Management Board – 28th August 2013
Integrated Performance
Report
M04 – July2013
Presented by: Paul Bostock (Chief Operating Officer) Des Holden (Medical Director) Yvonne Parker (Director of HR)
Paul Simpson (Chief Financial Officer)
An
University
HospitalHospital
of
AnAssociated
Associated
University
of
Brighton
andand
Sussex
Medical
School School
Brighton
Sussex
Medical
1
Performance July 2013
Summary:
•
DH Performance Framework - For July 2013 the Trust is expecting to be rated as “Performing” for the Quality of Services based
on the DH performance framework.
•
Deliver Safe, High Quality, Co-ordinated Care - 18 weeks continue to exceed expected standards and ED performance was
delivered in month. Stroke and #NOF performance remain challenging, partly driven by the high levels of bed occupancy at the
Trust but plans are in place to improve performance. Cancer performance has been adverse in two of the measures.
•
Ensure patients are cared for and cared about - The Trust continues to demonstrate improvements in ensuring patients are
cared for and cared about as reflected in the friends and family test and Your Care Matters results. The July friends and family
score is improved against June.
•
Work in Partnership with our community – the trust continues to work with the local health system to significantly reduce the
number of patients in the hospital who no longer require acute care with final commissioning decisions expected in September.
•
Become a sustainable, effective organisation - At Month 4 the Trust is favourable to plan with a £0.2m surplus. The forecast
remains breakeven. Within workforce, the focus is on continuous recruitment to our nursing vacancies and the most cost effective
use of contingent workforce to ensure that the highest quality standards are maintained and deliver financial savings.
Action: The Board are asked to note and accept this report
Notes:
Legal:
What are the legal
considerations
& implications
linked to this item? Please name
relevant Act
Regulation:
What aspect of
regulation applies and what are
the outcome implications? This
applies to any regulatory body.
Patient safety: Legal actions from unintentional harm to patients would normally be covered by negligence, an area of English tort
(civil) law, providing the remedy of compensation. Case law is extensive. Criminal action could be pursued if investigation judged
intentional harm and remedies will vary according to severity.
Staff safety: The Health and Safety at Work Act etc 1974 may apply in respect of employee health and safety or non clinical risk
to patients (usually reported under the Reporting of Injuries Diseases and Dangerous Occurrences Regulations (RIDDOR) 1995)
The Care Quality Commission (CQC) regulates patient safety and quality of care and the CQC register and therefore license
care services under the Health and Social Care Act 2009 and associated regulations. The health and safety executive regulates
compliance with health and safety law. A raft of other regulators deal with safety of medicines, medical devices and other
aspects.
An Associated University Hospital of
Brighton and Sussex Medical School
2
Contents
1. Overview
Overview of Performance against DH Performance Framework
2. Deliver Safe, High Quality, Co-ordinated Care
Page 3
Page 4
Page 7
Priority 1 - Achievement of national best practice in clinical care
Page 8
Priority 2 - Achieve best practice in the use of quality and patient safety indicators
Page 19
Priority 3 - Ensure patients are cared for in the right place at the right time
Page 20
Priority 4 -Work well within clinical networks and develop clinical partnerships
Page 21
3. Ensure patients are cared for and cared about
Priority 1 - Be recommended on the basis of Customer Care / Priority 2 - Always treat patients and their families / carers
with compassion, courtesy and privacy and dignity
4. Work in Partnership with our community
Page 22
Page 23
Page 26
Priority 1 - Work with patients, the public and partners to develop services that meet the needs of our community
Page 27
Priority 2 - Improve the way people see and talk about SaSH
Page 28
5. Become a sustainable, effective organisation
Page 31
Priority 1 - Live within our means both in year and sustainably into the future
Page 32
Priority 2 - Development of our Workforce
Page 34
Priority 3 - Implement our plans to become a Foundation Trust by 2014 / Priority 4 - Ensure that the estate and
infrastructure supports our sustainability
Page 36
6. Appendices
Page 37
An Associated University Hospital of
Brighton and Sussex Medical School
3
1. National Quality of Services Measures
Overview
• This section of the report outlines the Trust’s performance for Quality of Services under the Department of Health Performance
Framework.
• For July 2013 the Trust is expected to be rated as “Performing” for Quality of Services based on the ratings shown below for each
of the individual domains within the framework.
Month
CQC Registration
Integrated
Measures
February 2013
Performing
Performing (2.89)
User Experience
Performance
Charts
Overall Quality
Of Services
Performing
Under Review
March 2013
Performing
Performing (2.82)
Performance
Under Review
Performing
April 2013
Performing
Performing (2.60)
Performing Under
Review
Performing
May 2013
Performing
Performing(2.75)
Performing Under
Review
Performing
June 2013
Performing
Performing(2.71)
Performing Under
Review
Performing
July 2013
Performing
Performing(2.64)
Performing Under
Review
Performing
An Associated University Hospital of
Brighton and Sussex Medical School
4
1. National Quality of Services Measures
Integrated Measures
• For July 2013, the Trust is forecasting an in-month score of 2.64 which would rate the Trust as “Performing” for the
Integrated Measures.
• The table below shows the performance against each of the individual Integrated Measures on an in-month basis.
Integrated measures
ED 95% in 4 hours
MRSA Incidences - In Month (Trust acquired)
C Diff Incidences - In Month (Trust acquired)
RTT Admitted - 90% in 18 weeks
RTT Non Admitted - 95% in 18 weeks
RTT Incomplete Pathways - %age under 18 weeks
RTT - No of Specialties not achieving standards
%age of patients waiting 6 weeks or more for diagnostic
Cancer - TWR
Cancer - Breast Symptomatic (2 Week Wait)
Cancer - 31 Day Second or Subsequent Treatment (SURGERY)
Cancer - 31 Day Second or Subsequent Treatment (DRUG)
Cancer - 31 Day Decision to Treatment
Cancer - 62 Day Referral to Treatment from Screening
Cancer - 62 Day Urgent Referral
Delayed Transfers of Care (%age of bed days)
Mixed Sex Breaches per FCE
VTE Assessment on Admission
Feb-13
Mar-13
Apr-13
May-13
Jun-13
95.4%
0
2
91.2%
96.8%
95.0%
3
0.0%
96.2%
98.7%
95.0%
100.0%
99.0%
87.5%
86.3%
2.1%
0.0%
93%
95.0%
0
1
90.6%
96.7%
95.6%
2
0.0%
95.8%
97.0%
100.0%
100.0%
98.8%
84.6%
91.6%
1.8%
0.0%
94%
88.7%
0
3
91.3%
97.4%
95.2%
4
0.0%
94.1%
94.0%
96.3%
100.0%
97.4%
80.0%
86.2%
2.1%
0.0%
96%
96.8%
0
2
91.8%
96.8%
97.2%
2
0.0%
93.1%
87.5%
94.1%
100.0%
97.8%
100.0%
86.0%
6.0%
0.0%
96%
99.1%
0
1
94.0%
97.0%
96.8%
1
0.2%
95.2%
94.0%
100.0%
100.0%
97.4%
100.0%
85.8%
6.4%
0.0%
95%
Jul-13
TriggerTrigger
Text Point 1 Trigger Point 2
98.5%
> Target is Good
95%
< Target
is
Good
0
On plan
< Target
is Good
4
On plan
95.9%
> Target is Good
90%
97.6%
> Target is Good
95%
96.6%
> Target is Good
92%
< Target
0
is Good0
<0.9%
Target is Good
1%
94.0%
> Target is Good
93%
89.0%
> Target is Good
93%
94.0%
> Target is Good
94%
100.0%
> Target is Good
98%
99.0%
> Target is Good
96%
83.0%
> Target is Good
90%
86.0%
> Target is Good
85%
<5.6%
Target is Good
3.5%
<0.0%
Target is Good
0.0%
>95%
Target is Good
90%
94%
1Std Dev
1Std Dev
85%
90%
87%
20
5%
88%
88%
89%
93%
91%
85%
80%
5.0%
0.5%
80%
An Associated University Hospital of
Brighton and Sussex Medical School
5
1. National Quality of Services Measures
Integrated Measures
Significant points of note regarding performance include:
•
ED Performance was sustained in July 2013.
•
There were no incidences of MRSA and four incidences of C-Diff during July with the Trust being on plan for both indicators.
•
RTT performance continued to perform with the 90% Admitted, 95% non-admitted and 92% incompletes measures all being
achieved in aggregate and for the first time, all measures were achieved across all DH specialties.
•
Although there was an increase in patients waiting over 6 weeks for diagnostics resulting from the new radiology IT system
implementation, this was still within the 1% tolerance.
•
Cancer performance deteriorated in month with the breast symptomatic and 62 day screening targets not being achieved.
•
The delayed transfers of care measure continued to underperform in month although the percentage of delays has fallen
since June 2013.
An Associated University Hospital of
Brighton and Sussex Medical School
6
Contents
1. Overview
Overview of Performance against DH Performance Framework
2. Deliver Safe, High Quality, Co-ordinated Care
Page 3
Page 4
Page 7
Priority 1 - Achievement of national best practice in clinical care
Page 8
Priority 2 - Achieve best practice in the use of quality and patient safety indicators
Page 19
Priority 3 - Ensure patients are cared for in the right place at the right time
Page 20
Priority 4 -Work well within clinical networks and develop clinical partnerships
Page 21
3. Ensure patients are cared for and cared about
Priority 1 - Be recommended on the basis of Customer Care / Priority 2 - Always treat patients and their families / carers
with compassion, courtesy and privacy and dignity
4. Work in Partnership with our community
Page 22
Page 23
Page 26
Priority 1 - Work with patients, the public and partners to develop services that meet the needs of our community
Page 27
Priority 2 - Improve the way people see and talk about SaSH
Page 28
5. Become a sustainable, effective organisation
Page 31
Priority 1 - Live within our means both in year and sustainably into the future
Page 32
Priority 2 - Development of our Workforce
Page 34
Priority 3 - Implement our plans to become a Foundation Trust by 2014 / Priority 4 - Ensure that the estate and
infrastructure supports our sustainability
Page 36
6. Appendices
Page 37
An Associated University Hospital of
Brighton and Sussex Medical School
7
2. Deliver Safe, High Quality Coordinated Care
Achievement of national best practice in clinical care - Core Standards and Patient Safety
Indicator Description
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
0
0
0
0
0
0
0
6
1
7
93.6%
95.9%
1
7
0
45
3
75
93%
98%
92.8%
95.0%
0
15
1
79
0
123
94%
100%
0
3
14
92.2%
94.6%
0
9
0
50
1
112
96%
96%
0
3
12
95.4%
97.3%
0
13
0
40
1
92
96%
100%
0
5
15
90.3%
95.6%
0
14
0
48
1
93
95%
100%
1
6
17
94.0%
96.8%
0
12
0
50
0
89
95%
100%
Trigger Points
Priority 1 - Achievement of national best practice in clinical care - Core Standards
CQC Warning Notices
0
1
Priority 1 - Achievement of national best practice in clinical care - Patient Safety
No of Never Events in month
Serious Incidents - No in Month
Serious Incidents - No overdue for Trust Closure
Safety Thermometer - % of patients with harm free care (all harm)
Safety Thermometer - % of patients with harm free care (new harm)
Grade 3 and 4 pressure damage (Trust acquired)
Grade 2 Pressure damage (Trust acquired)
No of medication errors causing Severe Harm or Death
No of medication errors causing No, Low or Moderate harm
Number of falls resulting in Severe Harm or Death
Number of falls resulting in No, Low or Moderate harm
Percentage of patients who have a VTE risk assessment
WHO Checklist Usage - % Compliance
0
1
3
5
0
1
95%
90%
95%
90%
0
1
8
11
0
1
For Information
0
1
For Information
95%
90%
100%
99%
•
There were six serious incidents in July one of which was a Never Event.
•
The Trust has 17 serious incidents that are overdue for Trust closure and additional resources are being put in place to help resolve
this. It should be noted that although these SI’s have not been closed, key learning and actions have been taken where required.
Progress update from mid August suggests that due to significant work through July and August this figure should reduce
significantly during September.
An Associated University Hospital of
Brighton and Sussex Medical School
8
2. Deliver Safe, High Quality Coordinated Care
Achievement of national best practice in clinical care - Core Standards and Patient Safety
•
The previous months score (June ) for the NHS Safety Thermometer has triggered as Amber having dropped below the 95%
target. Following the drop, which was effected in part by changes in criteria of patients included in the data capture, the Trust
score for July rose to 94%. The score is based on four outcomes; pressure ulcers, falls, urinary tract infection in patients with
catheters and VTE. It is calculated based on the prevalence of both of these outcomes while patients are in hospital. Patients who
come into the hospital from the community with one of these outcomes will also be included in the audit. In month 4 The Trust
scored 95.68% in the delivery of no new harm.
•
The Safety Thermometer indicator remains a high priority for Nursing teams and is regularly discussed at all levels across the
organisation. Data collection allows for specific ward based analysis and interventions.
•
The never event was an “inappropriate administration of daily oral methotrexate”. There was one incorrect administration of the
drug, which was identified by the ward pharmacist. Although an incorrect dosage was given it was within the safe range for the
medication. The dosage is not believed to have caused any harm and initial investigation indicates human error as the cause of
the administration. There was no prescribing error. This has been declared as a Serious Incident.
•
There was no Grade 3 or 4 pressure damage in July 2013 but Grade 2 pressure damage was above expectations.
•
There were no medication errors resulting in severe harm or death.
•
VTE assessment and WHO checklist compliance achieved expected levels of performance
An Associated University Hospital of
Brighton and Sussex Medical School
9
2. Deliver Safe, High Quality Coordinated Care
Achievement of national best practice in clinical care - Mortality and Readmissions
Indicator Description
Feb-13
Mar-13
Apr-13
May-13
Jun-13
90.7
91.4
91.2
89.2
93.8
104.1
100.3
97.0
114.6
95.9
91.2
94.5
96.0
112.7
85.9
93.8
115.9
83.8
90.5
112.5
83.3
0.30%
1.70%
3.10%
13.50%
0.40%
3.20%
3.10%
14.40%
0.10%
2.10%
3.40%
13.80%
0.20%
2.60%
3.10%
13.50%
0.30%
2.50%
2.50%
13.60%
Jul-13
Trigger Points
Priority 1 - Achievement of national best practice in clinical care - Mortality
HSMR (56 Monitored diagnoses - 12 Months)
SHMI
HSMR - #NOF (Rolling 12 Months)
HSMR - Stroke (Rolling 12 Months)
HSMR - COPD (Rolling 12 Months)
100
100
100
100
100
105
105
105
105
105
1.0%
2.5%
6.7%
13.0%
1.1%
2.8%
7.4%
14.3%
Priority 1 - Achievement of national best practice in clinical care - Readmissions
Emergency readmissions within 2 days following elective admission
Emergency readmissions within 2 days following non elective admission
Emergency readmissions within 30 days following elective admission
Emergency readmissions within 30 days following non elective admission
0.30%
2.30%
3.10%
12.60%
• Overall mortality as measured by HSMR continues to remain below 100 on a 12 month basis and this is rated as ‘significantly lower
than the expected rate’ by Dr Foster. In all three monitored groups, mortality also fell and Stroke now falls within the expected range
as defined by Dr Foster when compared nationally although he rate remains higher than 100. COPD now has the third lowest rate in
the region and Fractured NoF is rated 5th lowest in the region. The latest SHMI data published in April showed a SHMI value of 0.94
reflecting deaths are in line with expected.
• There has been a mortality review by lead clinicians for the Stroke and NOF pathways. In both cases no clinical concerns were
identified the executive team has been reassured there is an on-going process in place for review and CCG’s are engaged.
• Readmission rates within 2 days are within expected levels and 30 day readmissions following non-elective admission have also
reduced in month. A joint clinical audit with commissioners took place in July to understand the underlying health system issues that,
if resolved, could help reduce readmission rates. After extensive clinical review by hospital consultants and local GPs, only 2% of
readmissions were viewed as avoidable (inappropriate or could have been treated in a community setting). Commissioners have
subsequently provided an alternative view and a contractual process has been initiated to resolve the differences.
An Associated University Hospital of
Brighton and Sussex Medical School
10
2. Deliver Safe, High Quality Coordinated Care
Achievement of national best practice in clinical care - Infection Control
Indicator Description
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Trigger Points
0
2
2
17
100%
0
1
2
20
97%
0
3
4
25
99%
0
2
2
20
99%
0
1
2
19
99%
0
4
0
36
99%
0
1
On Plan
1 Std Dev
For Information
For Information
100.0%
95.0%
Priority 1 - Achievement of national best practice in clinical care - Infection Control
MRSA (incidences in month)
CDiff Incidences (incidences in month)
MSSA
E-Coli
Hand Hygiene Compliance
• MRSA and C.Diff incidence remain on at expected levels.
• There were no MRSA bloodstream infections (BSIs) and four incidences of C.diff during July 2013.
• The Trust is 0.3 cases below trajectory for C. diff and on trajectory for delivery of the MRSA objective.
• The Infection Prevention Control & Antimicrobial Stewardship Team, working through the Task Force continues its focus on:
• Antimicrobial stewardship, driven primarily by the hospital’s medical staff and pharmacists which is reflected by on-going
improvements over recent months in compliance with the monthly Good Antimicrobial Prescribing (GAP) audits.
• Management of invasive devices such as urinary catheters and vascular cannula – with use of high intervention impact care
bundles.
An Associated University Hospital of
Brighton and Sussex Medical School
11
2. Deliver Safe, High Quality Coordinated Care
Achievement of national best practice in clinical care - Emergency Department
Indicator Description
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
95.4%
0
3.4%
95.0%
0
3.8%
88.7%
0
3.8%
96.8%
0
3.9%
99.1%
0
4.0%
98.5%
0
4.2%
Trigger Points
Priority 1 - Achievement of national best practice in clinical care - Emergency Department
ED 95% in 4 hours
Patients Waiting in ED for over 12 hours following DTA
ED Unplanned Re-attendance rate within 7 days
95%
0
4%
94%
1
5%
ED Performance is based on sum of weekly data to align monitoring with external reporting
• Performance against the 4 hour target has been maintained in July
• Median time to treatment continues to be maintained at consistent levels.
• The consultant led clinics continue to work well to maintain the performance for unplanned re-attendance within 7 days .
• Proposals for Ambulance Handover validation have been circulated and applied to July’s data, which has shown considerable
reduction in over 30 minute delays and there were no over 60 minute handover delays in July.
• The changes in staffing at streaming area have been maintained, this is now demonstrating an improvement in performance.
• Internal escalation and utilisation of CDU with a more structured admission process and guidelines is being implemented to support
on-going maintenance of targets.
An Associated University Hospital of
Brighton and Sussex Medical School
12
2. Deliver Safe, High Quality Coordinated Care
Achievement of national best practice in clinical care - 18 Weeks
Indicator Description
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
91.2%
96.8%
95.0%
3
90.6%
96.7%
95.6%
2
0.0%
0.0%
91.3%
97.4%
95.2%
4
0
2
0
0.0%
91.8%
96.8%
97.2%
2
0
0
0
0.0%
94.0%
97.0%
96.8%
1
0
0
0
0.2%
95.9%
97.6%
96.6%
0
0
0
0
0.9%
Trigger Points
Priority 1 - Achievement of national best practice in clinical care - 18 Weeks and Elective Access
RTT Admitted - 90% in 18 weeks
RTT Non Admitted - 95% in 18 weeks
RTT Incomplete Pathways - % under 18 weeks
RTT Number of Specialties not achieving standards
RTT Patients over 52 weeks on incomplete pathways
No of operations cancelled on the day not treated within 28 days
No of patients who have urgent operations cancelled twice
Percentage of patients w aiting 6 weeks or more for diagnostic
90%
95%
92%
0
0
0
0
1%
85%
90%
87%
20
1
2
1
5%
• In July, all RTT and diagnostic targets were achieved.
• The Trust achieved the Admitted, Non-admitted and Incomplete targets at aggregate level and for the first time all three measures
were achieved at speciality level, one month ahead of plan.
• Performance in relation to the 28 day guarantee for cancellations and urgent cancellations remains at expected levels.
• The diagnostic target was again achieved in July 2013 although there was a slight increase in radiology waits over 6 weeks as a
result of some of the operational issues following the implementation of the new Radiology IT system. This is expected to return to
normal levels in August.
An Associated University Hospital of
Brighton and Sussex Medical School
13
2. Deliver Safe, High Quality Coordinated Care
Achievement of national best practice in clinical care - Cancer
Indicator Description
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
96.2%
98.7%
95.0%
100.0%
99.0%
87.5%
86.3%
95.8%
97.0%
100.0%
100.0%
98.8%
84.6%
91.6%
94.1%
94.0%
96.3%
100.0%
97.4%
80.0%
86.2%
93.1%
87.5%
94.1%
100.0%
97.8%
100.0%
86.0%
95.2%
94.0%
100.0%
100.0%
97.4%
100.0%
85.8%
94.0%
89.0%
94.0%
100.0%
99.0%
83.0%
86.0%
Trigger Points
Priority 1 - Achievement of national best practice in clinical care - Cancer
Cancer - TWR
Cancer - TWR Breast Symptomatic
Cancer - 31 Day Second or Subsequent Treatment (SURGERY)
Cancer - 31 Day Second or Subsequent Treatment (DRUG)
Cancer - 31 Day Diagnosis to Treatment
Cancer - 62 Day Referral to Treatment from Screening
Cancer - 62 Day Urgent Referral
93%
93%
94%
98%
96%
90%
85%
88%
88%
89%
93%
91%
85%
80%
• Following the achievement of all measures in June, the Breast Symptomatic and 62 day referral from screening were not
achieved in July.
• Failure against the breast symptomatic standard in July was due to a higher level of patient referrals than in previous months. An
audit of processes and timeliness of booking mammography outpatient appointments is being undertaken.
• 62 Day Screening performance was not achieved in July 2013 due to one patient deferring diagnostics due to holiday. Sussex Breast
screening patients are now being offered the choice of referral to SaSH, although uptake rates are not as high as expected, but
volumes of treatments for this target will continuously remain low with single breaches impacting the performance
• SaSH Cancer services are currently being reconfigured within the Trust with the new structure expected to be in place in September
2013.
An Associated University Hospital of
Brighton and Sussex Medical School
14
2. Deliver Safe, High Quality Coordinated Care
Achievement of national best practice in clinical care - Stroke Care
Indicator Description
Priority 1 - Achievement of national best practice in clinical care - Stroke Care
% of patients admitted directly to a ASU within 4 hours of arrival
Stroke - 90% or more of time spent on stroke unit
High risk TIA treated within 24 hours
Stroke Patients Scanned within 1 hour of Hospital Arrival
Stroke Patients Scanned within 24 hour of Hospital Arrival
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
39%
60%
74%
57%
98%
35%
55%
63%
50%
98%
36%
49%
71%
54%
96%
50%
59%
50%
39%
100%
45%
56%
67%
48%
93%
53%
71%
65%
50%
100%
Trigger Points
90%
80%
60%
50%
100%
80%
70%
50%
40%
90%
• From month 05 the Trust will align it’s Stroke performance reporting with the outcomes and metrics that are collected
through the Sentinel Stroke National Audit Programme (SSNAP) This will provide reliable data from which the Trust can
benchmark it’s performance regionally and nationally. Although access to the unit remains a challenge, overall the Trust
scored in the upper quartile for quality of service as compared to other providers in the region.
• The July performance for admission to ASU within 4 hours has improved by 8%. While some of this is reflective of July it also pertains
to performance over previous months as Stroke performance is recorded based on the month of discharge. Daily reports for Stroke
admissions (via ED) during July are tracking at 80% for access to ASU within 4 hours. Ring fencing of the Stroke unit is having a
positive impact when effectively implemented.
• The percentage of patients spending 90% of their time on ASU shows a 15% improvement. Ring fencing will also assist this area of
performance but again this is dependant on consistently effective implementation.
• High risk TIA patients treated within 24 hours has maintained the expected level of performance.
An Associated University Hospital of
Brighton and Sussex Medical School
15
2. Deliver Safe, High Quality Coordinated Care
Achievement of national best practice in clinical care - Stroke Care
• Stroke patients scanned within 1 hour of arrival has continued to improve in month, albeit marginally. Policy authorising Stroke Nurses
to order scans is expected to help maintain and improve performance and has now been fully authorised. Effectiveness is being
audited by Radiology. Stroke patients scanned within 24 hours: 100%.
• The Stroke Mortality data for March showed an unexpected rise and has been investigated. The lead Clinician audited 10/17 notes
and presented findings to the Medical Division Board. There were no immediate clinical concerns however there were some coding
issues which significantly skewed performance. An action plan has been agreed and includes RCA of all stroke deaths. The coding
issues identified will be corrected but will take some time to be reflected in the HSMR due to the process of SUS submission and Dr
Foster processing.
An Associated University Hospital of
Brighton and Sussex Medical School
16
2. Deliver Safe, High Quality Coordinated Care
Achievement of national best practice in clinical care - #NOF Care
Indicator Description
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Trigger Points
43
47%
49%
84%
93%
49
64%
56%
76%
94%
52
80%
31%
81%
92%
59
68%
63%
78%
93%
33
54%
79%
79%
88%
38
59%
82%
47%
71%
For Information
85%
75%
67%
52%
75%
67%
89%
82%
Priority 1 - Achievement of national best practice in clinical care - #NOF Care
Number of #NOF admissions in month
Percentage of patients achieving all criteria of best practice
Admission to #NOF ward within 4 hours
Operation within 36 hours
Operation within 48 hours
• This month the Trust has changed it’s triggers to align with the National average as reported by the National Hip Fracture
database (NHFD) . As with the NHFD audit data; this will allow the Trust to benchmark itself nationally.
• The Trust continues to demonstrate overall steady performance in the access to ward in 4hours indicator, with our best
performance year to date, due to the ring fencing of orthopaedic beds.
• The percentage of patients achieving all criteria of best practice shows a marginal improvement of 3% on the previous month. Of the
patients not meeting the criteria, the majority were due to theatre delays and a small number experienced delayed Orthogeriatrician
assessments.
• The number of patients admitted to the #NoF ward has improved in month. 3 fractured NoFs resulted from in-patient falls on medical
wards and were not transferred to the #NoF ward until post surgery, as it is quicker to do this but it counts adversely in the data.
• Fractured NoF performance is closely linked to overall trauma activity for the trust, particularly regarding access to theatres. Trauma
complexity and activity remained high in July (140 cases) which impacted on theatre waiting times. It is also important to note that
16% of patients that failed the theatre targets were medically unfit for surgery during the first 48hrs of their admission.
• The time to theatre escalation process has been reviewed and reinforced with the clinical team to ensure patient’s have their
operation at the right time.
• With regards to mortality, we expect the next Dr Foster report to show an improved position following the resubmission of coded data.
A routine process to review of clinical coding for all fractured NoF deaths has been agreed and implemented.
An Associated University Hospital of
Brighton and Sussex Medical School
17
2. Deliver Safe, High Quality Coordinated Care
Achievement of national best practice in clinical care - Maternity Care
Indicator Description
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
98%
99%
84%
19.2%
8.4%
83%
0
1.0%
84%
18.5%
6.4%
81%
0
4.9%
95%
98 hrs
85%
15.9%
7.6%
83%
0
5.2%
95%
98 hrs
94%
12.7%
6.2%
83%
0
6.9%
97%
98 hrs
95%
18.5%
6.8%
86%
0
6.9%
98.0%
98 hrs
96%
18.5%
7.5%
80%
0
6.0%
Trigger Points
Priority 1 - Achievement of national best practice in clinical care - Maternity Care
Women seen by midwife within 12 weeks and 6 days
Weekly hours of dedicated consultant presence on labour ward
1 to 1 Care in Labour
C Section Rate - Emergency
C Section Rate - Elective
Breastfeeding Initiation
Neonatal deaths within 7 Days / Still Births
Admission of full term babies to neonatal care
90%
98 hrs
100%
13%
10%
85%
0
10%
80%
60 hrs
80%
15%
11%
70%
1
11%
• The Maternity services at the Trust continue to deliver high quality services following the significant investments over
previous years in midwifery and medical staffing.
• In July, 408 women were delivered, which was the highest number since October 2010. In part this is attributed to the
successful marketing campaign following the opening of the refurbished birthing unit.
• The improvement in the percentage of women receiving 1:1 care in labour is being sustained, although the Trust’s internal stretch
target of 100% has not been achieved, the Trust is providing 1:1 care to a larger proportion of women than many peers.
• The department is compliant with the Safer Childbirth recommendation in relation to the number of hours required for Consultant
presence on the Labour Ward. Based on a birth rate in excess of 4000 there is now 98 hour Consultant presence on the Labour
Ward.
• The number of emergency caesareans is adverse and all decisions are being audited daily. There does not appear to be a discernible
pattern, checking day or night time, weekday or weekends or individual clinicians. The review has identified very few emergency
caesarean sections that the reviewing consultant felt were not clinically justified. Where this was the case the appropriate learning has
been disseminated. The Division has been asked to present a clearer picture to better understand the position linked to performance
in other areas.
An Associated University Hospital of
Brighton and Sussex Medical School
18
2. Deliver Safe, High Quality Coordinated Care –
Achieve best practice in the use of quality and patient safety indicators
Indicator Description
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
On Plan
On Plan
On Plan
On Plan
On Plan
On Plan
On Plan
On Plan
Trigger Points
Priority 2 - Achieve best practice in the use of quality and patient safety indicators
National quality Dashboard implementation plan
Real-time ward quality / safety system implementation plan
On Plan
On Plan
Off Plan
Off Plan
• The Trust remains on plan for developments in relation to the two main schemes for the use of quality and patient safety
indicators
• Synbiotix is an electronic system which has been procured to enable nursing staff to audit quality practice at ward/Divisional level by
providing real-time data and identifying areas of best practice and areas that require support.
• The system rolled out within the Trust from 1st June 2013 as a trial period and various issues were identified, and are being rectified
before the full roll out is completed.
• The Trust continues to work with external parties as required in relation to the National Quality dashboard and until this is published
the Trust continues to review and incorporate into governance / oversight processes other similar national dashboard (eg the
Workforce Assurance Framework and Greater East Midlands Commissioning Support Unit Acute Care Dashboard) as well as the
outputs from the Dr Foster product suite that the Trust utilises.
An Associated University Hospital of
Brighton and Sussex Medical School
19
2. Deliver Safe, High Quality Coordinated Care
Ensure patients are cared for in the right place at the right time
Indicator Description
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
103%
75%
104%
77%
105%
79%
101%
81%
98%
84%
97%
86%
Trigger Points
Priority 3 - Ensure patients are cared for in the right place at the right time
Average bed occupancy vs substantive bed stock
Percentage of adult patients in an appropriate bed
90%
90%
95%
80%
• The Trust continues to operate at high levels of bed occupancy although there has been a significant improvement in the
percentage of patients in an appropriate bed.
• While neither indicator is achieving the expected levels of performance, a downward tread in bed occupancy and upward trend in
patients in the right bed can be seen.
• The trust has a significant programme of work across the health system to reduce the bed occupancy and improve the number of
patients that are cared for in the “right bed, first time”. The internal element of this programme falls within the Urgent Care and Patient
Flow Board and is focussed on the following:
• Embedding Professional Standards around patient care
• Review of Medical staffing rotas
• Developments of Frail Elderly services including the recruitment of Community geriatrics
• Implementation of Electronic whiteboards on inpatient wards
• Improvements to the discharge process
• Procurement of an Acute “Hospital at Home” Service
• The internal programme is expected to deliver improvements in bed occupancy which will be further bolstered by the Health system
plans to put in place c.100 community beds to allow the patients at the Trust who no longer require care in an acute bed to move into
a more appropriate community setting.
An Associated University Hospital of
Brighton and Sussex Medical School
20
2. Deliver Safe, High Quality Coordinated Care
Work well within clinical networks and develop clinical partnerships
Indicator Description
Feb-13
Mar-13
Yes
Yes
Apr-13
May-13
Jun-13
Jul-13
Trigger Points
Priority 4 -Work well within clinical networks and develop clinical partnerships
Vascular network implementation plan
Trauma Unit designation
Chemotherapy repatriation implementation plan
Radiotherapy implementation plan
Slippage Slippage Slippage Slippage
Yes
Yes
Yes
Yes
On Plan On Plan Slippage Slippage
On Plan Slippage Slippage Slippage
On Plan
Maintained
On Plan
On Plan
Off Plan
Removed
Off Plan
Off Plan
• Progression of Vascular network plans across the Sussex health system are experiencing some slippage. Arterial elective activity is
now undertaken at BSUH as part of the network arrangements. Emergency activity is yet to move. This is on hold while the financial
model is evaluated by all parties in the network
• The Trust continues to maintain its Trauma Unit designation.
• Chemotherapy – the first patients have been repatriated, with 2-3 patients per week receiving care at SaSH who previously had to
travel to Guildford. The remaining breast patients are due for repatriation by September, although this is dependant upon the
recruitment of an oncologist by Royal Surrey, which is proving challenging.
• Radiotherapy is likely to be slightly delayed due to build issues, the is expected to be on line by April 2014
An Associated University Hospital of
Brighton and Sussex Medical School
21
Contents
1. Overview
Overview of Performance against DH Performance Framework
2. Deliver Safe, High Quality, Co-ordinated Care
Page 3
Page 4
Page 7
Priority 1 - Achievement of national best practice in clinical care
Page 8
Priority 2 - Achieve best practice in the use of quality and patient safety indicators
Page 19
Priority 3 - Ensure patients are cared for in the right place at the right time
Page 20
Priority 4 -Work well within clinical networks and develop clinical partnerships
Page 21
3. Ensure patients are cared for and cared about
Priority 1 - Be recommended on the basis of Customer Care / Priority 2 - Always treat patients and their families / carers
with compassion, courtesy and privacy and dignity
4. Work in Partnership with our community
Page 22
Page 23
Page 26
Priority 1 - Work with patients, the public and partners to develop services that meet the needs of our community
Page 27
Priority 2 - Improve the way people see and talk about SaSH
Page 28
5. Become a sustainable, effective organisation
Page 31
Priority 1 - Live within our means both in year and sustainably into the future
Page 32
Priority 2 - Development of our Workforce
Page 34
Priority 3 - Implement our plans to become a Foundation Trust by 2014 / Priority 4 - Ensure that the estate and
infrastructure supports our sustainability
Page 36
6. Appendices
Page 37
An Associated University Hospital of
Brighton and Sussex Medical School
22
3. Ensure patients are cared for and cared about - Be recommended on
the basis of customer care
Indicator Description
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Trigger Points
Priority 1 /2 - Be recommended on the basis of Customer Care and Always treat patients and their families / carers with compassion, courtesy and privacy and dignity
Friends and Family Test
- Inpatients Friends & Family (Net Promoter Score)
- Emergency department Friends & Family (Net Promoter Score)
- Response Rate
Your Care Matters - Inpatient Care
- Dignity and respect
- Cleanliness of ward
- Pain Control
- Privacy
- Emotional Support
- Confidence in Doctors
- Confidence in Nurses
- Answers patients could understand from Nurses
- Answers patients could understand from Doctors
- Hospital Food rating
Your Care Matters - Emergency Department
- Cleanliness of clinic (% saying excellent or good)
Other Indicators
Number of Complaints in Month
Number of commendations in Month (Your care matters)
Mixed Sex Breaches
49
50
50
47
51
64
9%
54
50
16%
64
43
26%
For Information
For Information
18%
15%
9.1
9.3
8.9
9.7
8.2
9.1
8.9
8.4
8.4
5.2
8.8
9.2
8.5
9.3
7.7
8.6
8.5
8.2
8.1
5.3
8.9
9.2
8.7
9.3
7.6
8.6
8.5
8.1
7.6
5.4
9.1
9.2
8.8
9.6
8.2
9.0
9.0
9.0
8.3
5.8
9.3
9.4
8.9
9.4
8.3
8.8
8.9
8.6
8.2
5.9
9.5
9.5
9.1
9.6
8.8
9.4
9.2
8.9
8.7
6.4
For Information
For Information
For Information
For Information
For Information
For Information
For Information
For Information
For Information
For Information
84%
92%
91%
91%
For Information
47
88
0
49
121
0
34
158
0
56
213
0
35
39
For Information
0
1
47
76
0
52
85
0
• The Trust continues to demonstrate improvements in ensuring patients are cared for and cared about.
• The National Friends and Family Test results are calculated using an underlying “Net Promoter Score” ‘which takes the proportion of
patients who are ‘Extremely Likely” to recommend minus those who are unlikely or neutral, to give a score from -100 to +100. The
Friends and Family Test score for July 2013 for Inpatients is +64 an improvement on last month. For the Emergency Department
patients the score is +43 which demonstrates a decline in performance.
An Associated University Hospital of
Brighton and Sussex Medical School
23
3. Ensure patients are cared for and cared about
Be recommended on the basis of customer care
• The national FFT results were published in July 2013 and the Trust’s June inpatient Net Promoter Score (NPS) of 54 put it as the
seventh lowest Trust in England. The Trust also had one of 36 wards in England with a negative NPS – Newdigate – with a NPS of 17. (Of the six patients who completed the FFT survey for Newdigate in June only one recorded a negative view but the way the NPS
score works only counts Highly Likely votes as being promoters)
• The overall England mean NPS score was 70 putting the Trust someway behind the national average. Internal discussion suggests
that to some extent the reason for the Trust’s lower score is the time at which we ask the FFT question. The majority of Trusts use
simple, one question, paper returns completed at the time of discharge. The Trust previously found that this approach tends toward
a more positive response as patients appear reluctant to be negative whilst they are still in the hospital. As a result, the Trust elected
to use a more sophisticated tool – Your Care Matters (YCM) – which not only asks the FFT question but asks a much wider range
allowing much better understanding of the real issues affecting patients and providing the opportunity to address those concerns and
improve the patient experience.
• Given the disparity between our results and other Trusts we are now looking at simplifying the way that we ask the FFT question
whilst at the same time keeping all the benefits of the Your Care Matters programme. This work will be concluded so that the new
process starts from the beginning of September 2013.
• The July national data is not yet available however the Trust’s overall score has risen to 63. As a result of their negative score for
June, and recognising the acuity and dependency of Newdigate patients, the ward commenced FFT data collection in hard copy form
asking just the FFT question in July 2013. Newdigate now has a score of 89. This indicates some of the disadvantages in utilising
YCM on wards of this nature and indicates an improved scoring with hard copy on ward data collection.
• We had already recognised that some patients had difficulties with the full survey so had implemented a paper based return in some
other areas previously. Because of this we are able to calculate that our NPS score for paper results alone would be 71 in July against
the overall score of 63.
An Associated University Hospital of
Brighton and Sussex Medical School
24
3. Ensure patients are cared for and cared about
Be recommended on the basis of customer care
• The Safety & Quality Committee (August 2013) received a paper following a review of complaints in the Trust. The purpose of the
review was to provide information, assurance and highlight further work required on formal complaints received by the Trust.
• In accordance with Trust policy, the definition of the complaint is, an expression of dissatisfaction from a patient, their representative
or a potential user of Trust services requiring a formal response.
• During 2012/13 the Trust received 450 formal complaints. Issues ranked highest on the table are Medical Care followed by Diagnosis
and also Nursing/Midwifery, Communication and Attitude/Courtesy. All 450 complaints have been closed for the year.
• Ombudsman current cases are also included in the report with the current status. There are currently three cases open with the
Ombudsman. There is one case for the Medical division and two cases for the Surgical division. The three themes represented are
rudeness, delay in treatment and poor outcome. The complaints department have supplied the Ombudsman with the information/files
required and the Trust is awaiting feedback.
• A draft Standard Operating Procedure for Complaints was also developed as part of the paper outlining the functions and
responsibilities of the teams.
• The quality of the old complaints codes were identified as not sufficient to obtain in-depth analysis, subsequently new coding has
been developed, based on incident reporting, providing a systematic and structured approach to allow specialist sub categories to be
interpreted. As a result of the new incident coding, an opportunity for complaints and PALS to be aligned in future reports creating in
depth analysis of themes, trends and potential risks is now achievable.
• To note for the year 12/13 to 13/14 first quarters there is a decrease of complaints relating to treatment, communication,
attitude/courtesy and discharge.
An Associated University Hospital of
Brighton and Sussex Medical School
25
Contents
1. Overview
Overview of Performance against DH Performance Framework
2. Deliver Safe, High Quality, Co-ordinated Care
Page 3
Page 4
Page 7
Priority 1 - Achievement of national best practice in clinical care
Page 8
Priority 2 - Achieve best practice in the use of quality and patient safety indicators
Page 19
Priority 3 - Ensure patients are cared for in the right place at the right time
Page 20
Priority 4 -Work well within clinical networks and develop clinical partnerships
Page 21
3. Ensure patients are cared for and cared about
Priority 1 - Be recommended on the basis of Customer Care / Priority 2 - Always treat patients and their families / carers
with compassion, courtesy and privacy and dignity
4. Work in Partnership with our community
Page 22
Page 23
Page 26
Priority 1 - Work with patients, the public and partners to develop services that meet the needs of our community
Page 27
Priority 2 - Improve the way people see and talk about SaSH
Page 28
5. Become a sustainable, effective organisation
Page 31
Priority 1 - Live within our means both in year and sustainably into the future
Page 32
Priority 2 - Development of our Workforce
Page 34
Priority 3 - Implement our plans to become a Foundation Trust by 2014 / Priority 4 - Ensure that the estate and
infrastructure supports our sustainability
Page 36
6. Appendices
Page 37
An Associated University Hospital of
Brighton and Sussex Medical School
26
4. Work in partnership with our community
Work with patients, the public and partners to develop services that meet the needs of our
community
Indicator Description
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Priority 1 - Work with patients, the public and partners to develop services that meet the needs of our community
Delayed Transfers of Care
2.1%
1.8%
2.1%
Endoscopy / JAG Accreditation developments
On Plan
TB Service Development
On Plan
BOC Unit
On Plan
Chemotherapy repatriation implementation plan
On Plan
Radiotherapy implementation plan
On Plan
FT Membership on plan
On Plan
6.0%
On Plan
On Plan
On Plan
On Plan
Slippage
On Plan
6.4%
On Plan
On Plan
On Plan
Slippage
Slippage
On Plan
5.6%
On Plan
On Plan
On Plan
Slippage
Slippage
On Plan
Trigger Points
3.5%
On Plan
On Plan
On Plan
On Plan
On Plan
On Plan
5.0%
Off Plan
Off Plan
Off Plan
Off Plan
Off Plan
Off Plan
DTOC values have been re-stated for April 2013 onwards following a review of the methodology to convert weekly data into monthly performance.
• Delayed Transfers of Care decreased in July 2013 but remained above expectations .
• The Trust is currently working with CCGs and health and social care providers to reduce the level of DTOCs through:
•
Re-design the discharge pathway, both within the Trust and externally to reduce duplication, paperwork and complex
assessments and funding decisions in the acute environment. Moving to a ‘discharge to assess’ model
•
Increase actual or virtual bed capacity out of hospital by 100, supporting a model of “discharge to assess” for continuing
health and social care needs.
•
Implement an Integrated Discharge Team, with all partners working together to support discharges earlier in the patients
journey and resolve complex issues more rapidly
• While some impact is expected in August and September, the step change is not expected until October 2013.
• Other developments continue to be on plan with the new TB service now live and staff being recruited and the Endoscopy JAG
accreditation programme is on plan in preparation for the Trust’s assessment in October.
An Associated University Hospital of
Brighton and Sussex Medical School
27
4. Work in partnership with our community
Improve the way people see and talk about SaSH
Indicator Description
Priority 2 - Improve the way people see and talk about SaSH
NHS Choices Rating
Patient Opinion Rating - % that would recommend SASH
% of Press Coverage that is positive
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
3.5
76%
3.5
74%
4.0
75%
4.0
75%
4.0
75%
81%
4.0
75%
72%
Trigger Points
5
80%
80%
3.5
70%
60%
• NHS Choices and Patient Opinion continue to be key channels for engaging with patients and the public
• In July, 21 stories were posted on Patient Opinion that were viewed 2,884 times. 20 were about East Surrey Hospital and 1 comment
was about the services provided by SASH at Dorking Hospital.
• Patient Opinion rates the feedback received by the Trusts based on the stories content. Of the stories posted in July 48% were rated
not critical, 20% were scored minimally/mildly critical; 10% were scored as moderately critical; 5% were rated strongly critical – this
equate to 1 comment. 19% not rated (not rated stories are those which are fed from NHS Choices).
• One of the themes in the feedback this month was around outpatient clinics. As a result the Trust has made changes to how those
clinics are run to better address the needs of our patients. We will continue to engage with patients and staff to monitor the success
of the changes.
• As many Patient Opinion responses are from Surrey patients compared to Crawley and Horsham patients. This is different to last
month where three times as many responses were from Surrey patients.
• Patient Opinion allows us to have a direct conversation with patients and solve problems that may never have been heard through
traditional routes. All Patient Opinion stories are fed directly to the inboxes of senior staff. As a Trust we are able to respond in a more
‘real time’ manner to feedback received. In July over 50% of comments were responded to within 24 hours. To date, 26 changes
have been made through comments left on Patient Opinion. It is not always about solving issues, sometimes it is about listening and
reassuring patients or their relatives.
An Associated University Hospital of
Brighton and Sussex Medical School
28
4. Work in partnership with our community
Improve the way people see and talk about SaSH
• Press Coverage for the Trust has been mixed in July 2013 with no particular press story dominating the headlines. Stories included
news about the heat wave and the implications on our Emergency Department, a story resulting from an Freedom of Information
about unusual objects removed from patients, a story about health tourism sparked by MP Henry Smith stating that it is not
Xenophobic to recover costs.
• We responded to seven media enquiries, and all, or part of, of our statements were included in the articles. Of those responses,
three stories are ranked as positive, and four stories are ranked as negative.
•
Of the negative coverage; following the trust raising a safeguarding concern regarding a child, a family member was unhappy about
the police visiting the home. In this instance the correct procedure was followed by staff who placed the safety of the child first.
There was also a misleading article about high mortality rates following admission to hospital on a Monday. The data around the
mortality rates has been investigated. The investigation found that mortality rates on a Monday are not higher than any other day of
the week. A response was published on the homepage of our website and in the CEO’s weekly message. A radio interview with a
Consultant also took pace to explain the data.
• The Chief Executive Michael Wilson has a weekly column in the Surrey Mirror that continues to be an excellent channel for
communication with the public about the day-to-day challenges and achievements of the Trust.
• This month we issued three proactive press releases and achieved 100% pick-up rate.
An Associated University Hospital of
Brighton and Sussex Medical School
29
Contents
1. Overview
Overview of Performance against DH Performance Framework
2. Deliver Safe, High Quality, Co-ordinated Care
Page 3
Page 4
Page 7
Priority 1 - Achievement of national best practice in clinical care
Page 8
Priority 2 - Achieve best practice in the use of quality and patient safety indicators
Page 19
Priority 3 - Ensure patients are cared for in the right place at the right time
Page 20
Priority 4 -Work well within clinical networks and develop clinical partnerships
Page 21
3. Ensure patients are cared for and cared about
Priority 1 - Be recommended on the basis of Customer Care / Priority 2 - Always treat patients and their families / carers
with compassion, courtesy and privacy and dignity
4. Work in Partnership with our community
Page 22
Page 23
Page 26
Priority 1 - Work with patients, the public and partners to develop services that meet the needs of our community
Page 27
Priority 2 - Improve the way people see and talk about SaSH
Page 28
5. Become a sustainable, effective organisation
Page 31
Priority 1 - Live within our means both in year and sustainably into the future
Page 32
Priority 2 - Development of our Workforce
Page 34
Priority 3 - Implement our plans to become a Foundation Trust by 2014 / Priority 4 - Ensure that the estate and
infrastructure supports our sustainability
Page 36
6. Appendices
Page 37
An Associated University Hospital of
Brighton and Sussex Medical School
30
5. Become a sustainable, effective organisation
Live within our means both in year and sustainably into the future
Indicator Description
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Trigger Points
0.0
0.0
0.0
0.0
(3.5)
(3.5)
0.3
(5.5)
2.6
4.6
(9.0)
84%
93%
17.3
0.0
0.0
0.0
0.0
(3.5)
(3.5)
0.7
(6.5)
2.6
2.2
(9.0)
87%
90%
17.3
0.0
0.0
0.0
0.1
(3.5)
(3.5)
1.1
(6.5)
2.6
3.4
(9.0)
89%
90%
17.3
0.0
0.0
0.0
0.2
(3.5)
(3.5)
1.8
(6.5)
2.6
3.7
(10.0)
88%
90%
17.3
For Information
On Plan
Off Plan
For Information
On Plan
Off Plan
For Information
On Plan
Off Plan
On Plan
Off Plan
On Plan
Off Plan
On Plan
Off Plan
On Plan
Off Plan
On Plan
Off Plan
On Plan
Off Plan
On Plan
Off Plan
On Plan
Off Plan
Priority 1 - Live within our means both in year and sustainably into the future
Overall Financial Position
- Outturn £m Surplus / (Deficit) - Plan
- Outturn £m Surplus / (Deficit) - Forecast
- YTD £m Surplus / (Deficit) - Plan
- YTD £m Surplus / (Deficit) - Actual
- Outturn UNDERLYING £m Surplus / (Deficit) - Plan
- Outturn UNDERLYING £m Surplus / (Deficit) - Actual
- YTD Savings £m Fav / (Adverse) - Actual
- OT Risk £m Surplus / (Deficit) - Assessment
- Outturn Cash position £m Fav / (Adv) - Forecast
- YTD Cash position £m Fav / (Adv) - Actual
- YTD Liquid ratio - days
- YTD BPPC (overall) value %
- YTD BPPC (overall) volume %
- Outturn Capital spend Fav / (Adv) - forecast
•
At Month 4 the Trust is favourable to plan with a £0.2m surplus. The forecast remains breakeven.
•
The Trust is intending to write to the TDA regarding resolution of non recurrent income/cash support (as discussed at the Board
previously), as no further information has been received.
•
Month 4 has been another stable month, building on the improvements seen since the first couple of months of the year. This is
reflected in the overall position and the improved savings position (£1.8m achieved year to date). But, contract income is below the
Trust plan. Although we are reducing outsourcing early (hence the jump in savings) and 18 weeks performance is strong, in all
specialties volumes of elective activity have not caught up the loss of activity in April. It should be noted that several corporate
budgets are overspending slightly at M04.
An Associated University Hospital of
Brighton and Sussex Medical School
31
5. Become a sustainable, effective organisation
Live within our means both in year and sustainably into the future
•
The Trust has shared forecast annual contract performance with the CCG’s, and vice versa, and the different positions have been
aired at two major meetings. The Trust view is that there will be significant over performance (adverse) to CCG plans, while the CCG
view is that QIPP plans based on admission avoidance action for non elective activity will impact in the last half of the year. The latter
would require a 10-20% reduction in activity against a context of July having the greatest number of A&E attendances all year and
non elective activity volumes being the highest all year
•
The cash balance has dropped from last month but is still healthy at £3.7m, and is on plan. The cash flow forecast assumes receipt
of the £5.5m non recurring support income.
•
The PACS/RIS implementation problems reported elsewhere will have a financial impact (the cost of additional radiology
reporting/services) and potentially an income impact. It is difficult to quantify that at this stage.
An Associated University Hospital of
Brighton and Sussex Medical School
32
5. Become a sustainable, effective organisation
Development of our workforce
Indicator Description
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Trigger Points
3382
3001
11.3%
273
101
14
15.0%
7.5%
3385
3004
11.3%
342
111
17
15.5%
8.9%
3456
2991
13.5%
293
120
13
15.7%
8.5%
3453
2999
13.1%
268
100
15
15.1%
7.0%
3457
3023
12.6%
309
83
16
15.5%
6.5%
3460
3070
11.3%
280
87
19
15.1%
8.1%
For Information
For Information
10%
12%
For Information
For Information
For Information
12%
14%
4.0%
7.3%
4.6%
2.9%
1.7%
4.0%
2.5%
1.5%
3.9%
2.2%
1.7%
3.6%
2.0%
1.5%
3.6%
2.2%
1.4%
3.48%
2.1%
1.4%
3.5%
4.0%
For Information
For Information
76.2%
87.7%
93.7%
89.0%
89.9%
84.5%
5%
87.1%
80.7%
10%
86.2%
81.6%
18%
90.0%
81.2%
20%
90%
80%
35%
Priority 2 - Development of our Workforce
Establishment, Recruitment and Staff Usage
- Total Establishment (Funded WTEs)
- Total In post
- Vacancy Rate (All Staff)
- WTE Worked - Bank
- WTE Worked - Agency
- WTE Worked - Locum
- Staff Turnover rate
- % of Pay on agency
Sickness
- Overall Sickness Rate
- Sickness Rate - Short Term
- Sickness Rate - Long Term
Appraisals and Training
- %age of staff who have had appraisal in last 12 months
- %age of staff who have completed mandatory training in last 12 months
- %age of staff who have completed Information Governance training YTD
80%
70%
31%
• The focus of work within the Trust is on continuous recruitment to our nursing vacancies and the most cost effective use of
contingent workforce to ensure that the highest quality standards are maintained and deliver financial savings.
• The vacancy rate and turnover have fallen in July 2013. This is the first time both have fallen in month and is an encouraging sign that
recruitment and retention initiatives are taking effect.
• There is a small increase in agency use with a more significant reduction in bank use this month. Despite the reduction in agency the
% of pay on agency has increased due to the increase in use of locums.
An Associated University Hospital of
Brighton and Sussex Medical School
33
5. Become a sustainable, effective organisation
Development of our workforce
• Sickness absence has fallen slightly this month to 3.4% which is also lower than the same period last year (3.8%) with the reduction
being in short term absences. The summer months traditionally show lower absence rates and so the reductions over the past 5
months need to be sustained into the winter in order to achieve the 3.5% target.
• The top 3 reasons for absence are unchanged from last month (Surgery, Anxiety/stress/depression/other psychiatric illnesses
followed by Gastrointestinal problems ).
• Both appraisal and mandatory training compliance are now at target and actions will continue to ensure this is sustained throughout
the year.
• IG governance training compliance is below target for YTD with actions in place to ensure training activity is spread throughout the
year to minimise service disruption.
An Associated University Hospital of
Brighton and Sussex Medical School
34
5. Become a sustainable, effective organisation UPDATE
Implement our plans to become an FT by 2014 and Ensure that the estate and
infrastructure supports our sustainability
Indicator Description
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Trigger Points
On Plan
On Plan
On Plan
On Plan
On Plan
Off Plan
On Plan
On Plan
On Plan
On Plan
On Plan
On Plan
On Plan
On Plan
On Plan
On Plan
Off Plan
Off Plan
Priority 3 - Implement our plans to become a Foundation Trust by 2014
FT Programme Plan
Priority 4 - Ensure that the estate and infrastructure supports our sustainability
Capital Plan Implementation
IT Strategy Implementation
• The FT project board continues to meet on a six weekly basis. FT progress is also reviewed at the monthly TDA oversight meeting.
The Trust submitted its Long Term Financial Model in August to the TDA.
• The 2013/14 capital plan is progressing as expected with significant work underway on the Theatre rebuild.
• In relation to the IT Strategy, we are experiencing some problems with the PACS/RADNET implementation however there has been
considerable movement in addressing some of the issues in recent weeks We will continue to work closely with both BT and Cerner
to implement a solution as quickly as possible.
An Associated University Hospital of
Brighton and Sussex Medical School
35
Contents
1. Overview
Overview of Performance against DH Performance Framework
2. Deliver Safe, High Quality, Co-ordinated Care
Page 3
Page 4
Page 7
Priority 1 - Achievement of national best practice in clinical care
Page 8
Priority 2 - Achieve best practice in the use of quality and patient safety indicators
Page 19
Priority 3 - Ensure patients are cared for in the right place at the right time
Page 20
Priority 4 -Work well within clinical networks and develop clinical partnerships
Page 21
3. Ensure patients are cared for and cared about
Priority 1 - Be recommended on the basis of Customer Care / Priority 2 - Always treat patients and their families / carers
with compassion, courtesy and privacy and dignity
4. Work in Partnership with our community
Page 22
Page 23
Page 26
Priority 1 - Work with patients, the public and partners to develop services that meet the needs of our community
Page 27
Priority 2 - Improve the way people see and talk about SaSH
Page 28
5. Become a sustainable, effective organisation
Page 31
Priority 1 - Live within our means both in year and sustainably into the future
Page 32
Priority 2 - Development of our Workforce
Page 34
Priority 3 - Implement our plans to become a Foundation Trust by 2014 / Priority 4 - Ensure that the estate and
infrastructure supports our sustainability
Page 36
6. Appendices
Page 37
An Associated University Hospital of
Brighton and Sussex Medical School
36
6. Appendices
Glossary of Terms
AMI
Acute Myocardial Infarction
C diff
Clostridium difficile
CDS
Commissioning Data Set
FFCE
First Finished Consultant Episode
H&S
Health and Safety
HSMR
Hospital Standardised Mortality Rates
LOLER
Lifting Operations and Lifting Equipment Regulations 1998
MRSA
Methicillin-Resistant Staphylococcus aureus
RACP
Rapid Access Chest Pain
RIDDOR
Reporting of Injuries, Diseases and Dangerous Occurrences Regulations
SUI
Serious Untoward Incident
TIA
Transient Ischaemic Attack
WTE
Whole Time Equivalent
An Associated University Hospital of
Brighton and Sussex Medical School
37
6. Appendices
ry
Ga
st
ro
Ge ent
ne ero
r
l
Ge al M ogy
ne
ed
ic
r
Ge al S ine
u
ria
rg
e
t
Gy ric M ry
na
e ed
Ne colo icin
e
ur
g
ol y
o
Ne
g
ur y
os
Op urg
er
ht
y
h
Or alm
ol
al
Su og
Ot rge y
he
ry
r
Pl
as
tic
Rh Su
eu rge
ry
m
Th ato
or
l
ac ogy
Tr ic M
au
m edi
Ur a & c ine
ol
og Ort
ho
To y
pa
ta
ed
l
ics
0
0
0
0
2
0
0
0
0
2
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
2
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
ol
og Su
rg
y
e
EN
T
18 Week Waits – Breach Reasons
Ca
r
di
o
Ca log
rd y
i
De oth
rm ora
at cic
Admitted Pathways
Patient Choice
Patient non-cooperation (e.g. DNAs)
Patient chooses to wait longer than reasonable (as defined in local access policy)
Not in the patients best clinical interest
Capacity
Insufficient capacity
Capacity - First appointment
Capacity - follow up
Capacity - preassessment
Capacity – Theatre
Hospital cancellation
Hospital cancellation of Clinic
Hospital cancellation - no theatre
Hospital cancellation - no beds
Hospital cancellation - staff absence
Diagnostic delay
Insufficient diagnostic capacity to deliver local standards for diagnostic tests
Reporting delay
Medically not fit
Medically not fit at pre-assessment
Not fit while awaiting admission
Process delay
Paper process delay
Incorrect patient demographics
Referral vetting delay
Postal delay
Late transfer from another provider
Other
Total
0
0
0
0
3
0
2
0
0
1
2
2
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
5
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
1
0
13
0
0
4
0
9
0
0
0
0
0
0
0
0
0
0
0
1
1
0
0
0
0
1
16
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
0
0
0
0
0
0
0
0
0
1
1
0
0
0
0
0
2
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
1
0
6
0
2
0
0
4
1
1
0
0
0
0
0
0
0
0
0
2
2
0
0
0
0
0
10
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
2
0
2
0
9
0
1
0
0
8
0
0
0
0
0
0
0
0
0
0
0
1
1
0
0
0
0
1
13
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
1
0
12
0
0
2
0
10
0
0
0
0
0
0
0
0
0
0
0
1
1
0
0
0
0
2
16
0
0
0
0
5
0
3
1
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
6
5
0
5
0
50
0
8
7
0
35
4
4
0
0
0
0
0
0
0
0
0
6
6
0
0
0
0
7
72
An Associated University Hospital of
Brighton and Sussex Medical School
38
6. Appendices
ol
og Su
rg
y
er
Ca
r
EN
T
di
o
Ca log
rd y
i
De oth
rm ora
at cic
Non Admitted Pathways
Patient Choice
Patient non-cooperation (e.g. DNAs)
Patient chooses to wait longer than reasonable (as defined in local access policy)
Not in the patients best clinical interest
Capacity
Insufficient capacity
Capacity – Theatre
Capacity - First appointment
Capacity - follow up
Hospital cancellation
Hospital cancellation of Clinic
Hospital cancellation - no theatre
Hospital cancellation - no beds
Hospital cancellation - staff absence
Diagnostic delay
Insufficient diagnostic capacity to deliver local standards for diagnostic tests
Reporting delay
Medically not fit
Medically not fit at pre-assessment
Not fit while awaiting admission
Process delay
Paper process delay
Incorrect patient demographics
Referral vetting delay
Postal delay
Late transfer from another provider
Other
Total
Ga
y
st
ro
Ge ent
ne ero
r
l
Ge al M ogy
ne
ed
ic
r
Ge al S ine
u
ria
rg
e
t
Gy ric M ry
na
e ed
Ne colo icin
ur
gy e
o
Ne logy
ur
o
Op surg
er
ht
y
h
Or alm
ol
al
Su og
Ot rge y
he
ry
r
Pl
as
tic
Rh Su
eu rge
ry
m
Th ato
or
lo
gy
ac
Tr ic M
au
m edi
Ur a & c ine
ol
og Or t
ho
To y
pa
ta
ed
l
ics
18 Week Waits – Breach Reasons
0
0
0
0
4
0
0
4
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
4
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
1
0
3
0
0
2
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
4
2
0
2
0
7
0
0
1
6
1
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
2
12
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
10
10
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
4
0
0
3
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
4
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
1
0
4
1
0
2
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
3
8
1
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
5
1
4
1
5
0
0
3
2
2
0
0
0
2
0
0
0
0
0
0
0
0
0
0
0
0
2
15
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
1
0
1
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
3
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
0
0
8
0
1
0
7
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
10
0
0
0
0
2
0
0
0
2
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
2
12
2
10
1
38
1
1
16
20
3
1
0
0
2
0
0
0
0
0
0
0
0
0
0
0
0
19
73
An Associated University Hospital of
Brighton and Sussex Medical School
39