Benefits Tracking
17/09/2014
Outpatient
Assessment
Target Form Target form Difference to
Specialty
Scope Target (4 hrs) completed Value
Assessment
Cardiology
1
£133.9k
draft
£86.7k
-£47.2k
Cardiac Surgery
£.0k
Clinical Haematology
1
£148.9k
signed
£33.8k
-£115.2k
Oncology
1
£24.9k
signed
£13.3k
-£11.6k
Dermatology
1
£23.8k
signed
£35.6k
£11.8k
Gastroenterology
1
£62.3k
draft
£65.5k
£3.3k
General Paediatrics
1
£106.8k
signed
£129.6k
£22.8k
Neurology
1
£89.3k
signed
£101.4k
£12.1k
Rheumatology
1
£24.0k
signed
£36.6k
£12.6k
Cranio
£.0k
Dental
1
£6.2k
signed
£2.9k
-£3.4k
ENT
1
£63.3k
draft
£35.9k
-£27.4k
Max Facs
1
£.0k
draft
£11.7k
£11.7k
Neurosurgery
1
£27.7k
draft
£18.6k
-£9.1k
Ophthalmology
1
£82.4k
signed
£42.5k
-£40.0k
Plastic Surgery
1
£45.1k
draft
£28.5k
-£16.6k
Paediatric Surgery
1
£68.3k
signed
£34.9k
-£33.4k
T&O
1
£88.7k
signed
£28.1k
-£60.6k
Urology
1
£56.0k
signed
£24.6k
-£31.4k
Cleft
1
£11.2k
no form
-£11.2k
Nephrology
1
£51.8k
no form
-£51.8k
Hepatology and Hepa 1
£.0k
Endocrinology
1
£43.0k
draft
£36.7k
-£6.2k
Respiratory
1
£32.7k
draft
£23.0k
-£9.7k
Retinoblastoma
1
no form
£.0k
Burns
1
no form
£.0k
Diabetics
draft
£.0k
Metabolic Disease
signed
£.0k
Thoracic Surgery
1
no form
£.0k
Spines
?
£.0k
Interventional Radiolog ?
£.0k
Slot Utilisation
£240.0k
draft
£292.6k
£52.6k
Total
£1430.0k
£1082.4k
Page 14
Remarks
No improvement target % on form - estimated value
Pressures on specialty mean that value cannot be realised as expected
Block Contract
Lot of clinics overrunning. Needs further checking
Target form value lower as ~2000 FU activity = pre-admission clinic
Removed fracture clinic activity
Target form not yet completed
Target form not yet completed
Block Contract
Block Contract
Bringing slot utilisation up to 95% across all specialties delivers £293k
Surgical Flow Benefits Tracking
17/09/2014
Surgical Flow
Assessment
Target Form Target form
Difference to
Specialty
Scope Target (3.5 hrs) completed Value
Draft Identified Assessment
Cardiology
!
£68.0k
no form
£.0k
-£68.0k
Cardiac Surgery
!
£163.0k
no form
£.0k
-£163.0k
Clinical Haematology
£.0k
Oncology
£.0k
Dermatology
£.0k
Gastroenterology
1
draft
£27.0k
£58.6k
£27.0k
General Paediatrics
£.0k
Neurology
£.0k
Rheumatology
£.0k
Cranio
1
£.0k
£.0k
Dental
1
£2.0k
draft
£3.2k
£1.2k
ENT
1
£91.0k
draft
£144.8k
£195.7k
£53.8k
Max Facs
1
£6.0k
draft
£6.2k
£3.9k
£.2k
Neurosurgery
1
£12.0k
draft
£18.7k
£6.7k
Ophthalmology
1
£20.0k
draft
£22.5k
£31.9k
£2.5k
Plastic Surgery
1
£60.0k
draft
£95.4k
£170.1k
£35.4k
Paediatric Surgery
1
£85.0k
draft
£83.4k
£158.4k
-£1.6k
T&O
1
£44.0k
draft
£61.7k
£189.1k
£17.7k
Urology
1
£105.0k
draft
£109.5k
£191.6k
£4.5k
Cleft
1
no form
£.0k
Nephrology
£.0k
Hepatology and Hepat 1
£7.0k
draft
-£7.0k
Endocrinology
£.0k
Respiratory
£.0k
Retinoblastoma
1
£.0k
£.0k
Burns
1
£.0k
£.0k
Diabetics
£.0k
Metabolic Disease
£.0k
Thoracic Surgery
£.0k
Spines
?
£5.0k
draft
£6.4k
£1.4k
Interventional Radiolog 1
£15.0k
£.0k
Total
£668.0k
£578.8k
Remarks
Not requested - out of scope
Not requested - out of scope
small
7% late starts, 6% early finish.Aim 50% improvement// Util :73% to 80%
small
Block Contract, possibly a WLI reduction saving only
long turnarounds an issue. 'Ideal' lists with minimal early start, minimal early finish, a
4% late starts, 6% early finish. Aim 50% improvement // Util :75% to 80%
8%
8%
5%
7%
5%
late starts,
late starts.
late starts,
late starts,
late starts,
2% overruns, so 6% useful. Aim 50% impr. // Util :78% to 81%
Take a 50% improvement // Util :71% to 75%
4% early finish. Aim 50% improvement // Util :74% to 79%
5% early finish. Aim 50% improvement // Util :77% to 83%
5% early finish. Aim 50% improvement // Util :75% to 80%
small
Block Contract, possibly a WLI reduction saving only
Block Contract, possibly a WLI reduction saving only
Wrapped up into Paediatric Surgery
not BCH based activity
12% late starts, 2% early finish. Aim for 50% improvement // Util :66% to 73%
£1014.3k
August SF savings run rate £526k
(based on draft baselines)
Page 15
Combined Programme Cash Flow Forecast
Page 16
Appendix 5 – ‘HEIDI’ Examples
•
•
Screenshots
Example of scheduling process changes showing role of HEIDI
Page 17
HEIDI - Reporting Home by Site/Spec/Surg/Anaes
Page 18
HEIDI - Daily Gantt View of Lists
Page 19
HEIDI – Weekly/Monthly Trends
Page 20
Example of scheduling process changes showing role of HEIDI
Previously
With HEIDI in place
Relets
Relets
Relet Record
(Excel)
Rotas
ORMIS
(Trust system)
D4 list planning
ORMIS
(Trust system)
Theatres schedule
(Excel)
D4 list schedule
(Excel)
=
?
Relet Record
(intranet)
Rotas
HEIDI
(Trust system)
Theatres
Scheduling
D4 list planning
Page 21
=

Theatres
Scheduling