LONDON NORTH WEST HEALTHCARE NHS TRUST

Transcription

1 LONDON NORTH WEST HEALTHCARE NHS TRUST Approved Minutes of the public Trust Board Meeting held on Wednesday 28 th September 2016 at 9.15am Ealing Hospital, Postgraduate Lecture Theatre Present Mr Peter Worthington Jacqueline Docherty DBE Mr Andrew Farrell Mrs Janet Rubin Professor David Taube Mr Andrew van Doorn Mr Ruwan Weerasekera Mr Martin West Mr Jon Bell Dr Charles Cayley Mr Simon Crawford Mr Lee Martin Ms Amanda Pye In attendance Ms Claire Gore Mr Nigel Myhill Mrs Gurjinder K Nisar Apologies Dr Vineta Bhalla Chairman Chief Executive Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Interim Chief Financial Officer Medical Director Director of Strategy and Deputy Chief Executive Chief Operating Officer Chief Nurse Director of Human Resources and Organisational Development Director of Estates and Facilities Acting Board Secretary (Minutes) Non-Executive Director Item Discussion and actions 1. Patient story/summary of a patient story There was no patient story. 2. Welcome and apologies for absence Apologies noted from Dr Bhalla Declarations of Interest There were no new declarations of interest. Peter Worthington informed the Board that Professor Taube s re-appointment as Non- Executive Director was in the processing of being finalised; therefore he could contribute to discussions but would not be able to vote, if required. Minutes of the meeting held on 27 th July 2016 Item CCG replaced with Commissioners. Item 13.4 beds added after community. Item 18.7 local adults safeguarding arrangements include providing peer reviews added to paragraph. Item 22.2 Trust added before staff. With these amendments, the minutes of the previous meeting were agreed as a true record of the proceedings. Page 1 of 14

2 Matters arising and review of action points The Board members reviewed the action points and noted the progress update provided ahead of the Board meeting and reflected within the actions register as well as the updates provided at the meeting. Proposal for research funding from the Regional Rehabilitation Charitable Funds: the report was discussed at the Trust s Charitable Funds Committee on 22 nd July The minutes of that meeting were provided at item 18 of the Board meeting. Item closed. Closure of paediatric A&E at Ealing/NHS Choices: although the NHS Choices website pages had been updated, the main page needed to be clearer. Simon Crawford to discuss with the Head of Communications to resolve. Action: Simon Crawford Performance report, RTT: Lee Martin confirmed that each quarter the performance report to Board would include specific detail around specialties, diagnostics and community. Item closed. Dementia data: Dementia training had increased. Dementia patients would be flagged on the Trust s system. The data would be included in the Nursing Workforce Report and presented to the Safeguarding adults group and Integrated Governance Committee. Item closed Charitable Trust Funds: Simon Crawford confirmed that a report of priority items had been submitted to the Charitable Funds Committee. Item closed Central Middlesex Hospital (CMH) LIBOR Basis Swap: Nigel Myhill and Jon Bell confirmed that this item had been discussed at the Finance and Performance Committee and negotiations were underway for the swap. The actions associated with the Board minutes had been actioned and an update would be provided at the next Board meeting. Action: Nigel Myhill Care Quality Commission (CQC) inspection: the actions outlined within the actions log had been addressed. Item closed. Trajectories: Lee Martin confirmed that he had reviewed the performance report and the corporate objectives document and ensured that the trajectories were aligned. Item closed. Nursing Workforce Report: the actions had been addressed and included within the nursing workforce report which had been presented to the Workforce Committee. Item closed. Health and Safety Annual Report: the first draft was scheduled to be submitted to the Health and Safety Committee then to the Executive Team Meeting and Integrated Governance Committee which would have delegated authority from the Board to receive and approve this report. Agreed the report did not need to be presented to the Corporate Quality and Risk Committee so long as it was discussed by the Executive Team. Nigel Myhill would ensure that the report links in with the internal audit report. Item closed. In terms of health and safety engagement throughout the Trust, Claire Gore advised that health and safety was incorporated within the wellbeing pillar of the People s Strategy and measuring the associated risk could be incorporated into the staff survey. Andrew Farrell referred to the lack of risk assessments at corporate and divisional levels as highlighted within the internal audit report and advised that in this context engagement in Page 2 of 14

3 health and safety needs to increase Martin West enquired whether any related issues had been raised via the raising concerns process. Claire Gore advised that nothing specific to health and safety had been raised and would expect such issues to be raised via Datix incident reporting. It was noted that the general maturity of the Trust s overall risk culture was currently low and that a programme was in place which would take time to mature. Item closed Safeguarding Adults at Risk Annual Report 2015/16: Amanda Pye confirmed that discussions in regard to learning disabilities (LD) had commenced at the Adults Safeguarding Board and the Trust now has LD champions in place. Item closed. Smoking cessation: Lee Martin confirmed that he contacted Harrow Clinical Commissioning Group (CCG) who would undertake a survey. Nigel Myhill added that the Smoking Cessation Group had met, the membership of which included CCG representatives. Nigel Myhill confirmed that all the front entrances of the Trust s hospitals would be included in the review. Progress would be monitored by the Corporate Quality and Risk Committee and the smoking policy would also be reviewed. Item closed Diagnostics in UCC: Lee Martin confirmed that he contacted the UCC leads and that currently they are contracted to undertake small diagnostic work but as part of winter planning discussions, the Trust would request the UCC to increase some of their diagnostic work. Item closed Chairman s Report Peter Worthington provided the following summary of his Trust activities since the last Board meeting: Non-Executive Director meetings: - Pre-Board and Pre-Committee meetings Meetings/Events held with Trust stakeholders: - Volunteers Engagement Event - Deloitte Sir Howard Bernstein, the Chief Executive of Manchester City Council speaking on Greater Manchester Devolution - Annual General Meeting Imperial College Healthcare NHS Trust - Ealing CCG Public Engagement Event Sustainability and Transformation Plan for NWL Attended or attending the following: - Integrated Governance Committee - Finance & Performance Board Committee - Board Workshop Strategy, Emergency Care and Capital issues - Appointments & Remuneration Committee - Audit committee Chaired the following Board committees: - Three Consultant Appointment Panels Consultants for Radiology, General Surgery, Oncology Internal meetings: - Chief Executive meetings - Chief Operating Officer - Non-executive directors Page 3 of 14

4 External meetings: - NHS Litigation Authority various meetings with the Authority and its legal advisers - Imperial College, Medical Faculty The Board noted the Chairman s report. Chief Executive s Report Jacqueline Docherty summarised her report of Trust activities since the last Board meeting and advised that the report would be cascaded via divisions and departments. Junior Doctors Industrial Action: the junior doctors strike planned to take place over five consecutive days in mid-september 2016 had been cancelled following concerns around patient safety. Industrial action was planned for October, November and December The Trust has undertaken considerable planning as a result of previous episodes of industrial action. Dementia Strategy launch: on 2 nd September 2016 the Trust launched its new Dementia Strategy. The purpose of the strategy is to provide direction and drive implementation of the service and environmental developments required to achieve the Trust s pledge to become a Dementia friendly organisation. The Trust has also signed up to join John s Campaign whereby carer s of dementia patients at CMH, Ealing Hospital (EH) and Northwick Park Hospital (NPH) are now invited to ask ward staff for a Carer s passport entitling them to visit outside of normal visiting hours and to discuss their individual issues. Seasonal Flu Vaccine: Statistical information was outlined which showed that the uptake of the vaccination by Trust staff last year was only 38.2% and Jacqueline Docherty stressed the importance of staff taking up the vaccination to protect themselves, their patients and colleagues. NHS England s CQUIN guidance for 2016/17 includes a new indicator set at 75% with a financial incentive for the Trust to improve the uptake of flu vaccinations for frontline staff in NHS Trusts. In response to Andrew van Doorn s question, Jacqueline Docherty confirmed that the value of the CQUIN was c. 800,000 and in terms of publicity Claire Gore added that the Trust has a substantial action plan with worthwhile incentives. Flu vaccination sessions would begin to roll out across the Trust from October A session and photo shoot would be arranged for Board members to also receive the vaccination. Professor Taube commented that the uptake was likely to be less due to prevalence of covering a particular strain of flu. Lee Martin made reference to useful information from the Department of Health which he would share with Claire Gore. Action: Lee Martin Patient-led assessment of care environment (PLACE): the PLACE assessments provide a clear message from patients about how the Trust s environment or services might be enhanced. The assessments involve local people coming into hospital as part of teams to assess how the environment supports patient s privacy and dignity, food, cleanliness and general building maintenance. The Trust s PLACE scores for 2016 show an overall improvement against the 2015 scores. Congratulations were extended to Dr Siwan Thomas Gibson, consultant gastroenterologist who was appointed Chair of the Joint Advisory Group on GI Endoscopy (JAG). The Chair provides leadership, direction and strategy for the JAG at Page 4 of 14

5 national level. It is a highly prestigious post and Dr Thomas-Gibson was selected over many senior gastroenterologists in the country Congratulations were extended to Dr Nicki Panoskaltsis, consultant haematologist who was appointed Reader at the Imperial College London. A reader is an academic rank above senior lecturer and below professor, recognising a distinguished record of original research. The advancement reflects Dr Panoskaltsis contribution to the advancement of this field of medicine. A&E Performance: It was noted that week commencing 22 nd August 2016 was an exceptionally good week for the Trust. 75% of all ambulances to NPH and EH were turned around within the target of 15 minutes. NPH which was the busiest hospital for ambulance arrivals in London achieving 89% within 15 minutes and had 13 waits longer than 30 minutes and two longer than 60 minutes. EH had no 60 minute waits during this time. The Emergency Care Improvement Project have signed off the Trust as having achieved the actions required on ambulance turnaround and will continue to provide support on some work at EH. The Board noted the exceptional work being done by the Emergency Department and consultant body as significant progress had been made which is communicated to staff via the Chief Executive s weekly bulletin. Friends and Family Test (FFT) Maternity Services: data for June 2016 published on NHS Choices for the Trust s maternity services shows that the FFT had increased to 98% of respondents likely to recommend the Trust s labour ward/birthing unit to friends and family. Janet Rubin enquired how the Trust was publicising this positive news. Jacqueline Docherty advised that the FFT results are displayed on the Trust s Quality Boards and the Trust was also looking to produce a monthly newsletter to share its news with partners. Developing the Trust s culture and values: Throughout September 2016, Jacqueline Docherty and Claire Gore held open staff forums across the Trust to talk to staff about developing the Trust s organisational culture along with its values and associated behaviours. As part of the People s Strategy, a culture and values framework would be developed with staff involvement to reflect the outcome of the staff forums beginning with an outline of what good looks like. Staff were positively engaged and bespoke sessions would be held for clinical groups of staff. In the coming months more engagement opportunities would be available for staff to make suggestions followed by the chance to vote for the final values with a lunch event in the new year. Janet Rubin enquired how the values would be publicised and how staff would sign up to these. Jacqueline Docherty advised that the values would be publicised using an acronym so that the values can be remembered easily and would be added to all Trust correspondence in an effort for the values to be in the mind-set of staff. NHS Staff Survey 2016: the survey would be launched on 10 th October 2016 and would be open to all staff working for the Trust as at 1 st September Staff will be encouraged to complete the online survey which will close on 2 nd December A survey of all staff or a significant portion of the staff would enable the Trust to gain a richer data source. I want great care widget: the widget is embedded within the homepage of the Trust s website and is a positive step for the Trust to be open and honest as the widget allows Page 5 of 14

6 the Trust to show real time feedback from patients who leave comments about their care at the Trust s hospitals and community services. The reviews from the widget would be linked in with the Trust s FFT and the Trust would learn from negative comments Volunteers Summer Party and Long Service Awards: Jacqueline Docherty attended the Summer Party along with Amanda Pye, Chief Nurse, which included long service awards for 60 volunteers and thanked the volunteers for their hard work and years of dedication. Pride in our Staff Excellence Awards: nominations for the 2017 awards were open and will close on 31 st December NWL Sustainability and Transformation Plan (STP) Update: the Trust continues to work in collaboration with its NHS partners and local government organisations across NWL in the development of the STP. The draft STP submitted on 30 th June 2016 sets out the direction of travel for the NHS and local government to jointly improve health and care for the local people. The draft STP aims to encourage discussion on how services can be improved with public meetings held for engagement. Improving bus connections: Transport for London had launched the new bus route, 483, on 10 th September 2016 providing a direct link between NPH and EH via Wembley and Ealing Broadway. In addition, from 10 th October 2016 the Trust will pilot a shuttle bus for staff providing a transport link across EH, NPH and CMH. The pilot will be for a period of six months to monitor usage and a decision will then be made about whether the service continues. The report outlined the policies which have been ratified during August and September 2016 as well as consultant leavers and joiners. The Board noted the Chief Executive s Report. Medical Revalidation and Annual Organisational Audit Compliance Dr Cayley outlined the Trust s statement of compliance in respect of the framework of quality assurance for responsible officers and revalidation and advised that emphasis was being placed on quality not quantity although the new appraisal system had increased the number of appraisals. It was noted that question 6 of the statement should state yes otherwise Dr Cayley and the Trust s Appraisal lead were satisfied with the statement. It was noted that the hard to engage group were the non-career grades for which a plan was in place whereby senior appraisers were being engaged to address this area. In response to Janet Rubin s question regarding unapproved, incomplete or missed appraisals, Dr Cayley confirmed that these had been addressed and the number was now zero The following comments and actions were noted: Action: Dr Cayley and Claire Gore a) Andrew Farrell enquired what test is applied to ascertain those that have not completed the process. Dr Cayley advised that there are some groups of staff not captured such as those who have moved abroad or passed away and further work was required internally to capture this information on the system. b) Professor Taube enquired about the criteria in relation to temporary or short-term Page 6 of 14

7 contract holders: - Dr Cayley would check the criteria and inform Professor Taube; - Lee Martin added that a process must be in place where locums are made aware of the appraisal requirement which the Trust would undertake; - Janet Rubin requested a breakdown of the numbers associated with temporary or short-term contract holders; - Claire Gore informed the Board that a review of locums had been undertaken and that the Trust should not employ a locum in that capacity for more than 12 months. In response to Peter Worthington s question regarding making such posts substantive, Jacqueline Docherty advised that significant work was underway for Trust grade doctors as part of the Bank and Agency workstream and the Trust was a leader in NWL in this respect and a policy agreed. A model from Leicester hospital would be adopted. A report outlining the approach would be presented to the Patient and Staff Committee. c) In response to Jacqueline Docherty s question regarding revalidation in the event an appraisal has not been conducted, Dr Cayley advised that the rules allow for one deferment after which the registration would be withdrawn unless the GMC felt there was an adequate explanation. Jacqueline Docherty stated that a policy in this respect must be implemented The Trust was being inspected by NHS England and the General Medical Council on 24 th November The Board noted the update and the actions arising from the discussion to be taken forward by Dr Cayley and Claire Gore. Board Assurance Framework (BAF) Following the approval of the Corporate Objectives by the July 2016 Board, the objectives were incorporated into the 2016/17 BAF. The BAF has been updated with the relevant risk scores discussed and reviewed at the September 2016 Executive Team Meeting and then presented to the September 2016 Integrated Governance Committee (IGC). The IGC agreed that the Executive Directors would undertake a comprehensive review of the BAF to ensure as a leadership team, there was consistent agreement on the assurance, mitigations, actions and scoring within the BAF. The ICG also requested that the BAF is cross checked against the Corporate Risk Register to ensure the appropriate risks are reflected in the BAF. Peter Worthington added that the September 2016 IGC also discussed identifying the top 10 strategic risks which Simon Crawford would review and present a report to the IGC in November Andrew van Doorn advised caution as there was a danger of the BAF becoming too detailed and the Risk Register becoming too high level. This was noted. Andrew Farrell felt there that the actions in terms of delivering the objectives were missing from the process. Simon Crawford advised that the BAF and Risk Register would be reviewed together at an Executive session during November 2016 and for the October 2016 Board he would prepare a report regarding the corporate objectives outlining the actions required to deliver these. Action: Simon Crawford Peter Worthington asked the Non-Executive Directors to map the gaps for key risks they felt were missing and to report back to him and Simon Crawford. Action: Non-Executive Directors 9.5. The Board noted the update and the actions to be taken forward. Page 7 of 14

8 Corporate Risk Register The report outlined the Trust s response to the internal audit report and the next steps to improve the report and ensure that the Board is clearly sighted on the top operational risks within the divisions. The divisions will have completed their review by end of quarter 3. The 65 principal risks on the risk register were mapped against the Trust s six corporate objectives for 2016/17. The detailed risk register was presented to the IGC in September 2016 which outlined the new risks added following the internal audit review and noted that further work was underway to ensure all the risks were appropriately scored with mitigation plans. The Executive Team would review the BAF and Risk Register during November as at Item 9. The Board noted the update. Governance Report The reported provided an update on patient safety matters, healthcare associated infections, safety thermometer, completed coroner s inquests and closed clinical claims for July and August It was noted that the clinical governance dashboard referenced within the report would be provided within the next report to Board. The Board noted that the overdue serious incidents are monitored at the weekly serious incident (SI) monitoring meeting and reviewed by the Clinical Quality and Risk Committee as well as the Integrated Governance Committee. The commissioners are kept informed of progress and extensions on deadlines sought as required. Positive feedback had been received from the commissioners in respect of learning from SIs and Root Cause Analysis. In response to Peter Worthington s question, Amanda Pye confirmed that Governance Leads were in place within the divisions. Andrew van Doorn enquired about the categorisation of complaints and triangulating with incidents. Amanda Pye informed the Board that going forward for next year all complaints and action plans would be entered onto the Datix system which triangulate and assist with identifying themes. In terms of type of complaints, themes such as End of Life Care and Dementia were prevalent which were being reviewed. Janet Rubin enquired about the Medical Records leakage incident and whether the leakage issue had been resolved. Nigel Myhill advised that the specific area had been addressed. Andrew Farrell sought assurance in respect of all divisions having action plans and trackers as the report at table 3 showed some divisions not reporting. Amanda Pye advised that the report was still being refined and it would be fully populated as data emerges. Jacqueline Docherty added that an Executive monitoring meeting takes places weekly which is now attended by the divisional leads in respect of their SIs to discuss the granularity of their actions and therefore held to account. Peter Worthington enquired about the process of linking an incident to a legal claim or Coroner s inquest data. Jacqueline Docherty advised that the Trust would wait for the Coroner s report before closing, in order to comply with the Duty of Candour. In the event of a delay from the Coroner s Office, an extension on the deadline for the SI would Page 8 of 14

9 be requested from the commissioners. Martin West commented that the Coroner s report relates to deaths and enquired about cases other than those related to the Coroner s office. Amanda Pye advised that the data and report would be triangulated as the report develops Amanda Pye noted the comments and the following actions: Action: Amanda Pye a) Ruwan Weerasekera questioned whether it was appropriate for the Chair to also be the lead investigator for the incident. Amanda Pye advised that this was an error and would ensure the report is corrected. b) Professor Taube requested to see the closure rate of incidents. c) Claire Gore enquired about feedback to staff after the investigation is concluded as this was raised in staff surveys. Jacqueline Docherty added that divisions need to begin to feedback from SIs and complaints and suggested formally minuting at a divisional meeting might be an option. Amanda Pye advised that the Datix system automatically sends a communication to the originator providing they have an nhs.net , however she would ask the Head of Governance to review the type of comments generated by Datix but this would take some time The Board noted that the Trust was in a better position in terms of capturing and reporting information than previously. The Board noted the update and the actions arising from the discussion. Nursing Workforce Report In line with the recommendations set out in the National Quality Board guidance, How to ensure the right people, with the right skills are in the in place at the right time, the report to Board outlined the Trust s monitoring of patient acuity and dependency, use of the Safer Nursing Care Tool in order to establish the recommended nursing establishment per ward based on patients acuity and dependency. The Board noted phase one of the bi-annual Acuity and Dependency 2016/17 study which did not include specialist areas and would be included in a future review. It was noted that this was the first time Care Hour per Patient Day (CHPPD) data was available and although this information was available, the detail needed to be reviewed before using and taking further action. In response to Professor Taube s question regarding CHPPD, Amanda Pye advised that the purpose of the use of CHPPD was to compare staffing with peers and that a report would be available in due course. Other highlights from the report included the challenges in relation to district nursing service vacancy rate which was a national issue; vacancy rates in maternity services; and temporary staffing across wards and community. These areas are monitored and recruitment campaigns underway. It was noted that the first national upload of data would be during September In terms of the Carter programme, Jon Bell enquired whether the data collection included acuity and type of ward. Amanda Pye advised that only the specialty data was being reviewed at this time. Andrew van Doorn enquired what was driving the increase in nursing agency hours for the emergency speciality and at what point would a decrease be seen. Amanda Pye informed that the nurse specialist can undertake the functions of junior doctors and that Page 9 of 14

10 they are not general nurses. Claire Gore advised that once the recruitment process is streamlined a positive impact would be seen Andrew Farrell commented that judging from the Trust s data, it did not appear to be a major outlier and enquired what the main messages and alerts would be in the Chief Nurse s opinion. Amanda Pye advised that the data captured allows the identification of the issues and the hot spots and that further work was required to triangulate the data with other reports and data sources. The main areas of concern were district nursing staffing issues; 6 south at Ealing due to high turnover; and Frederick Salmon ward due to three MRSA cases. Actions were in place to address each of these areas, specifically in terms of Frederick Salmon Ward the placement of an additional matron has been positive and the teams were reviewing the acuity model for that ward. Professor Taube enquired whether there was a similar unit like Frederick Salmon ward in London that could be visited for learning purposes. Amanda Pye advised there was not and instead tertiary units are in place. The Board commended the report and gratitude extended to Mitchell Fernandez, Lead Nurse for Quality and Clinical Standard, the author of the report. Care Quality Commission Following the previous report to Board, the September 2016 report outlined the progress against the warning notice issued in December 2015 and the regulatory notice received by the Trust along with the inspection report in June In terms of ensuring appropriate staffing competency out of hours in radiology a re-audit has been completed of on-call SpR reports which was positive and would be presented to the Clinical Excellence Committee. Jacqueline Docherty enquired about the longer term plan. Lee Martin advised that interviews for radiologist had been scheduled and also added that the national error rate for radiology is 10% and that the Trust s rate is 5%. Amanda Pye advised that a re-inspection usually takes place within a year after the publication of the report. The Board noted the progress report. Update on Sustainability and Transformation Plan The draft North West London Sustainability and Transformation Plan (STP) was submitted to NHS England on 30 th June Detailed feedback was received following a review of the plan with NHS Chief Executive Simon Stevens on 14 th September Final submission is due on 21st October A wide range of collaborative activity was underway across the sector. An example of divisional involvement in the implementation of early STP activities was presented at the Board workshop on 19 th September A series of borough-based public meetings were being co-hosted by NHS organisations and local councils during September 2016 to engage with residents and service users about the STP. Simon Crawford confirmed that the Trust has had representation at all the meetings. System-wide change was being driven through five workstreams which align opportunities across NWL acute providers as agreed with the CEO group, namely: last phase of life; pan-nwl procurement; Orthopaedics; bank and agency; and patient flow. Page 10 of 14

11 Jon Bell informed the Board that a sixth workstream was being developed to review the potential of further savings from corporate functions and pathology contracts as required by the recent NHS Improvement letter to Trusts Five priority areas were agreed by partners in Brent under the banner of the STP. Initial scopes of work were due to be presented to the Brent Health and Wellbeing Board on 6 th October The Trust has been asked to take the lead role on Recognising the significant impact we could have by working together in a OnePublic estate model with Central Middlesex Hospital a priority. In addition the Trust is supporting the review of services to focus on the vulnerable population of older people. This work is being led by the Divisional General Manager for Integrated Medicine. The report references potential plans by the inner NWL CCGs for the introduction of Accountable Care Partnerships (ACP) as part of the NWL STP to enable increasing integration and enabling faster system change. 2017/18 would be used to prepare for a smooth transition to a formal ACP beginning in April In terms of the Trust s integrated care programme, work was progressing to develop the vision and outline plan to achieve the ambition which is closely aligned to the priorities of the NWL STP. The financial details of the STP were yet to be published. The programme costs of the provider productivity work streams are being finalised and will be split between participating organisations. This is expected to be fully mitigated by the saving opportunities arising from cross-sector collaboration. The STP is likely to increase pressure to redirect funding flows from healthcare to social and local authority spending and from acute to primary care. The financial impact of the shift to ACP models of provision have yet to be quantified. Martin West commented that if the savings are accounted for elsewhere and the Trust only gains cost then this may become a loss in income. Simon Crawford advised that the investment is only for the provider collaboration. Martin West acknowledged this but suggested this may become an unbudgeted variant. Jon Bell added that the planning for next year s discussions include the possibility of moving control totals amongst the providers. Andrew van Doorn supported the development of the integrated care organisation and suggested a Board workshop in 2017 to full understand the implications for the Trust. In terms of the STP governance, Andrew Farrell recalled being interviewed as part of the SaHF review process but stated he had not seen the outcome of the review. Simon Crawford would follow up and report back to Board. Action: Simon Crawford The Board noted the update. Integrated Performance, Quality and Finance Report Lee Martin outlined the performance and quality report for September 2016 which had been discussed in detail at the Trust s Finance and Performance Committee a few days prior to the Board. For future reports a summary indicator sheet would be included instead of the full accounting framework dashboard. A&E: the Trust achieved the August 2016 STP Trajectory. Performance was 91.67%. Continued improvement and redesign was underway to provide sustainability for the emergency care pathway. Winter planning was underway and an update would be provided in the next report to Board. LAS performance was referenced within the CEO s Page 11 of 14

12 report to Board Cancer: in July 2016, the Trust achieved six out of the eight national standards. Performance for the 62-Day Treatment standard was 73.9% but did exceed the STP Trajectory. Key areas of focus are implementing timed pathways across all sites and all tumour streams. 18 Weeks Referral to Treatment: for the end of August 2016, the Trust delivered 91.04% which was within the acceptable 1% tolerance of the agreed trajectory. Further work is underway to sustain performance. Six Week Diagnostics Standard: for the end of August 2016, performance was 99.6% which meets both the national standard and the STP Trajectory. Significant work is underway across NWL to review the capacity and demand for diagnostic procedures. A consolidated plan and steering group has been established to progress and longer term plan for diagnostic capacity. Infection Control: In August 2016, there were 2 cases of Clostridium Difficile which is below the acceptable tolerance of 3. There were 2 MSSA cases and 3 E. coli blood stream infections which are both within acceptable levels. However, there were a further 2 cases of MRSAb. Never Events: in August, there were no never events reported. Harm Free Care: in August, 94.8% patients received harm free care. The percentage of new harms was 1.5%, well below the threshold of 2.4%. Eliminating Mixed Sex Accommodation (EMSA): in month there were no unacceptable breaches. Mortality: SHMI levels are reported through HSCIC as within as expected range based on national benchmarking Friends and Family Test: the Trust is performing to all standards as reported by patients apart from Maternity. There was however a low response rate in August 2016 in this area. The Staff Friends and Family Test as reported in Quarter 1 was below expectation with 70% of staff recommending care and 22% of staff who would not recommend care at this Trust. Dementia: reported an additional month in arrears, the Trust achieved all three standards. In terms of the outliers relating to operational efficiency (inpatients), Martin West enquired about the decline in outliers at NPH and CMH and increase at EH. Lee Martin advised that a review of EU practices have a positive impact on admissions. Professor Taube stated he was surprised with the re-admission rate. Lee Martin advised that patients were being asked to return directly rather than via GP referral which was being inaccurately coded as a re-admission therefore incorrect coding and data calculations could have been attributable. The detail of this and mortality was being reviewed and would be discussed with the commissioners. Andrew van Doorn commented that complaints performance was adverse against the threshold however it was positive that people were highlighting issues to enable learning. Jacqueline Docherty noted the comment and advised that the Trust s ambition was to become an exemplar organisation with little need to complain. Amanda Pye added that the PALS data needed to be included and this would impact the complaints performance Page 12 of 14

13 statistics. Professor Taube enquired about the VTE rates on the safety thermometer and whether the increase in July 2016 was an exception. Amanda Pye advised that an analysis of community VTE had been undertaken and would be included in the safety thermometer report. The information presented was a snap shot of one day. Dr Cayley added that the target had not been met for three months and one ward was not submitting the data which had been rectified. This was being monitored more robustly. Andrew Farrell suggested that the Clinical Excellence Committee should review the still birth rate which was adverse against the threshold. Action: Lee Martin Andrew van Doorn commented that winter pressures could be critical and enquired how the Trust was planning in this respect. Lee Martin assured Andrew van Doorn that planning was underway and an update would be included in his next report to Board. Action: Lee Martin Finance Report The report outlines the organisation s financial performance to the end of July 2016 (month 4), a year to date deficit of 26.5m, 0.3m behind plan. The shortfall is as a result of the failure to hit some of the access performance trajectories linked to receipt of the Sustainability and Transformation Fund. CIP delivery to date is 12m, 0.1m better than plan. However the Clinical Administration CIP was at risk. The Improvement Director was confident that there were a number of opportunities to explore in order to close or reduce the gap. The forecast outturn for the year is in line with plan, a deficit of 61.5m. Capital expenditure to date is 4.7m, 6.3m behind plan. Better Payment Practice Code was improving and the Trust was on track to implement the Financial Process Management System during October Jon Bell advised that at a national meeting of Trust Chief Financial Officers it was made clear that there was intense scrutiny of control totals and any movement from forecasts. LNWHT has been placed in band 3 which was not in the special measures category. Jon Bell advised that CIP delivery was key and other areas of focus included commissioner challenge in terms of reconciliation of quarter 1; allowances for winter pressures; impact of the junior doctors contract allowance; and ITU business case for which a response from the commissioners was awaited. In respect of the Service Line Reporting (SLR), Jon Bell advised that a new process to drill into the cost of a patient s care was being implemented and currently his team were uploading 2015/16 data and would do the same for 2016/17. The information would be provided on a monthly basis and a bespoke session would be arranged for the Finance and Performance Committee and Board to outline the system and benefits of the data. The SLR data would identify data quality issues, assist with CIPs for the following year and identification of unsustainable services. The Board noted the update. 16. Approved Board Committee Minutes Page 13 of 14

14 The Clinical Excellence Committee minutes of the meetings held on 17 th June and 15 th July 2016 were noted. The Finance and Performance Committee minutes of the meeting held on 25 th July 2016 were noted. The Patient and Staff Committee minutes of the meeting held on 18 th July 2016 were noted. The Charitable Funds Committee minutes of the meetings held on 6 th May and 22 nd July 2016 were noted. AOB No other business reported. Questions from the Public The public member informed the Board that the Harrow CCG public meeting would be held on 13 th October 2016 which would include the commissioners two year commissioning intentions as well as discussion on the STP. 19. Date and time of next meeting Wednesday, 26 th October 2016, 9.15am to 12pm, Northwick Park Hospital Approved as a true and correct record. Signed Peter Worthington, Chairman Date: Page 14 of 14