Balanced Score Card Report Review of January 2018 Data

Transcription

1 Balanced Score Card Report Review of January 2018 Data

2 Balanced Scorecard Patient Access Quality & Safety Patient and Service User Human Resource Management Finance

3 Patient Access Emergency Department

4 6 Hr January

5 2017/ Day Moving Average 5

6 AMAU Activity AMAU Referrals January Admitted Patients Emergency Department General Practitioner Planned Repeat Admissions 13 Outpatients Department 5 Other Referrals

7 Non Admit PET January Comparison Annual Non Admit PET % 70% 60% 50% 40% 30% 62% 71% 73% 77% 74% 20% 10% 0%

8 >24 Hour PET PET >24hrs Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18

9 >75yrs Bed Wait >9hrs >75yrs Bed Wait >9 hrs (2017) Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18

10 Full Year Non Admit PET 80% 70% 60% 50% 40% 67% 71% 73% 79% 30% 20% 10% 0%

11 Targeted >14 Day Occupancy >14 Day Patients and >14 Day Occupancy /09/ /10/ /11/ /12/ /01/ /02/ /03/ Bed Days Patients

12 January Review 607 patients on trolleys compared with 719 in January 2017 (17% reduction) Decrease in Gen Medical Bed Stock Infection Control Measures were challenging 2 strains of flu and Norovirus Visiting restrictions difficult Only one day of surge of orthopaedic trauma

13 Project Flow Improving Patient s Hospital Experience Project Flow 2018

14 PF 18 Objectives Input Throughput Egress PET across acute floor non admit 95% overall 70-75% >75 years conversion rate 100% PDD documentation SAFER implementation Red to Green concept Bi-directional flow >14 days - >7days 14 day occupancy

15 PF18 Priorities Implementation of SAFER bundle: Senior review before 11am for all patients All patients must have PDDs Flow from assessment units to wards early Early discharges before 11am Review patients with extended lengths of stay Red2Green Increase communication to all staff

16 PF18 Priorities contd... Bidirectional flow with Mallow protocol Audit weekend discharge process Enhance links with community services re: LTC, transitional care, home care packages Continue PDD audits National Patient Experience Survey = enhance discharge information provided to patients

17 Patient Access - Outpatient Waiting Lists

18 Total Medical Patients to be seen by 15 Month Target (176) (14/02/2018)

19 Total Surgical Patients to be seen by 15 Month Target (3361) (14/02/2018)

20 Patients Currently Waiting Longer Than 12 Months (5081) (14/02/2018)

21 Ophthalmology Waiting List Validation 9253 patients - Summarised below Ophthalmology Return Waiting list validation Consultant E.O. G.O.Connor Connell S.Fenton A.Cullinane Z.Idrees Total Letters sent out Yes to Stay on w/l Pt request removal RIP No response to validation but attended TCI Query for service 1 1 Return Post, Trying to contact patient 0 Also attending Diabetic Screening -? Potential removals Hospital Removed Incorrect w/l entry Removed through no response to validation No response to date 26/02/2018, Still on w/l due to DNA,TCI Total Total removed through No response to validation 942 Total Re-instated after removal through No response 82

22 Patient Access - Inpatient Waiting List

23 Inpatient and Day Case Waiting List (23/02/2018) Count of IDWait category wl type ACTIVE PREADMIT SUSPENSION Grand Total Adult Child GI Scope Grand Tota

24 Patients waiting > 15 months 285 (17/01/2018)

25 Endoscopy Activity (Source: NQAIS) AAU Emergency Elective Total * (Jan-Nov Inc.)

26 Quality & Safety

27 Clostridium Difficile G 27

28 S. Aureus bloodstream infection G 28

29 NEWS Full Implementation G 29

30 ALOS All Inpatients November 2017 R

31 ALOS Excluding LOS over 30 Days R 31

32 ALOS Medicine November 2017 R

33 ALOS Surgery November 2017 R 33

34 HIPE Coverage November - % of cases entered into HIPE(A38) G

35 % of people waiting less than 13 weeks ( 13 weeks) for a routine colonoscopy G 35

36 Routine Colonoscopy December 2017 R 36

37 % day case rate for Elective Laparoscopic Cholecystectomy December 2018 (mean Jan Nov) 37

38 Cancer KPI Breast-Lung-Prostate October 2017 January 2018

39 Rapid Access Clinic Review Symptomatic Breast Service Review the current pathway for this patient group to be progressed by the NCCP Test messaging service to send outpatient appointment reminders to patients to be discussed with ICT The requirement for an additional Consultant for the Breast Reconstruction service Audit of the input from the GP sessions to be completed Prostate Service Requirement for additional Registrar to facilitate return patient clinics Additional access for MRI Scans, Bone Scans and CT Staging Scans. Access to Robotics which would provide many benefits in relation to patient treatment options

40 Thoracic Lung Service Rapid Access Clinic Review The SSWHG have funded an additional 5 CT slots for RALC to allow all patient to have their CT prior to first clinic visit CNS and consultant conduct a virtual nodule clinic and patients are either issued a clinic appointment or discharged over the phone by the CNS From February 2018 the RALC will change from Monday to Friday to allow for increased capacity Work has taken place to streamline the Cardio Thoracic MDM and it is anticipated that the MDM component of MOCIS will help further by allowing the meeting to be recorded electronically The ANP post funded by the NCCP is currently being progressed

41 Radiotherapy Patients In/Out of Target - January 2018 OUT OF TARGET, 60, 67% IN TARGET, 30, 33%

42 Consultants In/Out of Target January Dr Faisal Jamaluddin (Locum RO) Dr. Aileen Flavin (RO) Dr. Bolanle Ofi (Locum RO) Dr. Carol McGibney (RO) Dr. Frederik Vernimmen (RO) Dr. Paul Kelly (RO) Total InTarget Out of Target

43 Reasons for Out of Target January Personal choice Medical Capacity Data Missing Other Total

44 Chemotherapy Patients In/Out of Target January 2017 Outside Target, 4, 9% In Target, 39, 91% 44

45 Consultants In/Out of Target January Dr Deirdre Dr Dearbhaile Dr Derek Dr Derville Dr Oonagh Dr Richard Prof Seamus O'Mahony Collins Power O'Shea Gilligan Bambury O'Reilly TOTAL InTarget Out of Target

46 Reasons for Out of Target January Personal Medicial Capacity Data Other Missing Total

47 Risk Management January KPI data Serious Reportable Events reported CUH 4 communicated in January which occurred in previous months (1 in July, 1 in August, 1 in November, 1 in December) 5 SRE s occurred in January (currently being submitted) Medication Safety Incidents reported - 20 Complaints 10 complaints raised in July with 10% closed within 30 day timeframe New claims notified to hospital 78 Risk Register Risk Register no new risks added

48 CPE Screening Current CUH CPE Screening protocol: All patients on admission to ICU/CITU and NICU and weekly thereafter All patients on admission to the haematology unit 2D and weekly thereafter All patients epidemiologically linked to a CPE carrier all patients admitted from another hospital with a current CPE problem. All international transfers/admissions (inc NI) As directed by the Infection Prevention and Control Team

49 Falls Prevention Trial of Falls Prevention non-slip socks on Ward 1A will finish at the end of January Trial to be done on Medical Short Stay Ward Ward 4C have been using the safety cross for 1 year and have seen a 15% reduction in falls. Falls Prevention group currently appraising different falls risk assessments and will be updating the CUH falls policy.

50 Rate of Falls per 1,000 Bed Days 50

51

52 Spread Across the CUH Campus 52

53 Rate of Pressure Ulcers reported per 1,000 bed days Jan Dec

54 Human Resource Management

55 WTE s CUH Sick Leave 2016 v CHANGE CUH Total % Sick Leave 2016 v 2017 % Jan Feb Mar April May June July August Sept Oct Nov Dec 2016% 2017% % Target Aug Sep-16 CUH Long Term Sick Leave WTE s May-17 Apr-17 Mar-17 Feb-17 Jan-17 Dec-16 Nov-16 Oct Aug-17 Jul-17 Jun-17

56 EWTD Compliance January - December 2017

57 Finance

58 Finance Report January 2018 CUH /CUMH Actual outturn FY 2017 PAY & NONPAY Gross pay & non pay budget 363.1m (2016 : 352.9m) Actual pay & non pay 371.3m (2016: 355m) Actual Deficit 8.2m (-2.3%) o Less Adjustments 3.8m o Bad debts provision 3.19m o PCRS Drugs 626k Adjusted Deficit 4.4m (-1.2%) ((2016 : 2.1m/-0.6%) Income Income budget 77.7m (2016 : 80.5m) Actual Income 76.0m (2016 : 79.9m) Actual Deficit 1.7m (-2.2%) (2016 : 0.6m/-0.7%) 58

59 Finance Report- January

60 Finance Report -January 2018 Actual outturn Jan 2018 PAY & NONPAY (pre CUMH transfer) Gross pay & non pay budget 31.5m (2016 : 28.8m) Actual pay & non pay 33.1m (2016: 29.1m) Actual Deficit 1.6m (-4.9%) (2016 : 330k/-1.1%) PAY & NONPAY (excl CUMH ) Gross pay & non pay budget 28.1m Actual pay & non pay 29.7m Actual Deficit 1.6m (-5.6%) - Less adjustments Bad debts provision 0.9m - PCRS 45k Adjusted Deficit 0.6m (-2.2%) DIRECT PAY & NONPAY CUMH Gross Direct pay & non pay budget 3.44m Actual direct pay & non pay 3.43m Actual Surplus 13k (0.4%) 60

61 CUH Pay & Non pay Budget Surplus/(Deficit) %

62 CUH AGENCY WTE Jul-14 Sep-14 Dec-14 Jan-15 Jun-15 Sep-15 Dec-15 Jun-16 Sep16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Radiotherapist Radiographer Labs Cardiac Techs Physio Pharmacy Admin Nursing HCA House-Keeping Physics Catering Social Work Occ Therapy Dietician Medical Consult NCHD

63 CUH AGENCY COSTS k

64 Acute Nursing Agency WTE 2016 to 2018 Acute HCA Agency WTE 2016 to

65 CUH Average Nursing & HCA Agency WTE s per Week CUH Average Specials /Other Nursing & HCA Agency WTE s per Week

66 CUH Nonpay-Budget v Actual Jan 2018 NON-PAY Budget Actual Variance C U M H A c t C U H / C U M H A c t 2017 Act Medicines 2,688 2,722 -(34) 6 2,727 2,494 Medical & Surgical 2,323 2,420 -(98) 238 2,658 2,474 Blood (22) Medical Gases (3) Medical equipment (150) Radiology (76) Provisions (13) Catering Cleaning/Waste (16) Laundry (0) Energy Bedding/ clothing (16) Furniture (7) Pathology (48) Maintenance /Grounds (7) Transport /staff travel (20) Office expenses (23) Telecommunications (1) Computer Administrative expenses 506 1,491 -(985) 87 1, Staff recruitment/training (37) Miscellaneous (53) TOTAL NON-PAY 9,220 10,820 -(1,600) ,382 9,588 Less Bad debts NON-PAY excl Bad Debts 9,121 9,830 -(709) ,391 9,498 66

67 CUH /CUMH Actual Non-pay expenditure k Jan 2018 v 2017

68 Patient Income

69 CUH Patient Income Budget Surplus/Deficit % 69

70 C U H Ot her Inco me Jan Inco me B ud g et k A ct ual k V ariance k R ent al inco me & Licence f ees B eq uest s/ D o nat io ns 13 - ( 13 ) R esearch g rant s C arp ark D rug reb at es / PC R S Insurance claims / M isc 4 - ( 4 ) 1, , C U H R eco up ment s and R ef und s Jan Inco me B ud g et k A ct ual k V ariance k R eco up ment s Pay ( 0 ) R ef und s- Pay 15 - ( 15) R ef und s- Ot her ( 19 ) Po st ag e reb at e U nclassif ied ( 2 )

71 CUH Debtor Days Consultant Claims

72 MGH - Finance Report January 2018

73 Finance Report January

74 BGH - Finance Report January 2018

75 BGH - Finance Report January

76 Paediatric Unit Project Capital Projects Status Phase 1 - build programme completed Phase 2 funding received proceed to Design Stage Radiation Oncology Unit Builder commenced on site on Monday 20 th February Education and Training Centre Blood Sciences Project Draft Statement of Need completed and discussion ongoing with UCC Meeting held with UCC Design Team appointed Infrastructural works are near completion 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 OPD & Day Care Tender documents ready to issue in January 18 Theatre Accommodation tender documents being prepared for early 18 Helipad Meeting held with the IAA Ground Level Helipad the agreed option