BOARD OF DIRECTORS
MEETING IN PUBLIC
26 June 2014
PAPERS
Board of Directors’ Meeting
In Public
26 June 2014
The Education Centre, Birmingham Children’s Hospital
AGENDA
Item
Outcome
Time
Item
No.
14.139
Apologies for absence
Note
14.140
Declarations of interest
Note
Verbal
14.141
Minutes of public Board meeting 29 May 2014
Approve
Enclosure 01
14.142
Matters arising from public Board meeting 29 May 2014
Note
Verbal
14.143
Chairman’s Report
Note
09.05
10 mins
Verbal
14.144
Chief Executive’s Report
(to include Safeguarding)
Note
09.15
10 mins
Verbal
Note
09.25
30 mins
Presentation
*Quality Report - Vin Diwakar, Chief Medical Officer and Note
Michelle McLoughlin, Chief Nursing Officer
*Performance Report - David Melbourne, Deputy Chief Note
Executive & Chief Finance Officer
*Resources Report - David Melbourne Deputy Chief Note
Executive & Chief Finance Officer and Theresa Nelson, Chief
Officer for Workforce Development.
AOB
9.55
15 mins
Enclosure 02
Questions from members of the public
10.10
09.00
Allocated
time
05 mins
Report type
Verbal
Strategy
14.145
Patient Safety Strategy
Vinod Diwaker, Chief Medical Officer
Quality & Resources
14.146
14.147
14.148
14.149
Enclosure 03
Enclosure 04
BREAK 10.15 – 10.25
*For note, unless item becomes unstarred at the commencement of the meeting
05 mins
None
UNCONFIRMED
Item 14.141, Enc 1
BOARD OF DIRECTORS MEETING
Minutes of the meeting held in public on 29 May 2014 at 09.00
in the Education Centre, Birmingham Children’s Hospital
Present
Attending
Ref.
14.111
14.112
Christine Braddock
Sarah-Jane Marsh
Tim Atack
Vin Diwakar
Colin Horwath
Michelle McLoughlin
David Melbourne
Theresa Nelson
Roger Peace
Elaine Simpson
KL
SJM
TA
VD
CH
MM
DM
TN
RP
ES
Chairman
Chief Executive Officer
Chief Operating Officer
Chief Medical Officer
Non-Executive Director
Chief Nursing Officer
Deputy CEO and Chief Finance Officer
Chief Officer for Workforce Development
Non-Executive Director
Non-Executive Director
Matthew Boazman
Judith Smith
Simon Crooks
Georgina Dean
Janette Vyse
Iona Clayton
Dr J. Gray
MB
JS
SC
GD
JV
IC
JG
Director of Strategy and Planning
Non-Executive Director, elect
Executive Office Manager (minutes)
Deputy Chief Officer, Contracting and Performance
Lead Nurse for Participation and Patients
Patient Governor
Head Of Department, Microbiology
Item
Welcome
CB welcomed JS to the meeting who was attending as an observer.
Introduction
CB in her first meeting as chairman shared her early observations gained from attending recent
meetings as an observer.
She was keen to streamline the number of reports coming to the Board which had earlier been
considered at committee level. In future the Quality, Performance and Resources reports would
be ‘starred’ on the agenda for receipt only by the Board – if the chairman of a respective
committee wished for an item to be discussed, the receipt only classification would be
removed.
DM and RP asked for the performance report to be discussed this month to cover diagnostic
waits and cancelled operations.
CB stressed that the priority was to allow sufficient time for the Board to discuss more strategic
items.
Page 1 of 8
Action
UNCONFIRMED
Item 14.141, Enc 1
Ref.
14.113
14.114
Item
Apologies for absence
Apologies for absence were received from Deborah Bannister, Jon Glasby and Keith Lester.
Minutes of the Board meeting held in public on 30 April 2014
Save for a couple of typographical errors which SC would amend, the minutes were agreed as
an accurate record.
14.115
Matters arising from the Board meeting held in public on 30 April 2014
There were no matters arising not covered by the agenda.
14.116
Chairman’s Report
CB shared with the Board her initials thoughts gained since her appointment. She admitted to
having undertaken a steep learning curve to fully understand the Trust and the role of the
governors; the processes and in particular accountability were considerably different to her
previous roles in education.
Her initial thoughts centred on the layers of accountability that seemed to generate duplication
and believed there was a need to begin stripping out some and streamline processes. The
amount of paper work created for individual Board meetings was also a concern, was it
necessary to raise so much? A priority going forward was to reduce this amount.
In addition the important role clinicians played within the Trust was vital and she queried
whether the Board listened to and facilitated the views of clinicians sufficiently.
The Trust was now facing a challenging time, which meant huge demands on executive time – if
we could strip out the time spent on generating paper and attending meetings it would allow
for a more detailed focus on the strategic issues facing the Trust.
The Board noted the verbal report
14.117
Chief Executive’s Report
SJM reported verbally as follows:
Two high profile visits to the Trust had taken place during the month, the first by Lord
Hunt, shadow health minister and deputy leader of the House of Lords and Jennifer
Dixon, Chief Executive of the Health Foundation, to understand our approach to
improving quality and safety in the current financial climate. In particular they were
interested in good practice following some of the work we had undertaken on
redesigning care pathways, handover and also wider aspects of our organisation
culture. They had asked some challenging questions, particularly on how we embedded
good practice. Feedback had been very positive.
Mick Martin the managing director of the Parliamentary Health Service Ombudsman
had visited the Trust to look at our practice, particularly how we work with families on
Page 2 of 8
Action
UNCONFIRMED
Item 14.141, Enc 1
Ref.
Item
the wards who raise concerns, and include families in the complaints process.
CB on a wider point asked how the visits programme was arranged; were we targeting
and inviting the right people who could strategically help the Trust? It was agreed that
CB, JS and SJM would prepare a plan in this respect, identifying the right individuals and
groups – who and why – in order that could help benefit the development of the Trust.
SJM had attended a Health and Wellbeing Board strategic workshop, looking at the
future strategy for primary care. The primary care strategy is something the Trust is
also looking to develop internally, as it is clear there will be different opportunities
going forwards.
SJM had attended a meeting of the Greater Birmingham & Solihull Local Enterprise
Partnership, Life Sciences Advisory Group chaired by Steve Hollis, focusing on the
potential of Institute of Transitional Medicine on the Queen Elizabeth campus, and its
impact on the wider economy. John Bell the Chief Scientific Adviser was challenging
Birmingham to compete with other recognised academic regions.
CB mentioned that Steve Hollis was keen to facilitate a grand project for Birmingham,
based potentially on obesity and saw BCH as as an important component of this.
BCH had hosted the CLAHRC knowledge exchange forum on health promotion in
hospitals.
The first meeting of the BCH Leaders summit took place last week to consider the Next
Generation Project and how leaders could contribute.
Celebration of the 25th anniversary of the liver unit and 21st anniversary of the first
intestinal transplant had been held, culminating in a family day held at Villa Park with
every child who had received either a liver or intestinal transplant invited.
We are hosting a conference of the European Society of Paediatric Neurosurgery at
Coombe Abbey with representatives from all over the world attending.
RP raised the press coverage following the verdict of an inquest into the death of a patient
receiving treatment for cancer. VD highlighted that there was a risk of aspergillus from any
building work on site. However the Trust had learnt from this tragic incident and controls had
been put in place to further minimise any risks associated with any work on site that might
create dust, albeit this would never be nil.
The Board noted the verbal report.
STRATEGY
Page 3 of 8
Action
UNCONFIRMED
Item 14.141, Enc 1
Ref.
14.118
Item
Strengthening the Voice of Young People
MM introduced Janette Vyse, Patient Experience and Participation Lead and Iona Clayton, Chair
of the Young Persons Advisory Group to give a presentation on strengthening the voice of
young people, based on engaging and listening and how this related to the Trust’s mission and
values.
MM explained that the report had been received by SLT and there had been a lot of debate but
also that some of this report would be added to the Trust website. MM explained that the
principles of this report was in line with the Trust strategic vision and objectives.
JV described, in a local and National context the importance of listening and learning from the
engagement with children and young people. At BCH we use a toolkit approach designed to
give as many options as possible for young people and families to contact the Trust and tell us
about their experience. Feedback from SLT had been that some clinical colleagues were not
aware of how much was being done.
Engagement in the last year had been helped by the growing use the feedback app and social
media allowing direct access to staff at any time and immediate response. SJM agreed and
stressed how an immediate response from staff and listening to a query could encourage
positive behaviour by ward staff. In addition the Trust received very positive feedback through
Facebook.
During the last year, using a themed approach to patient feedback we had identified three
areas where we could improve the patient experience, the themes had been play and activities,
caring for children and young people with a learning disability and end of life and palliative
care. Focussing on these areas had provided a more structured process to improve outcomes.
Participation was defined as children, young people and families having the opportunity to
express their views, influence decision making and bring about change.
It was described in practice as happening at three levels,
1. Individual – The relationship between children, young people their parents / carers
and health care professional or member of staff
2. Directorate or specialty level - Improvements or changes to services and care
pathways
3. Organizational or Trust wide strategic issues – the role of YPAG at this level was
discussed
YPAG
IC provided a background on events YPAG had been involved in over the last year showing how
Page 4 of 8
Action
UNCONFIRMED
Item 14.141, Enc 1
Ref.
Item
young people could be involved and contribute to the Trust strategy. In particular the Big
Discussion which brought together local youngsters and healthcare professionals from all over
the UK. Key topics included mental health issues, health education and health promotion and
communication between young people and health professionals.
Last year a review of outcomes and the effect on young people arising from the Francis Report
had been considered as part of a residential and research project. Two specific research
questions were addressed, what made excellent care and how do you show compassion.
The need to develop and maintain the voice of young people was stressed as essential and that
strengthening the patient voice - further organized ward visits would help to support this - and
links with local community were required.
The recommendations arising from the Report, included better use of technology to capture
and share feedback, to build on the thematic approach and triangulation of patient experience
feedback with PALS and complaints, multi-professional education and training, development of
YPAG and encourage more child/ young person led initiatives and projects
From YPAG’S perspective a more structured approach to their role with a greater accountability
and specific targets to focus on would be helpful.
In addition IC, in her role as public governor felt that the experience of young people on the
council of governors could be improved, discussion included should the age of those that could
stand for election be lowered, better training for the role as well as the meetings being difficult
to understand and to speak up at.
CB expressed her thanks and appreciation at the hard work that had been done in compiling
the Report – the voice of young people and their commitment was a vital component of the
Trust. As an example, she stressed the commitment of a new young patient governor who had
attended the last governors meeting despite being in the middle of her A levels.
CB intended now to meet with YPAG but was keen for the Board to know how they can
facilitate and help the Group.
The Board authorised CB to pursue this matter further with YPAG.
The Board received and approved the report.
14.119
Infection Control Annual Report 2013/14
JG presented the annual report of the infection prevention and control team which it was
Page 5 of 8
Action
UNCONFIRMED
Item 14.141, Enc 1
Ref.
Item
noted was a requirement under the Health & Social Care Act 2008.
The report summarized the Trusts position to infection control, specifically in respect of two of
the most prominent infections, MRSA and Clostridium difficile. In the reporting year no cases of
MRSA had been discovered at the Trust (now four years since the last outbreak). There had
been one recorded infection of Clostridium difficile.
Cases of MSSA still existed, but the number was reducing each year down to 24 in the last
reporting year. The principal risk remained to children under the age of one. However the
introduction of a new body wash Octenisan had produced encouraging results.
During the year more rigorous environmental inspections had been implemented to ensure
that the highest infection prevention and control standards are maintained.
The Team now benefitted by the Integration of Infection & Prevention Control Nurses and
Advanced Lab Practitioners, plus seven day infection service and the introduction of new
technology - norovirus diagnosis by real-time PCR.
TN asked about the impact of new technology on new build hospitals and the zero infection
rates that were being achieved. MM explained that technology is important, but the key is
people and effective hand washing and infection control practices being everyone’s
responsibility. JG also expressed caution over this – zero rates usually were seen in the US due
to the mix of patients and their short stay in hospital. In the UK there were much more complex
patients. Instead we probably needed to look at patient flows and the mix between long and
short stay patients. Technology would help in the future but probably in different ways – more
work at point of care by hand held devices with much faster results.
CB asked whether the Report reflect the strategy of the Trust, was there anything missing, were
we doing everything we could? JD whilst expressing caution against complacency felt that our
position compared to other Children’s Hospitals was positive.
The Board received and approved the contents of the report.
QUALITY & RESOURCES
14.120
Quality Account
VD introduced the Account; final drafts had been seen earlier by the Board and subsequently
approved by the Governors Scrutiny Committee and the Council of Governor.
The Board approved the Account.
Page 6 of 8
Action
UNCONFIRMED
Item 14.141, Enc 1
Ref.
14.121
Item
Quality Report
The only item VD wished to raise related to investigation work on the issue of hospital incurred
trauma, particularly in respect of pressure ulcers.
MM reported on the issue of Safeguarding at Birmingham City Council – the latest report
recorded the service as inadequate again.
CB suggested that the next meeting should have a wider discussion on how we could
strategically support young people in Birmingham to see if there was more the Trust could do
or being seen to do. In addition it may be appropriate to invite Albert Bore the chairman of the
Council to a future meeting of the Trust Board so that we could explain how the Trust could
help.
In response to a question from CH concerning past problems over maintenance and availability
of surgical equipment, TA advised that the position had improved.
The Board noted the report.
14.122
Performance Report
DM advised that the last Board meeting had charged the executive team to review the
governance procedures and performance relating to cancelled operations and secondly
prioritisation of operations.
In terms of governance, a monthly performance board would feed directly into the Finance &
Resources Committee and be more focused on the issue. In addition there would be a weekly
operational meeting reviewing up to date data, to reflect where we were stood on key
performance indicators and to provide a more streamlined approach.
CB welcomed this but added that this should include an executive summary with details and
analysis of the main issues for review by the Board and suggested in this instance a deep dive
review on cancelled operations should be prepared for the next meeting.
On prioritisation, DM explained that this was a very complex and difficult area hindered by the
number of complex clinical cases that the Trust faced. April had been another demanding
month with over 189 operations cancelled in total. TA was now looking at this in a more
detailed way to see how appropriately we could look at changing priorities.
SJM stressed the small number of mandatory targets the Trust had to meet, and that there was
no scope for prioritising one target over another in anything but the immediate term to
prioritise patient safety. Instead VD had been asked to consider whether from a clinical
perspective there was a more sophisticated system, using technology similar to that used by
our KIDS service that could allow, in the future, the possibility of clinicians being able to
prioritise treatment.
CB asked if there was a possibility of stretching or changing targets, DM explained a number
were national targets set by the DH and were focused on by our regulators. The ability to
challenge a target was limited, principally only to more locally determined targets. There was
no flexibility for trade off between national targets.
Page 7 of 8
Action
UNCONFIRMED
Item 14.141, Enc 1
Ref.
Item
The Board noted the report
14.123
Resources Report
The Resources Report was received and noted.
14.124
Use of the Trust Seal
The Board was asked to endorse the use of the Trust seal for the Lease of Premises at Selly Oak
Hospital, Raddlebarn Road, Selly Oak, Birmingham for use by the CAMHS Directorate.
The Board endorsed the use of the Trust Seal
OTHER
14.125
Questions from the Public
There were no questions from members of the public.
Next Board Meeting: 26 June 2014, The Education Centre, BCH
Page 8 of 8
Action
Board of Directors
In Public
26 June 2014
Item 14.146
Report Title
Sponsoring Directors
Contributors
Previously considered by
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
Clinical Risk & Quality Assurance Committee, SLT
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
Please see the enclosed report for a discussion of the key risks.
Recommendations
Review the enclosed report
Key Risks
Risk Description
Failure to correctly identify the
greatest risks to the quality of care
and safety of our patients.
Controls
Directorate Governance
systems
Board Assurance
Framework
Risk Register
Safety Strategy
Safety Dashboard
Assurances
Monthly Board Safety Report
Mortality Review
Monitoring of incident trends
Monitoring of complaints
trends
Key Impacts
Strategic Objective
Strategic Priorities
CQC Registration
NHS Constitution
Other Compliance
Equality, diversity & human
rights
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
June 2014
Vin Diwakar, Chief Medical Officer
Michelle McLoughlin, Chief Nurse
Item 14.146
Enc 2
1
The BCH Vision of Quality
Strategic Objectives which reflect our commitment to Quality, Safety and a fantastic patient Experience.
Every child and
young person
requiring access to
care at Birmingham
Children’s Hospital
will be admitted in a
timely way, with no
unnecessary waiting
along their pathway
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
Every member
of staff working
at Birmingham
Children’s
Hospital will be
looking for, and
delivering better
ways of
providing care,
at better value
Clinical Quality is our organising principle. It has always
been our mission to provide outstanding care and
treatment to all children and young people who choose
and need to use our services, and to share and spread new
knowledge and practice, so we are always at the forefront
of what is possible. Our vision is to be the leading provider
of healthcare for children and young people, giving them
care and support – whatever treatment they need – in a
hospital without walls
The physical capacity of the estate is the biggest challenge
to this vision. Thus, our clinical quality strategy is founded
on capital investment in our estate, modernisation of care
pathways, equipping our staff with the skills to use our
existing resources more safely, effectively and efficiently,
and partnership working to deliver healthcare for children
and young people closer to their home wherever possible.
Birmingham Children’s
Hospital’s leaders will
work hard to strengthen
its position as a provider
of Specialised and Highly
Specialised Services, so
that it becomes the
national provider of
Children’s Healthcare
Services in the UK
Birmingham
Children’s
Hospital will
continue to
develop as ‘a
hospital without
walls’, working in
close partnership
with other
organisations
Birmingham
Children’s
Hospital will be
a champion for
children and
young people.
We have built in a relentless focus on the experiences of our children,
young people and families at every level.
We want to be a place where safety is everyone’s top priority and have
set the following 3 year objectives to reflect this:
• Continue development of tools to prevent predictable and
preventable cardiac and respiratory arrests, reduce extravasation
injuries and medication incidents, improve time from decision to
administration of antibiotics, and prevent Grade 2 pressure sores
• Reduce risks in the handover of patients between services and
caregivers during their inpatient stay
• Develop a Trust wide quality outcomes dashboard
• Introduce new methods of collecting and responding to the
experience of our patients and families in real time using all
appropriate means
• Ensure that Patient Experience feedback is used to inform the strategy
for ensuring that we continue to demonstrate our Core Values.
2
The June Report at a glance
New Events & Concerns
Past harm
•New SIRIs
•New Complaints
•New PED Need to Improve Comments
4
4
4
Highlights
•Zero new Never Events for 14 months
•No CVC Infections on PICU for 6 months
•Over 80% of Patient Experience Feedback is positive
•Our overall net promoter score was 83% (73% 12/13)
Learning from Experience
Integration & Learning
•Closed SIRIs
•Closed Complaints
5
6
Themed Analysis
Lowlights
•2 new SIRIs
•14 new complaints
•133 new Need to Improve comments
Sensitivity to Operations
•Patient Experience Database
7
Monitoring & Review
Reliability & Sensitivity to Operations
•Friends & family test
•Feedback App
•Focus on Breastfeeding – parent story
•Strengthening the voice of children & young people
•Celebrating Success – CVC Infections
•Infection Control
•Arrests, ALTEs and Unplanned Admissions to PICU
•Safeguarding
•Safety Thermometer & SCAN
8
9
10
11
12
13
14
15
16
We continue to align existing data to the 5 domains of patient
safety identified by the Health Foundation.
We also continue to align data to the Trust priorities wherever
possible.
Mortality
Past harm
•Absolute number & deaths /1000 admissions
•SMR Run chart
•SMR Funnel Plot & Bar Chart
•PICU Cusum
•Cardiac Cusum & VLAD
•Liver Cusum
17
18
19
20
21
22
3
New Events & Concerns
Past Harm
There have been no new Never Events (None since 15/4/13)
Complaints Overview 2013/14
There have been 2 new SIRIs
14/15:07
Haematology handover sheet was found outside the entrance to another hospital. There have been 2 other very similar
cases 13/14:83 and 14/15:01. Please see the actions already taken in relation to 13/14:83 later in this report.
14/15:12
A patient was administered an antibiotic instead of an analgesic via their epidural. This arose as a consequence of the
incorrect drug being selected from the drug cupboard. This error was not identified during the checking process.
15
96
67
105
Waiting, delays, cancellations and access to services
Staff Attitude
Quality of Treatment
Communication
There have been 14 new Formal Complaints
58
Other
Need to Improve
Comments May 2014
Mother has raised concerns about the quality of care received in ED. Mother states that she feels that during her
attendance an x-ray was not conducted and a fracture missed. Mother feels she was not listened to.
Dad raised concerns about an incident involving one of the members of the complex care team. Dad felt comments
were made to the patient that were highly unprofessional, and potentially racist.
Contact received from NHS England requesting BCH input into the complaint with concerns about
the documentation produced by BCH that was forwarded to a Health Visitor.
Father has raised concerns about the attitude of Consultant
Paediatric Surgeon and the quality of care received.
Mother has raised concerns about the attitude of a receptionist.
Mother states that the receptionist was unaccommodating and rude.
Mum raised concerns in relation to her daughter's treatment by Gastroenterology, in particular, a lack of urgency in diagnosing
the problem. Mum complained that the nursing staff had been rude and had not taken the temperature recordings seriously.
Father has raised concerns surrounding the cancellation and delay to his daughter's procedure related to the use of Bone
Morphogenic Protein and requires the procedure to be completed by a particular Consultant Neurosurgeon.
Concerns with the quality of care provided by the out of hours haemophilia unit on two occasions. Staff seemed uncertain
about what they should be doing.
Mother states she is unhappy with the provision of information received from the a
Consultant in CAMHS and feels that he did not listen to her concerns.
Foster Mum has complained about the lack of hearing tests for her foster child. She is very concerned that he has minimal
ways of understanding the world around him, and is acutely aware of the importance of early intervention in these situations.
Father requested a room in Ronald
McDonald House and was told that
there was a room available but that it
had to be cleaned. Father is upset that
the room was given to another family.
Concerns about unclear test
results and inappropriate
Concerns about misdiagnosis in general paediatrics and that there was a lack of communication about the withdrawal of medication. discharged resulting in a
readmission on the same day.
Concerns about conflicting information about a diagnosis – general paediatrics
Learning from Experience
Integration & Learning
There were 4 closed SIRIs in May
Summary
DGH admitted a patient with significant fractures indicating non-accidental injury. This
patient was under the care of BCH’s Paediatric Surgery and Cardiology teams and there
were problems with non-attendance at appointments as well as previous suspicions on
NAI. Safeguarding procedures did not result in adequate action to safeguard the
patient.
The RCA found that there were some elements of care which fell below BCH standards.
A patient known to BCH with a number of medical conditions was admitted with a
fever and diarrhoea. She deteriorated a week after admission and suffered from a
cardiac arrest and subsequently passed away. The RCA did not identify any care
management failures
A neurosurgical patient has experienced delays with outpatient review and
surveillance of their condition. This may have resulted in a potentially preventable
deterioration to their spinal pathology. The review identified that delays reviewing
the referral letter by the consultant team and delays requesting radiology tests were
compounded by administrative delays to result in delays investigating and treating
this patient’s neurosurgical condition.
Hospital transmission of H1N1 and parainfluenza A to two patients in our medical
high dependency unit. Both patients have recovered well and their treatment was
not affected. The RCA concluded that there was a lack of awareness that flu was still
an ongoing risk to patients at the beginning of March.
Key Actions
•Audit the standard of safeguarding medicals and
admission paperwork
• review and develop the ‘Was Not Brought’ policy.
• Share the findings of this investigation widely to
highlight the importance of adherence to correct
procedures.
The only recommendation that has been made is for
the Resuscitation Committee to consider if there is
benefit in having an individual allocated to manage
crowd control as a separate person to the
resuscitation team leader.
Standardisation of medical and administrative
processes for handling referrals is required. We will
also explore the introduction of a medium-term
electronic radiology requesting system while the
substantive solution is being implemented.
Work with the communications team to develop a
revised communication strategy for this year’s flu
plans.
5
There were 4 Closed Complaints in May
Summary
Concerns with care whilst an inpatient on Ward 12 under
the Cardiac Team and the Paediatric Surgical Teams.
There were issues with delay for the Paediatric Surgical
Team review. Mum felt that the Nurses on Ward 12 was
not attentive and the nappies were not changed regularly.
Concerns that the patient was allergic to the dressing
used in theatre following a procedure.
Concerns about the number of visits to the Emergency
Department for the same problem and inconsistent
advice.
Mother has raised concerns about the delay her son
experienced as an inpatient for surgery, the quality of
medical and nursing care, the attitude of nursing staff
and poor communication.
Mother has raised concerns about the delay in her son
receiving Cardiac Surgery. Mother states that this has
been due to unavailability of PICU beds as well as other
general delays.
Key Actions
•Surgical Grand Round meeting reinforcing the importance of accurate
documentation.
•The importance of good communication with families has been reiterated to
the staff who would normally liaise with the family immediately following
surgery.
Review of the clinical notes did not show that inconsistent advice was given,
more that a number of different possible diagnoses were considered. An
explanation and an apology for lack of clarity were given.
•Where a trauma patient is not deemed an emergency the patient will be asked
to return to the ward the following day, when a theatre slot will be allocated and
a post-operative bed dedicated for the case
•Where a family is not local to the Trust, and cannot return home, they will be
accommodated within a local hotel
•Locate all trauma admissions into one admissions area
•Develop role of Trauma Theatre Co-ordinator
•Develop starvation guidelines
•Apology provided for cancellation of surgery.
•Explanation provided in relation to bed pressures for PICU
6
Patient Experience Database
Total
Total
Positive
Need to
Improve
%+ve
CAMHS
72
40
32
55.56
Clincial Support Services
104
85
19
81.73
Medical
108
69
39
63.89
Specialised Services
285
252
33
88.42
Surgery
139
129
10
92.81
Trust
710
577
133
81.27
Adult
456
93
83.06
Young Person
121
40
75.16
The overall number of need to
improve comments are small in
number with the highest concerns
relating to waiting and delays the comments relate to a number
of areas but predominantly were
about ED and OPD waiting times,
and waiting to go to theatre.
The top 5 positive comments continue to
reflect satisfaction with nursing care, the overall
experience of children, young people and
families, care by Allied health Professionals and
overall quality of care. This is consistent with
the feedback from the Friends & Family
questionnaire and the patient experience APP
You said…
We did…
We could improve on distraction
in anaesthetic rooms………
“more distraction tools”
As a result of feedback from patients and families as well
as theatre staff we approached a charitable organisation
who have agreed to fund sensory/ distraction projectors
for each of our 13 anaesthetic rooms.
Friends and family
May-14
Monthly Adult Scores
Monthly Young People
Scores
May-14
Total number of Trust Discharges
1114
Total number of Trust Discharges
369
Total number of responses in period
415
Total number of responses in period
115
Number of promoters
353
Number of promoters
105
Number of passives
53
Number of passives
Number of detractors
9
Number of detractors
2
Net Promoter Score
83
Net Promoter Score
90
Response Score (20% Target)
37
Response Score (15% Target)
31
May-14
Ward
ED
Target
(15%)
178
Total
Total
Positive
Need to
Improve
81
70
10
%+ve
86.42
Target responses
achieved across
inpatient areas
8
In order to improve children and young people
responses in ED we have introduced more childfriendly forms
All detractor
comments have been
discussed with the
relevant individual
ward managers for
response and action.
Examples of comments relating to most need to
improve category of clean, safe & comfortable
environment
“Ensure correct food ordered”
““Need extra room to
see patients when bed
not ready eg consent,
paperwork.”
“Less of mixed age on
ward or separation of
older children and
younger ones”
“Better hospital signage”
“Quieter night times, staff
laughing loud and banging
a lot”
We will monitor noise at night issues and food ordering, both have
been commented on a few times and across all feedback methods.
Monitoring & Review
Reliability & Sensitivity to Operations
Feedback App & Social Media
During May we received 35 app comments, slightly
less than usual.
Immediate resolution!
Finalist
A comment about waiting times in the eye department was received, a member of staff
went to the department and spoke to spoke to the father minutes after it was sent,
resulting in the immediate de-escalation of the situation.
It turns out he's a physician associate at a GP practice and he's volunteered to be a mentor
of some of our physician associates too!
Social Media
Facebook and Twitter:
The past year has seen an increase of the use of social media by staff.
Social media and the app can support our ambition to be open and
transparent and encourage frank conversations as well as a great
opportunity to interact directly with children, young people and parents.
The app and social media provide an opportunity for parents, children and
young people to let us know about their experience, both positive and not
so good, in real time and for staff to respond directly in real time too.
In May 2014 we received over 170 comments via
the BCH facebook page and twitter account
@Bham_Childrens
All positive except 1, which related to an issue
with a plaster cast. The family were directed to
PALS by the communications team
9
An update on Breast feeding
Parent experience story …..
As discussed last month, feedback from parents suggests we could improve on our support for breast feeding mothers. The issues raised
related to lack of knowledge, privacy and dignity issues, equipment and problems with storage.
The following ideas are directly
from a parent who has had
several admissions with her baby
and wanted to offer her thoughts
from her own personal
experience with the aim of
improving the experience of
other breastfeeding mothers.
Equipment
The provision of equipment for
expressing milk is quite good,
although still patchy in places.
If there are no funds available
to provide a pump on each
ward, then a 'buddy system'
might help. That way each
ward knows where they can
borrow a pump should the
need arise. Sharing a pump
between two people on a ward
is just about manageable, I
recently brought my own
pump in as 7 of us were trying
to share 2 pumps (across NSW
and ward 9) which was just not
possible.
Resources
There are excellent websites which give clear
information about everything to do with
breastfeeding, breast milk supply, expressing, storing
etc, that mothers could make use of. There is also an
excellent book with all the evidence for the value of
expressing milk and information on how to do it
successfully long term. It is available as an ebook and
perhaps some ward areas could have copies available
for mothers to borrow. There are also smart phone
apps available to help mothers monitor milk supply
and storage (e.g. milk maid) which might be helpful.
In the longer term aiming for a UNICEF BFI award
would be a positive goal.
Access to milk on the
wards
Some kitchens are locked, I
understand why but could there be a
system of 'breastfeeding mum swipe
cards' on the ward, so that mothers
who are expressing can access the
kitchens to manage their milk? A £5
deposit for the card and a register of
who has them will allow the trust to
ensure that they are being
appropriately used.
Information and
support
I had no practical support
during the first few weeks of
stay in hospital and brought my
own breastfeeding support
into the hospital from the
community. Perhaps when
mothers are given kits for the
first time they could be given a
booklet/information sheet with
contact details of the trust
support with numbers and
outside (e.g. NCT, La leche
league etc.) It would also be
helpful to review the role of
the breast feeding support on
the ward as my understanding
is that the staff are part of the
numbers and therefore have
limited time to assist mothers
even when on duty.
Strengthening the voice of children
and young people
The chair of YPAG and Patient Experience & Participation Lead presented a paper on strengthening the voice of
children and young people at BCH this month. The key recommendations supported by the Trust Board were:
1. Build on toolkit approach to patient experience and explore more technical options eg - i-pads, screens etc.
2. Build on the thematic approach and triangulation of patient experience feedback with PALS and complaints.
3. Multi-professional education and training – the challenge is to engage more with medical colleagues
4. Further development of YPAG – explore accountability between Council of Governors and YPAG and vice versa
5. Review role of young people on Council of Governors
6. Formalise development of ‘gap year’ opportunity from YPAG to paid position
7. Development of Parent Advisory Group
8. Strengthen our local community Links
9. Encourage more child/ young person led initiatives and projects
10. Build on from and keep ‘The Big Discussion’ going!
Celebrating Success
6 months without a CVC Infection
on PICU
12
Monitoring Infection control
May 2014
Infection
No.
MRSA Bloodstream Infections (BSI)
0
MSSA BSI (pre 48 hour)
1
MSSA BSI (post 48 hour)
1
E. Coli bacteraemia (pre 48 hour)
2
E. Coli bacteraemia (post 48 hour)
0
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
3.5
3
2.5
2
1.5
1
0.5
0
E-Coli - pre 48 hours 2011/12
E-Coli - pre 48 hours 2013/14
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
13
Monitoring & Review
Reliability & Sensitivity to Operations
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 May there were 2 cardiac
arrests outside PICU. Both were
on Ward 12.
Neither have been classified as
predictable or preventable.
Number of Emergency Events
No of Cardiac Arrests (ex PIC)
No of Cardiac Arrests (PICU)
No of Respiratory Arrests
No of ALTEs
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
14
Monitoring & Review
Reliability & Sensitivity to Operations
Safeguarding
Key Figures
Child Protection Training
Level 1
99.2%
Level 2
86.1%
Level 3
85.8%
There has been 0 Safeguarding SIRIs
There has been 0 new Safeguarding Complaints
There has been 2 “Position of Trust’ cases
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
Child Protection Level 2 Training
In response to the Safeguarding Children and Young people: roles and
competences for health care staff: INTERCOLLEGIATE DOCUMENT 2014
Level 2 Training has been reviewed.
In order to support the face to face training, we launched an online Level
2 module utilising a national programme located on the National Skills
Academy Core Learning Unit eLearning site. This has made a significant
improvement to the training figures for Level 2 which are now compliant
with the Trust KPI of 85%.
We will continue to closely monitor the training figures for all the Levels.
Birmingham South Central Clinical
Commissioning Group
The Vulnerable People and Families Assurance Visit took
place on 2nd June 2014.
This is the first time that we have been visited and the
focus was on the following areas:
•A&E
•Outpatients
•Teenage Cancer Trust Unit
•Burns Unit
•Plastic Surgery
•Speech and Language Therapy
•Neonatal Surgical Unit
•Cardiology
•PICU/KIDs
As part of the visit , the Safeguarding Team presented 4
patient stories to demonstrate the Trust’s achievements,
good practice and challenges within the safeguarding
arena.
The verbal feedback on the day was generally very
positive. The team felt that everyone was very
committed, took pride in the work they do and were very
knowledgeable around safeguarding issues.
Monitoring & Review
Reliability & Sensitivity to Operations
Safety Thermometer & SCAN
We continue to work with Haelo and NHS England to further test the safety
measures that were designed for SCAN. The intention is to develop the process
measure into outcome measures. We have participated in weekly testing of one
definition per week and will contribute to the WebEx.
At this point there is no data available to present.
We are no longer required to survey using the
Classic Adult Safety Thermometer.
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.
Deaths
Deaths per 1000 Admissions
16
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 fallen from 164.31 to 161.77
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. In 2000-2005, the overall mortality rates (30 days postoperatively) was 4.8%. In the period October 2010 – September 2012
this had dropped to 3.3%.
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
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 6 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.
Note: Updated data for June Report not yet available
No Change
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
Board of Directors
In Public
26 June 2014
Item 14.147
Enc 3
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 – May 2014 Performance Report
Sponsoring Director
Deputy Chief Executive
Author(s)
Deputy Chief Officer Contracting and Performance
Previously considered by
Finance and Resources Committee
Situation
This report provides the May update on this month’s Trust Performance supporting
improving our patient experience. The report highlights where performance is not being met
and any concerns or improvements.
The attachments provide:
Further details on our current and comparative performance
Background
There are four areas to highlight:
Access to services
1. Diagnostic waits
There were 121 patients who at the end of May who had been waiting over 6-weeks for a
diagnostic test, (101 for MRI and 20 for CT). This is 11.2% of all diagnostic waits and above
the 1% NHS standard. The NHS as a whole missed the target in March 2014 across a range
of modalities.
The trajectory for zero breaches by the end of June now looks unachievable with latest
forecasts being 28 breaches which is around 2-3%. The majority of these (24) are for nonGA. The mobile scanner is due on site in June and it had been assumed that increasing the
number of days on site would mean that this number would be reduced and so the overall
target met. However upon detailed patient by patient review there are not sufficient suitable
patients that can be scanned on the mobile scanner which has led to the forecast breaches.
The service is now identifying those that are suitable as soon as the referral is received so
that any potential issues can be identified in advance. The mobile scanner is booked again
for July and September. A further 57 breaches are forecast in July.
The waiting list dropped in early May due to the mobile scanner but has increased slightly
again. The movement being seen in the non-GA list whilst the GA list has remained fairly
static.
The team are continuing to review and identify any other opportunities. There remains
limited flexibility in the service and so a shift in the number and types of referral still has the
potential to affect this.
Demand for MRI does show an increase over the past 12 months. When shown on a SPC
chart it can be seen that there have been two weeks where demand has been over the
upper confidence limit, in November and early May as previously reported. The chart also
shows that overall demand since October has generally been between the mean and the
upper confidence limit compared to earlier in the year when it fluctuated above and below
the mean. Given the service is running at maximum capacity it does help to explain why
reducing the breaches has been a challenge.
Forward look
Recruitment for additional radiographers and radiologists has been successful and a number
of experienced staff have been appointed. This will provide more sustainable capacity from
October.
The independent review commissioned with a specialist from the Royal College of
Radiologists transformation team has now commenced with Commissioner input. This will
consider how the team works and what actions can be taken to improve the performance.
2. 18 weeks waiting time.
Whilst the targets were met in May this remains a risk for the organisation. There is
increased scrutiny and weekly reporting is now required to Monitor and Commissioners. In
addition it has been announced that additional funding will be made available to support
organisations to meet the targets. Given our challenges are around capacity and we have
struggled to identify alternative providers previously whether we would benefit from this
needs to be explored.
The 18-week standard was met in May with performance for admitted patients at 91.3%
against the 90% standard. 87 admitted patients and 4 non-admitted patients were not
treated within 18 weeks due to insufficient capacity.
The performance for incomplete pathways remained fairly static achieving 92.3% against
92% standard. This standard is expected to be the focus of commissioners and Monitor. As
shown on the chart on page 6 the drop in the numbers of those waiting over 14 weeks
without a TCI and over 18 weeks without a TCI seen in January has been reversed and has
continued to increase in May. When patients receive a TCI late in their pathway it makes it
difficult to meet the target and so this trend is a concern.
The outpatient waiting list has seen a huge increase across a range of specialties. This is
being reviewed by Directorates and plans identified to reduce. However if these need
inpatient treatment it will put further pressure on the targets.
Looking forward, based on current assumptions and forecasts the standard will be met in
June but there is greater risk than in previous months.
The number of patients waiting over 30 weeks is 140 in line with April.
There were three patients reported to be waiting over 52 weeks, this is due to patient choice
and once seen will be validated out.
The overall waiting list size showed a small increase which was as expected due to the high
levels of cancellations in May.
CAMHS achieved 100% for 18 weeks with the average wait being less than 4 weeks.
Utilisation of resources
3. Cancelled operations
In May there were 28 patients or 1.42% of all operations were cancelled on the day due to
hospital reasons. This is less than previous months and May 2013. In addition there were a
further 141 patients that had their operation cancelled by the hospital before the day of the
operation. The total number is above the upper confidence level and any previous months.
There were eleven breaches of the 28 day standard in May. The target is zero except that it
is recognised that there may be breaches due to no PICU capacity. These were all due to
no ward beds reflecting the challenge of meeting this standard after several months of high
cancellations. Directorates have been challenged to review how they are managing this
target given the relatively small numbers in the context of the total activity each month.
Over the last few months it has been reported that there was a shift in the reasons for
cancellation as well as the specialties impacted and this has continued. Of the total number
of cancellations year to date 93 (27%) were due to no ward bed being available and only
25(7%) were due to no PICU bed. This compares to 24% of all cancellations being due to
no PICU beds for 2013/14 and 14% being due to ward beds. In terms of the specialties
impacted, 130 (69%) of the total cancellations were in surgical specialties with only 16 in
cardiac/cardiology (8%).
There are a significant number of cancellations that have been categorised under cancelled
by the clinician/hospital which is due to reasons such as no longer needing the operation or
not being fit for the operation. This category has increased significantly and so further
validation and review is being carried out.
Twelve patients had their operation cancelled more than once by the hospital, ten being
cancelled twice, one three times and one five times.
Further work is being completed by the Directorate team and Informatics to understand the
drivers for the cancellations and bed capacity issues. This includes looking at levels of
emergency admissions, length of stay and tertiary referrals.
4. Long stayers and delayed discharges
As noted above the hospital has suffered pressures around beds now for a number of
months and this has impacted on our ability to deliver elective activity. Further work is being
completed to understand the drivers for this but an increase in children staying over 7 days
plus delayed discharges are contributing factors as well as young people waiting for Tier 4
CAMHS inpatient beds.
The charts on page 17 of the report show the change in profile of those in inpatient beds.
The overall number of children staying more than seven days has increased, in particular
since the last quarter of 2013/14, this increase is also seen in those over 30 days and over
90 days. Focusing on those over 90 days the second chart shows that a year ago we had
three who had in total been in for 260 days, in June 2014 this has increased to eleven with
1299 days. Some of these will link to the delayed discharges referred to below whilst others
still need treatment in hospital reflecting the complexity.
There were 7 children and young people at the end of May who were fit for discharge but
waiting for other reasons. A reduction from 9 in April. One has waited for over a year. The
reasons are for housing and social care reasons. The total number of bed days relating to
these delays is 904 days. This has been escalated to commissioners.
In addition there were five young people waiting in Parkview. This is the same as at the end
of April. This has been escalated to commissioners.
Update on other areas of performance
Emergency Department
The Trust continues to perform well against the 4 hour standard and met the target in May.
The 95th percentile performance was 3.9 hours. This was despite continued high levels of
demand.
There was one Emergency Department (ED) standard that was not met:
The local ED triage objective (all within 15 minutes), the 95 percentile performance
being 32 minutes (previous month was 34).
Generally performance in May was an improvement on prior years.
Tertiary referrals
There were four West Midlands patients who couldn’t get a bed in May and no out of region
patient. When reviewing the long term trend it can be seen that there has been a significant
drop in refusals since December 2010 with the numbers fluctuating between 0 and 6 each
month.
Twenty seven, of which twenty one were West Midlands patients that were admitted had to
wait over 24 hours before a BCH bed was provided. This is a significant improvement on
April. This was despite continued high levels referrals. When a referral is received the
specialty consultant is asked to identify the time period in which the child should be admitted.
This is under 12 hours, 12 – 24 hours or 48 hours. When comparing actual time to
admission against recommended time for admission it can be seen that 87% of requests
were met of this 99% of patients who were assessed as needing a bed within 12 hours were
admitted within the timeframe.
This indicator is currently being reviewed by Internal Audit focusing on data quality.
PICU (Paediatric Intensive Care Unit) referrals
The West Midlands (WM) 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.
Eight West Midlands (WM) patients and four non WM patients could not be supported due to
hospital reasons.
Overall the KIDS team continue to be successful in supporting local hospitals, 20% of
children did not need to be moved because of the support provided.
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. Seventeen patients could not be supported by BCH CAMHS in May which was
higher than last month due to no capacity and urgency. There continues to be significant
capacity pressures across the West Midlands and nationally for Tier 4 beds. We are still
awaiting the results of the national review but early indications are that it will not make
significant changes. A procurement exercise is likely to be carried out which we will need to
respond to.
Internally the ERA service has now extended to 7 days a week and this has had a positive
impact providing a more rapid response where needed and ensuring young people receive
support whilst waiting.
Assessment
A reduction in capacity due to staffing and a spike in demand has led to an increase in the
waiting times for MRI and pressures around ward beds and PICU beds has led to continued
high levels of cancellations.
Plans to reduce delays include:
PICU Capacity:
We expect a delay to increase beds from 28 to 31 beds. This is predominantly due to
staffing issues. Therefore there will continue to be an impact on performance.
A review is being carried out by NHS England to consider paediatric critical care capacity
across the region, the Trust are supporting this.
Theatre Capacity:
Weekend working is now taking place as well as additional capacity at the Birmingham
Treatment Centre.
A Theatre Working Group is in place with a focus on improving staffing levels to maintain
and increase theatre capacity.
A Cancellations Working Group is in place which is running a series of pilots to reduce
total cancellations. A project is underway to look at how we ensure all elective patients
undergo pre-admission which will help to reduce the risk of cancellation.
Additional anaesthetists now in place.
Business case for extending capacity through use of the Plaster room approved.
Further business case under development for development of Interventional Radiology
capacity.
Newton have been appointed to support the Trust in terms of flow management through
theatres.
Diagnostic waits - MRI capacity:
A medium term capacity plan for Imaging is being produced which includes new ways of
working.
New consultants are now in place with further interviews in May.
Additional lists for GA were agreed both in week and on Saturdays for January and May,
with discussion over this continuing in future months.
Mobile scanner planned for end of May, May and June.
Extended working hours agreed with radiographer workforce.
New roster agreed with radiologists.
Overall bed capacity:
Analysis being completed to understand the drivers behind the current pressures.
The Medium Term Clinical Estates Strategy is being developed to identify future demand
and solutions to meet demand.
Recommendations
The Board is asked to note the performance and plans for further improvement.
Key Risks
Risk Description
Controls
Insufficient capacity in place Appropriate
to meet service demands
systems in place
Assurances
escalation Daily, weekly and monthly
reporting in place.
Capacity
plans
being Revised capacity plans being
renewed and developed. produced.
This
includes
modelling
capacity/demand
between
now and 2020 (new hospital)
Winter plan implemented
providing
additional bed
capacity & flexibility
Key Impacts
Strategic Objectives
CQC Registration
outcome)
NHS Constitution
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.
Other Compliance (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 2 2014/15
Performance for May 2014
Georgina Dean
Deputy Chief Officer for Contracting and Performance
Item 14.147
Enc 3
1
Operational Performance Indicators
How our patients access care
ED - time in ED
18 weeks performance (incomplete)
PICU – non WM patients supported
ED – time to seen
18 weeks performance (admitted)
PICU – non WM patients not supported
ED – Time to triage (all)
18 weeks performance - CAMHS
PICU – WM patients not supported
ED – time to triage (ambulance)
Long waiters - patients not treated within 18 weeks
due to insufficient capacity
MRI waits over 6 weeks
ED – Left without being seen
Long waiters - patients not treated within 30 weeks
In region Tertiary referrals sent elsewhere
ED – Unplanned readmissions
Long Waiters - patients waiting over 52 weeks
Tertiary patients waiting over 24 hours for a BCH
bed
18 weeks performance (non admitted)
CAMHS Patients that requested a T4 bed and were
not admitted
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 2 2014/15
Performance for May 2014
How our patients access care
3
Emergency Department
95th % time
in A&E:
3.90hrs
95th % time to
triage (all):
32 minutes
95th % time to triage
(ambulance):
13 minutes
Median time
to be seen:
59 minutes
Left without being
seen:
1.95%
ED re-attenders for
related condition
2.90%
ED overall position: In May all but one of the targets in the ED department has been met.
This target of all patients (not just
ambulance patients) having an initial assessment within 15 minutes is routinely not met however we continue to see ambulance patients
within target and have met the four hour wait target for 14 consecutive months. We met the median target for the % of patients to be seen
within 1 hour, and only small numbers of our patients are not leaving the Dept. without being seen.
Total Time Spent in A&E
Standard ≤ 4 hours (95th Percentile)
% Patients Who Left ED Without Being Seen
Standard < 5%
7.0
4.70
6.0
4.50
Time to be Seen
Standard ≤60 minutes (Median)
90
80
70
5.0
60
4.30
4.0
50
4.10
40
3.0
30
3.90
2.0
20
3.70
1.0
0.0
10
0
3.50
A
M
J
J
A
S
O
N
D
J
F
M
A M J
J
A
S O N D
2012-13
2013-14
2012-13
2013-14
2014-15
Target
2014-15
Target
J
F M
A M J
J A S O N D J
2012-13
2013-14
2014-15
Target
F M
4
18 week waits
Admitted
Non admitted
• 91.3%
• 97.1%
Incomplete
• 92.3%
18 weeks overall position: all targets were met in May 2014. The admitted performance remained at the same level as last
month. The incomplete pathways remain only just above target. Numbers waiting over 30 weeks 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
91 patients were not treated within 18 weeks due to
insufficient capacity
18 weeks admitted performance
94.0%
Patients not treated within 18 weeks due to insufficient capacity
93.0%
92.0%
14
91.0%
14
10
12
11
90.0%
8
4
7
89.0%
88.0%
4
87.0%
14
44 42
86.0%
118
118
97
112
90 87
75
73
3 patients were waiting over 52 weeks
(2 patients had patient related pauses which
reduces their wait to below 52 weeks. )
Admitted
May-14
Apr-14
Mar-14
Feb-14
Jan-14
Dec-13
Nov-13
Oct-13
Sep-13
Aug-13
Target
Jul-13
F M
Jun-13
J
2014/15
May-13
D
54
128
105
61 56 62
Apr-13
N
41
8
0
83
Mar-13
O
25 29
Feb-13
S
2013/14
4
8
Jan-13
A
3
Dec-12
J
Nov-12
J
2012/13
Oct-12
A M
3
2
4
1
2
Non admitted
Of the 3 patients waiting over 52 weeks, two had patient related pauses which reduces
the wait to below 52 weeks. The third patient has breached the target on a non
admitted pathway where patient has chosen to wait longer than 18 weeks and did not
attend several times but this is still counted as a breach.
5
18 week waits
Fig 1 - % still waiting for clock stop (incomplete) under
18 weeks
18 weeks: Current problem, future problem
600
100.0%
500
98.0%
96.0%
400
94.0%
300
92.0%
200
90.0%
100
88.0%
0
25.05.14
27.04.14
06.04.14
16.03.14
23.02.14
02.02.14
12.01.14
Target
M
15.12.13
F
24.11.13
J
03.11.13
2014/15
D
13.10.13
N
22.09.13
O
01.09.13
2013/14
S
28.07.13
A
07.07.13
J
16.06.13
2012/13
J
26.05.13
M
05.05.13
A
Performance for patients still waiting for their initial treatment (either admitted or non admitted pathway) has increased slightly since last month to
92.3% (Fig 1.)
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 showed a large increase in December 13 and has steadily decreased until
March, when it started to increase again.
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 decreased in
May. The red line illustrates patients who are waiting 14 plus weeks and do not have a TCI date yet, and this is increasing.
The potential for increased breaches is greater due to the increase in those still not having a date late in their pathway.
6
Whole Inpatient waiting list and long waits
Whole Waiting List Size (not just RTT patients)
140 RTT patients either still waiting or
whose clock stopped after 30 weeks
8000
7000
Specialty break down of the 140
patients still waiting over 30 weeks
All RTT Patients Still Waiting or Whose Clock
Stopped Over 30 Weeks
6000
160
Paediatric Plastic Surgery
34
Paediatric Surgery
22
Paediatric Cardiology
Paediatric Trauma and
Orthopaedics
20
Paediatric Ear Nose and Throat
18
140
5000
120
4000
100
140
80
3000
140
60
2000
94
40
20
1000
39
54 49 54 57 61
109
99 107
73
Inpatients
Surg/Cardiac Inpatient
At end of May, there are still 140 patients
waiting over 30 weeks (either still waiting or
who had their clock stopped in the month)
This is the highest value since Nov 12.
Outpatients
The overall waiting list for surgical and cardiac stood at
2199 at end of May, with the total list standing at
3862. The Cardiac/Surgical list was reducing since the
new calendar year but has increased in the last 2
months. The outpatient list size has increased
significantly in the last month and this is being
investigated
Of the 140 patients 8 had their clock stopped
over 30 weeks and 132 are still waiting.
May-14
Apr-14
Mar-14
Feb-14
Jan-14
Dec-13
Oct-13
Sep-13
Aug-13
Jul-13
Jun-13
Nov-13
01/06/2014
01/05/2014
01/04/2014
01/03/2014
01/02/2014
01/01/2014
01/12/2013
01/11/2013
01/10/2013
01/09/2013
01/08/2013
01/07/2013
01/06/2013
01/05/2013
01/04/2013
0
May-13
0
18
Paediatric Urology
8
Paediatric Burns Care
4
Paediatric Neurosurgery
4
Craniofacial Surgery
3
Paediatric Cardiac Surgery
2
Paediatric Gastroenterology
2
Cleft Lip & Palate Surgery
1
Paediatric Neurology
1
Paediatrics
1
Paediatric Thoracic Surgery
1
Paediatric Dermatology
1
7
Diagnostic waiting lists
The charts below illustrate that demand for diagnostic test continues to be high and
the waiting list is showing a slight decrease. There is a switch in the make up of the
list towards non GA.
Diagnostic waits overall position: we continue to fail to
meet our key target for MRI and are a significant outlier
nationally in this area . Demand continues to be high.
MRI Waiting list
1500
Number of patients waiting over 6 weeks for MRI (actual
and forecast)
97
500
123
107
101 106
101
0
88
71
45
NON GA WL
2012-03-19
2012-04-16
2012-05-14
2012-06-11
2012-07-09
2012-08-06
2012-09-04
2012-10-01
2012-10-29
2012-11-26
2012-12-27
2013-01-21
2013-02-18
2013-03-18
2013-04-15
2013-05-13
2013-06-10
2013-07-08
2013-08-05
2013-09-02
2013-09-30
2013-10-28
2013-11-25
2013-12-23
2014-01-20
2014-02-17
2014-03-17
2014-04-14
12/05/20…
02/06/20…
115
GA WL
1000
139
133
Total WL
57
51
28
Total external referrals
UpperCI
Linear (Total Additions by week)
Jul-…
Jun…
Ma…
Apr…
Ma…
Feb…
Jan-…
Dec…
Nov…
Oct…
Sep…
Aug…
Jul-…
Jun…
Ma…
Total waiting list additions by week
Total Additions by week
Lower CI
180
160
120
100
80
60
40
07/06/…
07/05/…
07/04/…
07/03/…
07/02/…
07/01/…
07/12/…
07/11/…
07/10/…
07/09/…
07/08/…
07/07/…
07/06/…
07/05/…
07/04/…
07/03/…
0
07/02/…
20
07/01/…
The SPC chart (right) on total waiting list additions shows that whilst
the level of demand has been above the upper confidence limit
only a couple of times it has shown less variation between upper
and lower limits and has been between the mean and UCI since
November 2013.
140
Patient numbers
The MRI service continues to be under significant pressure with 121
patients breaching the 6 week target in May 2014 (101 for MRI and
20 for CT scan.) The position is forecast to drop again in June but
there will be 57 breaches at end July. Previously it was projected
that we would have enough capacity to reach zero breaches for end
July 14, but whilst the capacity is there, it cannot all be utilised as
some patients are not suitable for treatment on the mobile facility.
8
Access to CAMHS
Community CAMHS - Waiting Time to Assessment
A:- 0-4 wks
CAMHS 18 Weeks Performance
105
100%
CAMHS continue to achieve against their 18 week wait target
with 100% of their patients being seen within target in May.
100
80%
60%
95
364
B:- 4-8 wks
383
C:- 8-13 wks
361
708
1060
756
870
765
40%
838
186
1299
20%
85
80
1466
1114
873
0%
2010/2011
2012/2013 2013/2014 2014/2015
Financial Years
CAMHS are now successfully assessing more of their patients within
four weeks (96% so far in 2014/15 compared with 56% in 2013/14.) The
average wait has reduce to 1.9 weeks from 4 weeks in 2013/14, and 8
in 2012/13. The overall level of assessments has reduced over time
following the introduction of improved protocols for the management
and assessment of referrals.
75
Apr May Jun
Jul
2012/13
Aug Sep Oct Nov Dec Jan
2013/14
Feb Mar
2014/15
Target
CAMHS Patients that requested a T4 bed and were not
admitted (month trend)
18
14
6
171
952
90
16
D:- >13 wks
25
2011/2012
CAMHS Tier 4 Gateway Referrals
The no. not admitted
has increased to 17
40
35
30
25
20
15
10
5
0
12
10
8
6
4
2
0
Apr May Jun
Jul
2012/13
Aug Sep
Oct Nov Dec
2013/14
Jan
2014/15
Feb Mar
Total No Referrals
GA Completed
Referred to SCT
Tier 4 referrals (in blue) and gateway assessments (the red line) show
an increasing trend, and more patients are not able to access a bed and
9
are referred to the Specialised Commissioning Team (17 in May)
Urgent Tertiary and Home Referrals
217 referrals for
specialist beds,
184 admitted
4 in region
patients unable to
get a bed
0 out of region
patients unable to
get a bed
29 patients no
longer required a
BCH bed
21 in region patients
waited over 24 hours
to get a BCH bed
6 out of region waited over
24 hours to get a BCH bed
Overall position: Tertiary and home urgent referrals in May at 217 is once again high. Four in region patients did not get a bed and 21
in region patients waited over 24 hours . However 87.5% of requests were still met within the required clinical timescale.
Urgent Tertiary and Home Referrals
Activity levels
250
200
Levels of urgent referrals
remain high; with this month
being the second highest since
October 2012
199
197
177 188 181 173 163 169
175 186
175 170 188 191 172 182
150
100
50
0
Home
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 what was achieved for
May.
Overall 87.5% of requests were met in
May (compared to 83% in April).
225 209 217
Tertiary
Total
Performance vs clinical tgt time for patients provided a bed - home and tertiary referrals
100
80
100%
99%
80%
82%
60
77%
60%
40
40%
20
20%
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
Referrals Waiting over 24 Hours
Four referrals were sent elsewhere in May 14. Referrals sent
elsewhere for 14/15 is now 28% of the entire 13/14 financial year
total, indicating that the management of these urgent referrals has
been challenging.
The number of children waiting over 24 hours for a bed
after a tertiary referral is close to the average. Referrals
continue to be high, and 87.5% of referrals were managed
within the clinical target time.
Tertiary and Home Urgent Referrals Sent Elsewhere
Paediatrics
Trend - Tertiary and Home Referrals Waiting Over 24
Hours for a Bed
T&O
50
45
40
35
30
25
20
15
10
5
0
Surgery
Resp Med
Neurology
Nephrology
Medical Oncology
ENT
May-14
Apr-14
Mar-14
lower ci
Feb-14
Jan-14
Dec-13
Nov-13
Oct-13
15
Sep-13
YTD 14/15
10
Avge
Aug-13
5
Jul-13
0
Jun-13
Apr-13
Over 24 Hr Waits
May-13
Mar-13
Feb-13
Dec-12
Hepatology
Jan-13
Cardiology
Nov-12
Oct-12
Clin Haem
upper ci
20
Tot 13/14
11
PICU Demand and KIDS Service
8 West Midlands patients
could not be supported
4 non West Midlands patients
could not be supported
PICU demand overall: Referrals
7 additional non West Midlands
patients were supported
were lower than the previous month. 10 patients could not be supported within the local network
and had to be taken out of region.
Year on Year Comparison of Total Referrals to KIDS
250
There were 104 referrals to KIDS in May 2014. 20% of referrals
were avoided , 41% were admitted to BCH, 27% were referred to
other WM hospitals and 12% went out of the region
200
150
100
50
Referrals to KIDS Service Taken Out of Region
(Leics or Other Non WM Provider)
0
Apr
May
Jun
Jul Aug
2012/13
Sep Oct
2013/14
Nov
Dec Jan
2014/15
Outcome of Referrals to KIDS - Trend
70%
Feb
Mar
30
25
20
15
60%
Total
10
50%
Avge
5
40%
0
May-14
Mar-14
Jan-14
Nov-13
Sep-13
BCH
Out of Region
The red line shows that
BCH took fewer referrals
in the first part of Winter
2013, but is now able to
return to a more normal
level.
Jul-13
Avoided Admission
UHNS and Other WM
May-13
0%
Mar-13
10%
Jan-13
20%
Nov-12
Sep-12
30%
For the winter periods patients
are more likely to be taken out of
Region.
12
Operational Performance Report
Month 2 2014/15
Performance for May 2014
Utilisation of our facilities
13
Cancelled operations trends
Cancelled operations overall position: the number of cancelled operations flagged as nationally reportable in May 2014 is
below average (28). Total hospital cancellations at 169 are high compared to previous month and we remain above our strategic goal of
a reduction on 12/13 levels. There were eleven breaches of the 28 day standard in May.
Cancelled Operations On The Day - National Definition
There were 28 nationally reportable* cancelled operations in May 14,
which is below the monthly average since April 2012
80
66
* Cancelled by hospital for non medical reasons on the day of admission or after admission
60
All Hospital Cancelled Operations
50
200
40
28
30
150
20
100
10
50
Apr-14
Jan-14
Oct-13
Jul-13
Apr-13
Jan-13
Oct-12
Jul-12
Apr-12
Jan-12
Oct-11
Jul-11
Avge
Total
Data
1
Total
28
1
4
2
0
May-14
Lack of theatre time
0
4
Apr-14
1
2
5
3
Mar-14
Theatre staff unavailable
3
6
Feb-14
1
7
Jan-14
1
Total Hospital
Cancelled
Operations are
well above the
upper
confidence
interval in May
14 (169
cancelled.) As
part of
improvements
to the way the
data is analysed,
some have been
re-classified as
hospital
cancelled
11
Dec-13
Anaesthetist unavailable
16
Nov-13
4
lci 2stdev
Breaches of 28 Day Cancelled Operations Standard
18
16
14
12
10
8
6
4
2
0
Oct-13
Emergency/Trauma
uci 2stdev
Sep-13
9
There were 11 breaches of
the 28 day standard in
May 2014. 5 Plastic
Surgery, 3 ENT and 2 in
Urology. Bed shortages,
accommodating more
urgent patients and
general high levels of
demand were the causes
of this
mean
Aug-13
11
Bed shortage
Equipment failure/
unavailable
2014/15
Jul-13
ICU/HDU beds unavailable
2013/14
0
May-13
Nationally Reportable
Cancellations by Reason
Aug Sep Oct Nov Dec Jan Feb Mar
Apr-13
2012/13
Jul
Apr-11
Apr May Jun
Jun-13
70
14
All Hospital cancelled operations year to date by specialty
All Hospital cancelled operations year to date by reason
Clin Haem
3%
Plastics
15%
Other Dir 3
4%
Radiology
9%
Hepatology
4%
Surgeon
unavailable
4%
Other Dir 4
7%
Cardiac
Surgery
9%
Paed Surgery
15%
Urology
9%
Other Dir 2
4%
Admin error
2%
Other
4%
T&O
6%
Ophth
4%
Patient not
suitable for op
12%
Bed shortage
27%
Lack of
theatre
time
6%
ICU/HDU beds
unavailable
7%
ENT
11%
Unfit with
acute illness
Anaesthetist
(hosp canc)
unavailable
8%
3%
Emergencies/t
rauma
14%
Operation not
necessary
(hosp canc)
13%
The hospital has cancelled 342 operations so far in 2014/15. The Surgical Directorate have the most cancellations (226) with Paediatric Surgery
and Plastics being the largest single specialties. The biggest reason for the cancellations is due to bed shortages. This has reduced from 64 in
month 1 to 29 in month 2. Staff unavailability has accounted for 27 cancellations in month 2.
15
Multiple cancellations
Patients cancelled more than once in same specialty during
previous twelve months
14
Cancelled Operations Associated With Patients cancelled more
than once in same specialty during previous 12 months
40
12
35
10
30
8
25
6
20
4
15
2
10
0
5
0
Twice
3 times
4 times
5 times
6 times
7 times
In May 2014 12 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 12 patients had 28
cancellations between them in total in the previous 12 months
in the relevant specialty.
Strategic objective: Year to date hospital cancelled
operations are running 271% higher than the equivalent
year to date figure for 2013/14. (Target 10% reduction)
Classification changes account for this in part.
Twice
3 times
4 times
5 times
6 times
7 times
Strategic Objective – patients cancelled more than twice
(Hospital Cancellations Only)
two patients had an operation cancelled in May 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: In May 2015, no patients or operation slots
were cancelled due to admin error, and 1 patient due to
equipment failure or unavailability (Target is zero)
16
Long Stay Patients
Fig 1 - The Blue line shows the trend in patients who are in hospital for seven days or
more at any particular day in time. This has been increasing significantly in the final
quarter of 2013/14 but has started to show some reduction since April. The over 30 day
curve has also shown a slight reduction this month. However the rise in recent nos. of
patients who have been in the hospital for more than 90 days continues.
30
20
Fig 1 – All Specialties - Patients with Over 7 Day Stay at
Point in Time
Sum of GT7
Sum of GT30
Sum of GT90
Fit For Discharge Days
CAMHS - Long Stay patients at end of May - Fit for Discharge Days
Patient 5
Patient 4
Patient 3
Patient 2
Patient 1
0
0
06/06/…
20/06/…
04/07/…
18/07/…
01/08/…
15/08/…
29/08/…
12/09/…
26/09/…
10/10/…
24/10/…
07/11/…
21/11/…
05/12/…
19/12/…
02/01/…
16/01/…
30/01/…
13/02/…
27/02/…
13/03/…
27/03/…
10/04/…
24/04/…
08/05/…
22/05/…
10
100
200
Before fit for discharge
300
400
After fit for discharge
500
The same 5 CAMHS patients were fit for discharge as reported last month. 2 were
waiting for adult placement place (since 2013), 1 was waiting for suitable available
bed (since March) and 2 were waiting social services to complete assessments
(since Feb). In total these five cases have been fit for discharge for 597 days.
Long Stay patients at end of May - days fit for discharge
Fig 2 - shows the trend in bed days used by patients who are in hospital for thirty
days or more. This shows a steady increase. At the start of the period 3 patients had
used 260 days, by mid June 14 we had 11 patients in hospital who had used 1299
days, illustrating the impact on bed availability of a cohort of long stay patients
Patient 5
Patient 3
Patient 1
0
100
200
Before fit for discharge
12/06/2013 00:00
26/06/2013 00:00
10/07/2013 00:00
24/07/2013 00:00
07/08/2013 00:00
21/08/2013 00:00
04/09/2013 00:00
18/09/2013 00:00
02/10/2013 00:00
16/10/2013 00:00
30/10/2013 00:00
13/11/2013 00:00
27/11/2013 00:00
11/12/2013 00:00
25/12/2013 00:00
08/01/2014 00:00
22/01/2014 00:00
05/02/2014 00:00
19/02/2014 00:00
05/03/2014 00:00
19/03/2014 00:00
02/04/2014 00:00
16/04/2014 00:00
30/04/2014 00:00
14/05/2014 00:00
28/05/2014 00:00
11/06/2014 00:00
1400
1200
1000
800
600
400
200
0
Fig 2. Bed Days Already Used at Point in Time by
Paediatrics Patients with 30 day stay or more
Patient 7
300
400
500
600
After fit for discharge
7 patients were waiting for discharge at end of May. Four patients were
waiting for a care package (with one of these also waiting for housing and one
having social issues). The other two patients were waiting for housing and
social issues to be sorted. The final patient is on a staggered discharge and also
required training to be completed. In total these 7 patients have been fit for
discharge for 904 days. Assuming an average length of stay (excluding day
cases) of 4 days, another 226 patients could have been seen at the hospital if
17
these patients had been discharged, as they became fit .
Board of Directors
Public Meeting
Thursday 26 June 2014
Item 14.148
Enc 4
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 – 31st May 2014
Sponsoring Director
Chief Finance Officer
Author(s)
Director of Finance and Procurement, Chief Officer for
Workforce, Deputy Chief Officer for Performance and
Contracting and Interim Deputy Chief Finance Officer
Previously considered by
N/a
Situation
This report is to communicate the various aspects of Trust performance in the financial
year to date, period ending 31 May 2014, and to identify any key risks that are evident
within the organisation.
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 Trust has now had its 2013/14 Quarter 4 ratings confirmed as:
Governance – Green (as plan);
Continuity of Service – 4 (as plan).
The key ongoing governance issue for the Trust is the performance against the 18 week
target for admitted patients. Performance in month was 91.3% i.e. 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.
The Trust has also had formal feedback on its Operational Plan. Our self-assessed
ratings have been confirmed with Monitor stating that “There are no further changes to
our regulatory approach as a result of our review of the Trust’s Operational Plan.”
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
+7.7%
+6.3%
Emergency/Non-Elective
-4.6%
-14.6%
Planned Care
+2.6%
+2.7%
Outpatients
+2.4%
+3.2%
From a financial perspective income has underperformed by a further £0.5m in the
month. The level of cancelled operations and the causes of these cancellations as
reported in the Performance Report are instrumental in this.
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 remained at 3.8% in the
month. The cumulative rate has increased above 3.5% meaning both measures are well
above the Trust’s 3% target.
The combined substantive and bank staff level decreased in May by 24wte. Bank use
dropped by 6wte whilst substantive staffing reduced by 18wte. Compared to April 2013
substantive wte have increased by 4% whilst Bank Staff has decreased by 7%.
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 has
dropped below 78% in the last month and remains short of the 90% target.
Finance
The second financial report of the new year sees the Trust performing slightly below plan.
An in-year surplus of £1.6m whilst strong falls short of the plan submitted to Monitor and
is below the actual levels reported in each of the last 5 months of 2013/14.
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 May although we have started the year more strongly than in 2013/14. The key
areas of shortfall are within trust-wide schemes (contract penalties and drugs).
The key issue financially in April and May has been the impact of cancelled operations on
clinical income, which is £1.1m under target. If this continues it will have a dual impact on
the finances:
Impact on the flow of patients through the Trust reducing expected activity
levels.
Incur financial penalties from our commissioners as we miss service
targets.
Our cash balances remain strong and after being 5% under plan in April have now
recovered to within 0.1% of plan.
The Capital Programme is due to be ratified by the Finance and Resource Committee in
July after which capital expenditure will start to increase.
Recommendations
The Board review, discuss and approve the Resources Report.
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
June 2014
Phil Foster
Theresa Nelson
Georgina Dean
Director of Finance and Procurement
Chief Officer for Workforce
Deputy Chief Officer for Contracting and Performance
Item 14.148
Enc 4
1
Reporting on resources use
1. Summary
2. Monitor Assessments and Declarations
3. Volume and mix of activity
4. The impact on our workforce
5. Productivity
6. Financial Performance Summary
2
Summary.
May 2014
The first full financial report of the new year sees the Trust performing below slightly plan. The year to date
surplus of £1.6m is a strong position but it does fall short of the plan submitted to Monitor and is also below
the actual levels reported in each of the last 5 months of 2013/14. At this stage achievement of the Trust’s
planned £4.4m surplus is expected.
The operational difficulties at the Trust with regards to PICU and acute bed capacity, with increasing numbers
of long stay patients, are leading to high levels of total cancelled operations. This is having a direct impact on
clinical income, which is 3% below plan. Should this continue it could impact on the planned surplus of the
Trust. These operational difficulties have an added impact on the financial position – not only is the flow of
patients across the hospital effected but the Trust will be liable to a range of fines from commissioners for
missing service targets. Based on the first two months of the year this could be a significant amount by year
end.
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 May although we have started the
year more strongly than in 2013/14. The major area of variance to date is the Trust wide scheme focussing on
drug expenditure.
Bank usage in May was 7% lower than the equivalent period last year although substantive staffing levels are
4.2% higher. In-month sickness remained static at 3.8% for the 3rd month running with the April (sickness is
reported one month in arrears) position 1% higher than April 2013. Year to date sickness is now above 3.5%.
Our cash balances remain strong and have recovered to 0.1% below plan. Receipt of cash during May
countered the problems experienced in April.
The Capital Programme has been provisionally agreed by the Investment Committee and awaits formal
ratification by the Finance and Resource Committee after which capital expenditure will start to increase.
3
2. Monitor Assessments and Declarations
4
Our month two regulatory position remains strong.
Quarter 4 - 2013/14
The predicted ratings for Quarter 4 reported
to the Board in April 2014 have now been
confirmed by Monitor.
Month 2
Based on this performance the predicted
measureable Month 2 performance is Green.
Monitor Quarter 4 2013/14 (Confirmed)
Finance risk rating - Continuity of Service Risk Rating
Governance risk rating
Finance risk rating - Compliance Framework
G (4)
G
G(4)
Monitor Quarter 1 2014/15 (Predicted)
Finance risk rating - Continuity of Service Risk Rating
Governance risk rating
Finance risk rating - Compliance Framework
G (4)
G
G(4)
The Continuity of Service Risk Rating for May
is a 4 (the highest level).
For information under the old Compliance
Framework regime a FRR of 4 would have
been reported in Month 2.
The above will result in the Trust achieving its
planned Risk Ratings for 2014/15.
5
Monitor Annual Plan Feedback.
The Trust received feedback on its Operational
Annual Plan submission from Monitor on 6
June. An excerpt from this is included
opposite.
If deemed necessary through identified
specific weaknesses in Trust’s plans Monitor
can ask for plans to be resubmitted. No such
action is required of the Trust.
The underlying risks within the Trust’s plans
were discussed as part of the Annual Plan
conference call and these will continue to form
part of the dialogue with the Trust during the
year.
The 5 year Strategic Plan will be submitted at
the end of June.
6
3. Volume and Mix of Activity
7
Emergency activity profile
ED attendances
Emergency
Department
(ED)
attendances continue to rise and
have increased by 6.3% YTD
compared with last year.
In May there was a 6.1% increase
on the May 2013 figure.
Activity against plan (YTD) for ED
attendances is 7.7% above plan.
6000
5000
4000
3000
2000
1000
Emergency /Non Elective FCEs
2000
1500
1000
500
0
A M
0
A
M
J
2011/12
J
A
S
2012/13
O
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
Despite the additional ED demand,
emergency FCE activity in month
has decreased by 14.8% compared
with May 2013 and shows a
decrease of 14.6% in YTD figures
compared to the same period last
year.
Emergency FCE activity is 4.6%
behind plan YTD, with May activity
levels being 6.5% lower than
planned.
J
2011/12
J
A
S
2012/13
O
N
D
J
2013/14
F M
2014/15
2014/15 Emergency/non elective FCEs
activity against plan
1800
1600
1400
1200
The main reason for this change is
the large reduction in the number
of zero day length of stay patients
being admitted from the ED
Department.
1000
800
600
400
200
0
A M
J
J
A
S
2014/15 actual
O N
D
J
F M
2014/15 plan
A M
J
J
A
2014/15 actual
S
O
N
D
J
F M
2014/15 plan
8
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 March was 1.2% higher than in May 2013 and YTD activity shows a 2.7% increase over 2013/14.
Elective activity is now 2.6% above plan YTD, however activity was 0.2% below plan in May 2014 and is therefore impacting on
both clinical income and the size of the waiting list.
9
Outpatient activity profile
Outpatient Procedures
New OP attendance
1200
4000
May 2014 saw a 6.1% decrease for
new attendances and 1.0%
decrease for follow up patients
when compared with May 2013.
3500
3000
2500
1000
800
600
YTD activity shows that new
attendances have decreased by
4.6% and follow ups YTD have
increased by 2.9% when compared
to 2013/14.
2000
1500
1000
500
0
A
M
J
J
2011/12
A
S
2012/13
O
N
D
J
2013/14
F
M
2014/15
Follow up OP attendance
10000
9000
8000
7000
6000
5000
4000
3000
2000
1000
0
A
M
2011/12
J
J
A
2012/13
S
O
N
2013/14
D
J
F
M
2014/15
400
200
0
A M
Outpatient procedures performed
in May are 48.8% higher than for
May 13 and 33.3% higher than for
same period in 2013/14. There has
been in increase in the level of
diagnostic coding in outpatients
which may be impacting here.
2011/12
J
J
A
S
2012/13
O N D
J
2013/14
F M
2014/15
2014/15 outpatient activity against plan
(excl AHP CNS and Phone)
Against plan, all outpatient activity
was 3.3% below plan in May 2014
and overall 2.4% ahead of plan YTD.
16000
For new attendances against plan
the largest areas of growth are
Orthopaedics (7%), Ophthalmology
(7%) and Cardiology (19%). For
follow ups the biggest area of
growth is Paediatric Surgery (28%).
For procedures Cardiology and ENT
are both over plan significantly for
both activity and income
10000
14000
12000
8000
6000
4000
2000
Activity excludes AHP, CNS and phone attendances
0
A M J J A S
2014/15 actual
O N D J F M
2014/15 plan
10
4. Workforce
11
Workforce Report Summary May 2014
Sickness Summary – In month sickness has increased to 3.81% and is higher than this time last year. Long term sickness has increased slightly to 2.42%,
these staff are being supported through our processes. Short term sickness has decreased slightly to 1.39% during April 2014.
The top 3 reasons for sickness during April are Anxiety/Stress (782.36 WTE days lost), Musculoskeletal (704.29 WTE days lost) and Gastrointestinal
(415.61 WTE days lost). There is some evidence to suggest that gastrointestinal absences are linked to stress related absences (e.g. IBS exacerbated by
stress).
The majority of stress sickness absence episodes are due to personal circumstances, for example bereavements, change in family circumstances, financial
pressures and carer responsibilities. However where work related factors are identified, these are addressed by way of individual stress risk assessments,
OH referrals, signposting to the Trust’s support mechanisms and regular 1:1s with managers as appropriate.
Bank/Agency Usage – There has been a slight decrease of 5.47WTE during May 2014 to 164.95 WTE, compared to April. Admin usage has decreased by
6.87 WTE, however it continues to be high in the Medical Secretary profession (15.79 WTE) and also in Health Records (10.28 WTE).
Top 3 Clinical departments using bank are:
• PICU (23.88 WTE) to cover vacancies and maternity leave.
• Theatres (12.77 WTE) to cover vacancies and maternity leave. Theatres are addressing more accurate recording of the reasons for bank usage and this
should be reflected in future reports.
• Ward 7 (8.13 WTE) – Increased usage to due to opening of more beds that are managed solely by the bank staff.
PDR Summary - PDR % has dropped below 80% for the first time in 12 months. This has been highlighted as a priority and Directorates are 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 slightly decreased for the 12 month period ending May 2014 but remains above the Trust KPI
(9%) at 12.19%. All Directorates have a 12 month turnover % above the Trust 9% KPI target.
In comparison with other Trusts we are slightly higher than the Royal Manchester Children’s Hospital whose turnover is 11.45% and lower than Great
Ormond Street Hospital whose turnover is 17.34%.
The top 4 reasons for permanent staff leaving BCH are:
132.61 WTE Voluntary Resignation - Other/Not Known
50.79 WTE Relocation
30.40 WTE Promotion
25.48 WTE Retirement
12
Workforce Dashboard
Indicator
Trust Target
CSS
Medical
Specialised
Surgical
CAMHS
Corporate
Trust (Previous
Month)
Trust (Current
Month)
Trend
Sickness % (YTD)
<3.00%
3.55%
4.54%
3.72%
2.96%
3.06%
2.77%
3.47%
3.54%
▲
Sickness % (Month)
<3.00%
4.15%
5.17%
3.35%
3.32%
2.75%
3.43%
3.75%
3.81%
▲
85
138
118
80
49
62
555
532
▼
LT Sickness %
3.00%
3.49%
2.12%
1.56%
1.09%
2.44%
2.40%
2.42%
▲
ST Sickness %
1.16%
1.69%
1.23%
1.76%
1.67%
0.98%
1.40%
1.39%
▼
Cost of sickness
£57,786.03
£78,949.80
£50,666.83
£29,731.83
£23,188.78
£37,277.35
£274,343.93
£277,600.62
n/a
Cost of sickness YTD
£57,786.03
£78,949.80
£50,666.83
£29,731.83
£23,188.78
£37,277.35
£2,954,494.53
£277,600.62
n/a
633.09
997.44
757.49
434.68
233.52
550.70
3678.01
3606.92
▼
80.14%
79.87%
79.96%
86.71%
79.65%
63.33%
82.15%
77.87%
▼
Starters FTE
2.00
8.80
12.00
5.80
3.70
9.10
63.78
41.4
▼
Leavers FTE
1.40
4.00
12.40
4.50
2.00
5.75
67.79
30.05
▼
9.50%
10.90%
12.40%
11.03%
15.33%
15.73%
12.86%
12.19%
▼
In Month Turnover %
0.28%
0.68%
0.49%
0.91%
0.72%
1.10%
1.63%
0.67%
▼
Headcount
WTE in post
577
509.30
711
649.85
829
761.10
467
430.36
318
287.11
569
527.88
3494
3184.30
3471
3165.60
n/a
n/a
18
11
4
8
2
15
52
58
▲
5.71
39.22
44.58
24.77
8.26
42.42
170.43
164.96
▼
3.50%
4.54%
3.57%
4.19%
5.10%
1.52%
3.52%
3.64%
▲
6
19
17
11
4
6
53
61
▲
2
2
n/a
Episodes
FTE days lost
sickness
PDR's %
Rolling Turnover %
Active Recruitment
Bank Usage
Maternity Leave %
Staff in Difficulty
90%
<9%
Org Change
0
0
1
0
0
1
Please note that sickness is still one month behind so we are currently reporting on Aprils 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 now excludes apprentices on a 12 months fixed term contract
13
Sickness Absence
BCH Monthly Sickness %
Long and Short Term Sickness %
4.50%
4.00%
3.50%
3.00%
2.42%
3.00%
3.49%
2.12%
1.39%
1.16%
1.69%
1.23%
BCH Trust
Sickness
284 Dir 1
Clinical
Support
Services
2.50%
2.44%
2.00%
1.50%
1.09%
1.56%
1.67%
1.76%
0.98%
1.00%
0.50%
0.00%
13/14
14/15
Month
Trust Target
284 Dir 2
Medical
Directorate
284 Dir 3
Specialised
Services
Short Term Sickness
284 Dir 4
Surgical
Directorate
284 Dir 5
CAMHS
Services
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%
3.75%
3.80%
3.80%
14/15
3.81%
BCH Sickness Absence April 2014
Number of
Episodes
Cumulative 12 Month
Monthly Sickness %
Sickness %
532
3.81%
3.54%
85
4.15%
3.55%
138
5.17%
4.54%
118
3.35%
3.72%
80
3.32%
2.96%
49
2.75%
3.06%
62
3.43%
2.77%
Work will be done over the coming months and a priority will be to support the directorate with
their workforce monitoring and to ensure robust processes are in place
34 employees on LTS, 4 due to employee relations cases and the remaining due to MSK and long
term health conditions. Sickness Management interventions continue to be managed tightly.
BCH Total
Clinical Support Services
Medical Directorate
Specialised Services
Surgical Directorate
CAMHS Services
Corporate
• Haem/Onc (4.2%) – designated HR Advisor working with this area to coach and support managers
in all aspect of people mgt including sickness.
• Ward 2 – (11.9%) – This includes LTS primarily due to Stress and pregnancy related sickness.
• Complex Care (13.5%) – LTS due to MSK issues, one due to injury at work resulting in temporary
injury benefit (Inappropriate equipment). This equipment has been risk assessed and appropriate
intervention taken.
Review meetings with all dept/ward managers scheduled for July and each quarter thereafter.
PICU has reduced from 4.73% to 3.11%. 5 employees on long term sick have returned to work in
May, leaving only 2 employees on LTS sick so the % will drop again next month. This has been
supported by the sickness absence/ stress audit . This has been a successful pilot, which will now be
rolled out across the directorate. Confirm and challenge meetings are taking place for departments
where the sickness is over 3%. Ward 8 and 12 have high sickness and are part of the top 10 hotspot
areas which are currently being audited.
14
Bank/Agency Usage
Dec 13
Jan 14
Feb 14
Mar 14
Apr 14
May 14
CSS
5.68
8.29
8.20
8.88
4.66
5.71
Medical
40.16
41.03
39.80
57.04
39.14
39.22
250
Specialised
45.98
47.33
48.30
57.12
44.95
44.58
200
Surgical
18.52
17.62
19.60
27.99
26.57
24.77
150
CAMHS
9.19
9.27
7.80
9.01
9.07
8.26
Corporate
36.08
40.46
35.54
43.91
46.05
42.42
50
Total
155.62
163.99
159.24
204.00
170.44
164.96
0
WTE
Trust Bank/Agency Usage (WTE) Yearly Comparison
100
* The latest month is an indicative figure and about 95% accurate. The previous month figure will be updated
each month
Top 3 reasons for Bank/Agency usage
2013/14
2014/15
1. Vacancy – 112.96 WTE
2. Sickness – 25.16 WTE
3. Specialist Skills Required – 9.63 WTE
Admin bank and agency usage = 74.59 WTE. This is a decrease of 6.87 WTE (Aprils ’s usage
was 81.46 WTE).
% Bank/Agency
Usage May 14
Top 3 reasons for Admin usage are Vacancy, Backlog and Sickness.
Directorate Admin bank and agency is as follows:
10.76
45.22
Priority
7
CSS - 2.50 WTE - Labs, Radiology and Surgical Day Care
Medical - 7.16 WTE - Primarily Medical Secretary Areas
44.02
Specialised - 5.04 WTE – Cardiac Service, PICU and Theatres
Surgical - 18.63 WTE - Primarily Medical Secretary Areas
CAMHS – 4.49 WTE - Primarily East Locality
A&C
Reg
Non Reg
Corporate – 36.75 WTE – Primarily in Health Records not replacing leavers due to the
introduction of the Electronic Patient Record System and also staff being seconded to
support other areas i.e. reorganisation of the Library, follow ups on the waiting list trial.
15
Turnover Analysis
Permanent Staff Turnover %
The current turnover % of 12.19% excludes Apprentices and Non
Consultant Medical Staff. When excluding the other fixed term
contracts from the % the figure drops to 10.99% (316.07 WTE).
The top 4 reasons for leaving for permanent staff for each
Directorate (excluding Other/Not known) are:
Directorates are aware of the increase in turnover and a couple of examples of work
that is currently being done to help retain staff are:
Specialised Services - in the hotspot areas e.g. PICU, A buddy system is being
introduced for new starters, so that will not only have the support of their line
management team but also a designated ‘buddy’ to help orientate them into the unit
and offer support. All PICU exit interviews are supported by the HR team to ensure
that patterns and trends are identified, with actions taken within the department to
ensure that any issues are addressed for the individual and the wider team.
Medical Directorate - Staff engagement activities are taking place with new starters.
At 4 weeks new starters meet with the ASD and HRBP to welcome them to BCH,
pickup any issues they may have and remind them of staff benefits. At week 12 –
new starters in the last quarter are invited to lunch with Senior DMT team.
We have identified that for 132.61 WTE of leavers the reasons for leaving is
Other/Unknown. Work is due to commence to capture accurate reasons for
leaving to support robust monitoring. HRBP’s will support DMTs and their
managers so that accurate reasons for leaving are recorded.
CSS
Specialised
1.60 WTE Dismissal
8.00 WTE Promotion
5.84 WTE Retirement
5.57 WTE Relocation
13.47 WTE Relocation
6.36 WTE Promotion
4.75 WTE Work Life Balance
4.00 WTE Retirement
Medical
Surgical
16.20 WTE Relocation
9.88 WTE Retirement
16.20 WTE Relocation
4.64 WTE Work Life Balance
5.88 WTE Relocation
2.39 WTE Education/Training
2.24 WTE Promotion
2.17 WTE Retirement
CAMHS
Corporate
4.60 WTE Promotion
4.70 WTE Retirement
2.00 WTE Dismissal
1.90 WTE Work Life Balance
17.20 WTE TUPE Transfer
8.67 WTE Relocation
7.80 WTE Promotion
4.49 WTE Retirement
16
PDR - AFC Staff
Staff Group - Table 1
Add Prof Scientific & Technical
Additional Clinical Services
Admin & Clerical
AHP's
Estates & Anciliary
Healthcare Scientists
Nursing
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
87.82%
86.43%
83.50%
87.25%
86.60%
83.07%
85.05%
88.89%
89.49%
87.54%
85.02%
76.95%
76.77%
77.96%
77.22%
77.38%
76.81%
72.58%
Table 2
BCH
Clinical Support Services
85.05%
87.76%
87.96%
89.09%
82.89%
78.76%
88.28%
89.92%
90.40%
88.19%
85.39%
68.46%
83.64%
83.78%
83.04%
76.00%
76.23%
75.61%
86.33%
87.50%
85.76%
85.47%
82.97%
81.43%
Medical Directorate
Table 1 shows via staff group the Appraisal compliance. Compared to last months
report all staff groups PDR’s continue to decrease.
Directorate Plans to target PDR %
Clinical Support Services
Departments have been identified as hotspots areas and they will be reviewed
over the coming months to ensure appropriate support is in place.
Medical
Dropped every month for past 5 months. This has been escalated at DMT and
monthly reports continue to be sent
Specialised
• PICU has increased from 80 to 85%. A robust support and monitoring process has been
put in place to support the PICU Senior sisters to monitor PDR’s.
• Theatres has remained at 77% - Theatre Practitioners support the Theatre leads to
undertake and monitor the PDR’s. PDRs are now in the diaries, and cancellations due to
the need to work clinically are being reviewed.
• Ward 8,11,12 – The Lead nurse for the 3 wards is focusing on and monitoring the PDR
figures to support the ward mgrs to improve the uptake and quality of the PDR’s.
Surgical
Still above 85% - Monthly reports are sent out, highlighting those that have expired and
are due in the next 3 months.
Specialised Services
Surgical Directorate
CAMHS Services
Corporate
Dec
Jan
Feb
Mar
Apr
May
84.03%
85.23% 84.29% 83.83% 82.15% 77.87%
85.68%
87.23% 87.71% 87.70% 86.91% 80.14%
86.15%
87.34% 87.18% 85.75% 81.88% 79.87%
81.16%
81.79% 80.40% 81.79% 81.33% 79.96%
85.54%
91.09% 89.47% 91.22% 89.35% 86.71%
92.34%
92.86% 90.59% 84.62% 86.40% 79.65%
78.52%
76.80% 75.29% 74.83% 71.62% 63.33%
This table shows the PDR %. Each months totals is for PDR’s that have taken place and
recorded on ESR during the last 12 months, so for May the PDR period is June 13 to
May 14.
All directorates have seen a decrease in their PDR % during May 14 with Corporate
seeing the biggest decrease of 8.29% to 63.33% compliant. All directorates are now
below the 90% target.
Directorate Plans to target PDR %
CAMHS
Monthly reports are going to be distributed to managers highlighting those
that have expired and are due in next 3 months.
Corporate
The latest updates have been sent to the chief officers
to review current status and ensure that quality PDR’s
are being completed and inputted on ESR.
17
Staff in Difficulty
Staff in Difficulty Cases (December 13 to May 14)
70
61
Number of Cases
60
53
50
40
40
37
30
38
35
20
10
0
December
January
February
March
April
May
Breakdown of Cases May 14
A large proportion of the staff in difficulty cases are
due to conduct issues. Managers are becoming more
effective at dealing with inappropriate behaviour and
measuring against the Trust values.
25%
Disciplinary
44%
Managers are identifying and managing staff in
difficulty more effectively. This is supported by the
HR team through the roll out of the master classes.
Grievance
Harassment
16%
Performance
15%
18
Prevent Awareness Workshops
Prevent Workshops are delivered at Induction and Mandatory Training, at the request of managers as part
of team meetings, away days etc. and as a stand alone workshop. Education and Learning are still seeing a
lower engagement with the stand alone workshops and are working with the Communications Team to
develop a campaign to improve numbers.
To date we Education and Learning have trained 1089 staff in total and 120 in May.
Referrals
No referrals in May 2014.
One referral submitted previously which is now closed with no further action.
Priorities
CAMHS
ED
Burns
PICU
4 Prevent workshops organised between now and end of June 2014.
Undertaking training through mandatory updates/independent scheduled workshops however
the Prevent Team are working with ED to see if there are other opportunities to deliver
workshops more quickly.
Planning in progress.
Group session planned end June 2014.
Future Developments
• Regional Steering Group report revised WRAP3 programme with new case studies due later in year.
Possibility of eLearning module development.
• Prevent Lead working with BCH Comms on a campaign to improve engagement at the stand alone
workshops.
• Education Reporting to commence Quarterly reporting to Directorates to communicate the Directorate
training profile for Prevent and identify areas where there is a need to promote engagement.
Contact
Prevent Lead:
Jan Furniss
prevent@bch.nhs.uk
0121 333 8358
19
Mandatory Training Update
Mandatory training compliance is currently 81.78%. This represents a 3.27% increase compared to the average for mandatory training taken at the end of Dec 2013
which in terms of the Trust KPI is 13.2% below the target of 95% . The table below identifies the compliance statistics for all mandatory topics between Jan 2014 and
June 2014 (source: Vesper 3/6/14). Notable improvements are in BLS, Blood Sampling, Blood Admin, Child Protection L2, Equality & Diversity, Conflict Resolution and
Manual Handling Practical.
Reporting suggests that despite improvements, there is low engagement with face to face mandatory refresher training; attendance at the clinical refresher is 46%
and non clinical refresher is 39% out of a total of 184 places offered across the 4 recent training dates. The opportunity to update through Moodle may explain the
lower numbers however Education and Learning are reviewing communications strategies to ensure managers are aware of training dates and maximise
opportunities to update staff at the face to face sessions. In terms of DNA’s the clinical refresher recorded an 11% DNA rate and the non clinical refresher recorded a
19% DNA rate. All DNA’s are reported on the day to an individual’s line manager for them to follow up and action as appropriate. Initial exploration of reasons
behind DNA’s suggests there are challenges in releasing staff to training. As stated in the previous report, Education and Learning are reviewing the use of “Training
Boards” in areas as another option for staff to access training which may help in the challenge of releasing staff to face to face training and provide an alternative
update method.
Issues and Risks
•
•
•
•
•
Staff engagement low on face to face
training
DNA rates result in underutilised training
places
Exclusions need reviewing for some topics
Top 3 staff groups with low compliance –
Nursing, Medical and Additional Clinical
Services
Email reminders – not received by some
due to incorrect email address or no email
address on ESR
Future Plans:
•
Completed Actions:
•
•
•
•
•
•
Blood and Child Protection exclusion rules in place.
Ongoing development of Ed Reporting systems
Child Protection Level 2 training now available online through Skills for Health.
“Hot Topics” page in development to post late availability training places to managers/staff
“Email Checker” – developed to correct email anomalies and gaps to ensure reminders reach staff
Moodle updated (15th May 2014)
•
•
•
•
Continue exclusion rule amends across all
mandatory topics
Booking reminder service pilot – work in
progress
Implementation of “Email Checker” to support
email reminders
Training Boards - pilot scheme to be planned
Explore Refresher training to be assessment
based avoiding repetition of training where
competency can be demonstrated with the
assessment
20
5. Financial Performance
21
Financial Performance Summary
FINANCIAL PERFORMANCE REPORT
Monitor Risk Assessment Framework
Criteria
Financial Performance
Plan
Actual
Capital Service Capacity
4
4
Liquidity
4
4
Status
Direction
Issue
of Travel
Income and Expenditure
Cash Balance


ramew ork seeks assurance regarding w hether the Trust is a going concern.
Capital Programme
CIP
Plan
£'000
Actual
£'000
Variance
£'000
1,706
1,567
-140
48,341
48,283
-58
729
1,050
321
1,026
881
-145
Status
Direction of
Travel




Incom e and Expenditure
(M o nito r assesses financial risk o n a scale fro m 1(high risk) to 4 (no evident co ncerns)
The Trust is reporting a below plan position in Month 2. The key cause of this is a shortfall in clinical
Foundation Trust Requirements
income. Bed pressures and subsequent cancelled operations are the prime causes of this.
Issue
Measure
Plan
Actual
Private Patient Cap
Not to exceed 49%
0.4%
0.1%
Status
Direction
of Travel

Cash Balance
At the end of May the cash balance w as 0.1% below plan.
Capital Program m e
The Trust is performing ahead of plan in Month 2 due to greater levels of expenditure being incurred
on schemes carried forw ard from the previous financial year.
CIP
Performance in May w as 14% below plan. This is a result of 2 trust-w ide schemes.
22
Income and Expenditure against Plan
The Trust’s I&E position has recovered slightly
in May with an overall deficit against plan of
£0.1m now being reported.
Headlines are:
• The Trust is reporting a deficit against Clinical
Income;
• The key issue is the financial impact of
cancelled operations, long stay patients and
the associated causes of these. This has
impacted upon the Trust’s elective activity
performance most notably within cardiac
surgery;
• Pressures are being felt in Directorates due to
the impact of the clinical income
performance (this is being particularly felt in
Specialised Services) and the phasing of
trust-wide CIP targets. This latter issue will be
reviewed prior to Month 3;
• At this stage of the year the Trust remains
confident that the planned surplus of
£4.377m will be achieved.
2013/14 I&E to May 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)
Brackets indicate adverse
variance
Clinical Support Services
Medical Directorate
Specialised Services
Surgical Directorate
CAMHs
Corporate
Total Operational Budgets
Bad Debts
Donated Assets
Operating Leases
Teaching & Research
Reserves and Provisions
Total Other Budgets
Total Budgets
Annual
Revised
YTD Plan
Plan per Annual Plan per LTFM
LTFM
£'000
£'000
£'000
217,995
216,160
37,569
19,666
21,701
3,078
-225,841
-226,106
-37,640
11,820
11,755
3,007
243
243
41
-4,624
-4,560
-771
0
0
0
0
0
0
-2,762
-2,762
-460
-300
-300
-50
4,377
4,377
1,767
Revised
YTD Plan
£'000
37,358
3,595
-38,026
2,927
38
-760
0
0
-445
-54
1,706
May
Income
Variance
Pay
Variance
Non-Pay
Variance
Total
Variance
53
-29
-24
19
4
123
146
-98
-129
-194
-268
42
-121
-767
-16
-51
-434
-36
-9
-335
-880
0
-60
-208
-653
-285
38
-333
-1,502
0
-0
-20
190
2,167
2,337
835
-0
-20
190
190
336
0
0
-767
2,167
2,147
1,267
YTD Actual
£'000
36,329
3,931
-37,526
2,733
16
-773
0
0
-362
-47
1,567
Variance
£'000
-1,029
336
499
-194
-23
-14
0
0
83
7
-140
April
Variance
£000
In-month
Movement
£000
-158
-401
-55
-84
58
-409
-1,049
0
-192
-3
50
1,711
1,566
517
98
193
-597
-201
-20
76
-452
0
192
-17
140
456
771
318
23
Profitability against Target
The EBITDA (Earnings Before Interest, Taxation, Depreciation
and Amortisation) Margin has started the year
below target (6.9% compared with 7.4%). In
monetary terms EBITDA was also above the
Monitor Plan, which is the measure of
efficiency used in the Financial Risk Rating
calculation. This position is much improved
compared to Month 1 with the shortfall
halving in size during May.
The I&E Surplus Margin has also commenced
ended the year below plan (3.9% compared
with 4.3%) which is reflecting the EBITDA
margin. This too is an improved performance
compared to Month 1.
With the plan of both metrics due to reduce
in June it is expected that the variance
between planned and actual %s will shorten
further in Month 3.
EBITDA Margin
8.0%
7.5%
6.8%
7.0%
6.5%
6.0%
Actual
5.8%
5.5%
Plan for
Year
5.0%
4.5%
4.0%
Apr May Jun
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%
Actual
Plan for
Year
Apr May Jun
Jul
Aug Sep
Oct Nov Dec
Jan
Feb Mar
24
CIP
This is the second CIP report for the new 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 2 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 the Directorate;
• Quality Impact Assessment review process has commenced with a further progress review at 30 June;
• Corporate is the area which is furthest from target for overall schemes – deadline for bridging gap is 30 June;
• The May performance although under plan is potentially a prudent position as work continues on the
evidencing of savings in some key areas;
• The shortfall on the trust-wide schemes is within Contract Penalties (where pressures are evident for
Diagnostics and 18 weeks) and Drugs (where schemes have been developed but await implementation);
• Delivery against schemes in the year to date for Clinical Directorates is on target;
• Phasing throughout the year is back-ended. This will be reviewed prior to Month 3 being reported.
Directorate
CAMHS
Corporate
CSS
Medicine
SSD
Surgery
Trustwide
Totals
Annual Target In Year Identified
£389,526
£723,251
£666,136
£1,324,237
£1,390,984
£725,583
£4,240,000
£9,459,716
£388,640
£474,724
£662,967
£1,649,825
£1,420,330
£740,282
£4,241,400
£9,578,168
YTD Plan
YTD Actual
YTD Variance
% Plan To Date
% Annual Target
£31,598
£40,956
£68,745
£256,171
£217,716
£72,700
£338,333
£1,026,219
£31,598
£42,841
£91,948
£255,195
£207,283
£99,664
£152,801
£881,330
-£0
£1,885
£23,203
-£976
-£10,433
£26,964
-£185,532
-£144,889
100%
105%
134%
100%
95%
137%
45%
86%
8%
6%
14%
19%
15%
14%
4%
9%
25
Cash and Capital
The Capital performance in May was £0.3m ahead
of plan. With the core 2014/15 Capital Programme
now due to be agreed at July’s Finance and
Resource
Committee,
although
provisional
agreement was reached at the Investment
Committee, expenditure to date relates to schemes
carried forward from 2013/14. The impact of these
is higher than anticipated although over the course
of the year this will have a neutral impact upon
cashflow.
2014/15 Plan
Mar-16
Jan-16
Feb-16
Dec-15
Oct-15
Nov-15
Sep-15
Jul-15
Aug-15
Jun-15
Apr-15
May-15
Mar-15
Jan-15
Feb-15
Dec-14
Oct-14
Actual
Nov-14
Sep-14
Jul-14
Aug-14
Jun-14
Apr-14
Although cash is below target the Trust’s liquidity
remains significantly above the Continuity of
Service threshold of 4.
May-14
With capital expenditure remaining above plan this
is directly linked to the minor variation in cash
balance.
2014/15 Cash Position and Rolling Forecast
55,000
50,000
45,000
40,000
35,000
30,000
£k 25,000
20,000
15,000
10,000
5,000
0
Mar-14
Cash is 0.1% below plan at Month 2. This equates
to only £58k meaning that the reasons for the 5%
shortfall at the end of April have now largely been
overcome.
Rolling Forecast
2014/15 Cumulative 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
Aug
14/15 85%
Sep
Oct
14/15 115%
Nov
Dec
Jan
Feb
Mar
14/15 Plan - Original
26
Debtors and Creditors
Debtors over 90 days have increased in May in both
percentage and actual terms. The overall level of
debt is such that the top 5 debts reported below
account for over 10% of our overall debt.
Although major legacy debts have now all been
cleared a wide range of other medium-high value
debts remain.
The overall debt curve has 56% of debts in the 6190 day category which requires careful
management to avoid an escalating debt problem.
% Debtors and Creditors over 90 days
30%
25%
20%
15%
10%
5%
0%
Apr
May
Jun
Jul
Aug
Debtors>90 days %
The Creditors position over 90 days has
deteriorated in the month. However, of the %
outstanding 4% was associated with one supplier
for whom credit notes were awaited (these have
now been received) and 9% is a disputed value.
Top 5 Debts Over 90 Days Old
Customer
Sep
Oct
Nov
Dec
Creditors>90 days %
31st May 2014
Age
(Days)
Value
(£k)
102
171
University Hospitals Birmingham
106
145
Private Patient - MK
1033
Slater & Gordon (UK) LLP
235
Target
30th April 2014
139
1002
139
136
204
136
198
107
120
77
Birmingham Community Healthcare
158
Mar
Value
(£k)
464
Birmingham Women's Hospital
NHS Birmingham Cross City CCG
Feb
Age
(Days)
397
Solihull PCT
Health and Social Care Board
Jan
57
649
923
27
Financial summary.
May 2014
The Monitor Financial Risk rating is 4 per plan, with liquidity remaining strong. This 4 is per the Compliance
Framework and the Continuity of Service Risk Rating (CoSRR).
The I&E position is below the Monitor plan and the revised plan at £1.567m.
The EBITDA and Income Surplus margins are 0.5% and 0.4% below plan, respectively.
Clinical Income performance in May was below the Monitor plan and this was the key cause of the shortfall
against the I&E plan.
CIP has started the year more strongly than previous years. This will remain the primary focus throughout
the year. To date the schemes identified exceed the Trust’s total requirement. In April 92% of the YTD plan
was achieved.
Cash balances are slightly below plan in May. The causes of the shortfall are known and being acted upon.
Capital in month 2 performed ahead of plan.
The Forecast position for the Trust remains to achieve the planned surplus of £4.377m, excluding any further
benefit of donated asset income.
28