Balanced Score Card Review of July 2015 Data
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1 Balanced Score Card Review of July 2015 Data
2 Balanced Scorecard Finance Patient Access Quality & Safety Human Resource Management
3 Finance
4 Finance Report - July 2015 Actual outturn YTD July 2015 Group budget 164.2m ( m) Group actual expenditure 164.1m ( m) Group actual surplus 138k ( 2014 deficit: 7.8m) CUH Budget 154.2m (2014: 148.6m) CUH /SMOH actual expenditure 154.6m ( 156.0m) CUH /SMOH actual deficit 375k ( m) Mallow Budget 10.0m (2014: 9.7m) Mallow actual expenditure 9.5m ( m) Mallow actual surplus 514k ( 2014 deficit 560k)
5 Forecast 2015 Group Budget m ( m) Group projected expenditure 282.2m ( 284.2m) Group Projected Surplus 358k ( surplus 0.7m) CUH Budget 265.3m (2014: 262.8m) CUH projected actual 265.4m ( 265.2m) CUH projected Deficit 79k ( 2.4m) Mallow Budget 17.3m (2014: 17.5m) Mallow Projected Actual 16.8m ( 16.8m) Mallow Projected Surplus 461k
6 CUH Summary Budget v Actual Expenditure June 2015 Pay k Non-Pay k Income k Total CUH SMOH CUH-SMOH Mallow Total
7 CUH Budget v Actual Pay YTD - June Actual Budget k k Variance k % Variance 2014 Actual k v 2014 Variance k Medical/Dental 31,818 32, % 31, Nursing/Midwifery 43,227 43, % 44, Paramedical 15,969 15, % 15, Housekeeping 5,984 6, % Catering 1,972 1, % 2, Portering 3 2, % 3, Administration 8,837 8, % 8, Other Staff 1, % 1, Total 112, , % 113,
8 CUH Actual Non-pay Expenditure k YTD July 2015 v 2014
9 CUH Group Surplus / (Deficit) percentage %
10 CUH Debtor days July 2015
11 CUH AGENCY COSTS k 2013 July 2015
12 CUH Agency Costs June 2015
13 CUH Average Nursing & HCA Agency WTE s per Week CUH Average Specials /Other Nursing & HCA Agency WTE s per Week
14 Cost Containment Plan
15 Patient Income 2013 July 2015
16 Consultant Private Insurance Claims O/s Consultant claims at 31 st July 2015 Consultants at 13 th Aug No of claims Value k HARTY, JAMES ,353 ANDREWS, EMMET J ,390 TAYLOR, COLM ,871 DODDAKULA, KISHORE ,414 KEARNEY, PETER ,325 REIDY, DECLAN ,449 O'REILLY, SEAMUS ,477 CLARKSON, MICHAEL ,874 MCSWEENEY, NIAMH ,721 GUERIN, SHANE 8 124,723 SWEENEY, BRIAN ,134 O'BROIN, EOIN ,899 KELLY, PETER ,282 REDMOND, PAUL ,728 KHAN, HAMID ,662 O'LEARY, PAULA ,539 BORAN, SINEAD ,376 PLANT,WILLIAM ,201 TOTAL 3,591,584
17 Mallow Budget v Actual YTD June 2015 Budget Actual Variance % Variance Pay 7,530 7, % Non Pay 2,149 2, % 9,679 9, % Income -1,113-1, % Total 8,566 8, %
18 Patient Access
19 CUH Weekly INMO Trolley Report Week ending 14 th August 2015
20 Daily Trolley Numbers June August 2015 (23/8/2015)
21 Ambulance Turnaround Times (June)
22 ED 6hr & 9hr Target (17 th August) (9hr 77.4% - 6hr 59.6%) R
23 Delayed Discharges January August (18 th August)
24 Inpatient Day case Waiting Lists
25 Total Waiting List 14/08/2015 Wait category 0-3 Months 3-6 Months 6-8 Months 8-12 Months Months Months Months Months Grand Total ACTIVE PREADMIT SUSPENSION ACTIVE PREADMIT SUSPENSION
26 18 Month Breaches (54)
27 18 Month Breaches by Speciality G Fulton B O'Reilly C Burke M Hewitt J Coulter P Kelly C Brady E Andrews M McCourt P Redmond Vascular Gynae. Gynae. Gynae. Gynae. Cardiology Gen Surgery Gen Surgery Gen Surgery Gen Surgery
28 15 Month Breaches - December 2015 (313) Cardio Th 7 Cardiology 10 Pl Surgery 11 G Surgery 51 Respt 3 Urology 15 N/Surgery 1 Vascular 73 Gynae
29 15 Month Breaches by Specialty
30 Outpatient Waiting Lists
31 Patients in breach of the 18m deadline- 30 th June
32 Patients Currently in Breach 0f 12mth Target
33 Medical Patients to be seen by the 31/12/2015 (1,382)
34 Surgical Patients to be seen by the 31/12/2015 (5,244)
35 Women and Children Patients to be seen by the 31/12/2015 (2,329)
36 Scope Waiting List
37 Scopes Routine June 2015 R
38 Medical ALOS (June Dashboard) G
39 New Patients Treated with Radiation Oncology - July 2015
40 Reason for Treatment Delay - July 2015
41 Quality & Safety
42 Time to Surgery (June Dashboard) G
43 ALOS Excluding LOS over 30 days (June Dashboard) G
44 Cancer KPI Breast-Lung-Prostate -Jan July
45 Serious Reportable Events (SRE s) 11 SREs communicated in communicated in July & August 3 environmental events serious disability for patient associated with a fall whist in hospital 3 care management events Maternal death, serious disability associated with a diagnostic error & stage 3 pressure ulcer after admission 1 surgical event Unintended retention of a foreign object post surgical procedure
46 Reportable Events
47 Re Reportable Events portable Events
48 Patient Experience - Complaints Complaints received - July Safe and Effective Care 6 Access 2 Dignity and Respect 2 Communication and Information 1 Accountability 1.73% of complaints investigated within 30 working days
49 Patient Experience - Complaints 3 Appointment 1 Alleged inappropriate behaviour 1 Delivery of Care 5 Treatment and Care 1 Accessibility / Resources 1 Hygiene 1 Admission 2 Medication 1 Parking 1 Communicatio n Skills 1 Human Resources
50 Risk Register Risk Register update in June Open Risk Assessments on register Update & amendments made to 11 risk assessments Closed 6 previously identified risks - CUH 16, CUH 31, CUH 44, CUH 45, CUH 46, CUH 49 Reopened 1, CUH 39 - Theatre Staffing Four new risks identified CUH 52, CUH 53, CUH 54, CUH 55 6 risk assessment escalated to CEO South / South West Hospital Group for consideration of additional controls CUH 17, CUH 39, CUH 52, CUH 53, CUH 54, CUH 55
51 Reducing Healthcare Acquired Infection (MRSA) (June Dashboard) G
52 Reducing Healthcare Acquired Infection- C diff (June Dashboard) G
53 Reducing Healthcare Acquired Infection (June Dashboard) G
54 National Early Warning Score National Early Warning Score programme extending to include sepsis recognition and treatment National sepsis screening tool and pathway Implementation on implementation Audit results indicate a decrease in compliance - a number of measures identified for improvements Mandatory online education nurses, NCHDs and consultants- you must do it to work here Commitment that NEWS score will be used in all patient handover e.g. ward, virtual hospital, bed management Commitment to ISBAR Support for an electronic tool Irish Maternity Early Warning Score - New Modified IMEWS Chart rolled out in CUMH, ISBAR sticker for IMEWS developed and in use
55 NEWS Implementation (June Dashboard) G
56 IMEWS Implementation (June Dashboard) G
57 HIQA Reports - Portlaoise Presentation at EMB and Executive Quality & Safety Committee Self assessment report submitted against S/SWH Group template Filling of permanent Director of Midwifery post, Clinical Director post and experience Risk Manager post Critical Care Capacity
58 Human Resource Management
59 Sick Leave July % 5.0% 5.06% 4.45% 4.39% 4.0% 3.5% 3.5% 3.5% 3.5% 3.5% 3.5% 3.0% 3.08% 2.40% 2.0% 1.51% 1.0% 0.0% Med/Dent Nursing H & SCP Man. Admin Gen. Support Other
60 Staffing & Costs
61 EWTD Compliance
62 MRI Unit Paediatric Unit Mental Health Unit Project Acute Medical Assessment Unit Phase 3 & Endoscopy Unit Capital Projects Completed and operational Status Phase 1 - build programme commenced in July Phase 2 submitted for capital funding Completed and operational Completed and operational Radiation Oncology Unit Planning permission granted Enabling works to commence in November 2015 Cystic Fibrosis/ Respiratory Ward Blood Sciences Project Ward refurbishment completed operational from October Design Team appointed request for managed service approved Oncology Service Expansion of Day Unit plan signed off submitted for Philanthropic funding (ACT) Refurbishment of Ward 2D capital funding in place Medical Oncology Centre developing Statement of Need Ophthalmology Transfer phase 2 Helipad Step Down Unit Project group in place Interim helipad in place - final solution being assessed by CAA. Discussion has commenced on Procurement Process
63 Key Issues Recruitment of Nursing staff 31 beds closed Recognition of Budgetary performance Dependency on patient income 2016 Estimates Undergraduate Training costs - 6.5m per annum Management of Unscheduled Care Implementation of Change Programme Initiatives Scheduled Care Implementation of plan to meet waiting list targets Hospital Group approach to maximise capacity
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