Annual report and accounts 2016/17

Transcription

1 Annual report and accounts 2016/17 University College Hospital National Hospital for Neurology and Neurosurgery Eastman Dental Hospital Royal National Throat, Nose and Ear Hospital Royal London Hospital for Integrated Medicine

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3 University College London Hospitals NHS Foundation Trust Annual Report and Accounts 2016/17 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 Annual Report and Accounts 2016/2017 3

4 2017 University College London Hospitals NHS Foundation Trust

5 Contents 1 Performance report Overview of performance Performance analysis Accounting officer approval 32 2 Accountability Report Directors Report Remuneration Report Staff Report Code of Governance disclosures Single Oversight Framework Statement of accounting officer s responsibilities Annual governance statement Accounting Officer approval 78 3 Quality Report 80 4 Annual Accounts (including Auditor s Report and Certificate) 156 Annual Report and Accounts 2016/2017 5

6 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) 1 Performance Report 1.1 Overview of performance The purpose of the performance report is to provide an overview of our organisation, its purpose, the key risks to achieving our objectives and our performance in the year Chairman and Chief Executive s overview Welcome to our 2016/17 Annual Report. We are all acutely aware that the NHS is facing a period of unprecedented demand on its services, amid rising public expectations. This is against a backdrop of a tough climate for public spending. But, despite this challenging context, UCLH continues to perform well and provide high quality care to its patients. We were delighted that the Care Quality Commission (CQC) rated us as Good in its inspection report published in August Inspectors praised the compassion, dignity and respect shown by our staff and the innovative environment at UCLH. We are also proud that our mortality rates are the second lowest in the country. We provide care to more than one million patients a year and, in the vast majority of cases, our patients are happy with the care they receive. In the 2016 Picker Institute inpatient survey, 89 per cent of respondents rated their overall experience at UCLH as seven out of ten or higher; this puts us among the best performers of our peers. Overall, feedback from our staff is also positive with UCLH sitting in the top 20 per cent of acute trusts for staff engagement, a measure closely linked to patient experience. We continue to make great strides in the areas of education and research which are integral to our vision. The number and size of research grants awarded to UCLH and our academic partner UCL in the past year are testament to the quality and breadth of work being undertaken by us. Most significantly, the National Institute for Health Research (NIHR) awarded 111.5m to our Biomedical Research Centre (BRC) to expand its ground-breaking work. This represented an increase of 13 per cent on the 98m awarded in Smarter and bolder use of information technology will be vital to our future success as an organisation. There have been a number of significant ICT developments this year as part of our transformation programme, uclh future. For example, our plans to become a paperless hospital by 2020 took a big step forward when the Board approved a business case for a single, integrated electronic health record system (EHRS), subject to external funding. The Board also approved a digitally-enabled coordination centre programme. This will provide staff with the technology and processes they need to better manage patient admissions, their flow through theatres and departments, discharges and transfers, allowing us to make the best use of our capacity. It will also tell us the location of equipment so that we can provide our patients with the best possible care. We are looking forward to seeing these and other projects progress in 2017/18. We finished this financial year on target, delivering a 2016/17 reported surplus of 34.8m ( 45.8m ahead of plan), while protecting frontline services. This was partly due to one-off sales of some of our assets, but also due to our staff who faced the challenges head-on. It is important to note that the underlying financial position, excluding exceptional items such as asset sales and one-off sustainability funding from NHS Improvement was a 5.8m deficit. We know, however, that there are a number of areas in which we need to improve. For example, we have been unable to meet the target to treat all cancer patients within 62 days of referral. We need to work more closely with referring trusts and their commissioners so patients receive their treatment more quickly. Along with most other trusts we have struggled to meet the national four-hour accident and emergency waiting target, although we have performed better than average in London and nationally. CQC inspectors also identified a number of areas for improvement in our emergency department (see section A&E four-hour wait and the Quality Report section 3.2). We have embarked on an action plan to address the recommendations made by the inspection team, and work is well under way 6 University College London Hospitals NHS Foundation Trust

7 on a 21.7m redevelopment of the department to accommodate better the needs of our patients and staff. Next year will be much tougher for the NHS and we are not immune to the challenges being experienced by the wider system. This year our cost saving target was 36.5m and we achieved 39.1m. However next year we will need to deliver a 10m surplus which will require us to make 42m of cost savings. This is an extremely challenging target and will require a huge commitment from all our staff to ensure that we meet it. NHS England s report, Next Steps on the NHS Five Year Forward View, published in March 2017, gives a clear indication of the wider challenges and priorities ahead. We will continue to work closely with our colleagues in health and social care across North Central London (NCL) to provide better care to our communities through our Sustainability and Transformation Plan (STP). Our role in the national Cancer Vanguard means we are in a strong position to deliver on the Next Steps ambition to improve cancer survival rates through better prevention, early diagnosis and innovative treatments. Our previous Chief Executive, Sir Robert Naylor, retired from UCLH on 30 September 2016 after 16 years in post. We would like to pay tribute to his fantastic contribution in so many ways to the success of UCLH and to wish him well with his future plans. Finally, it is of course only through the energy, dedication and sheer professionalism of our staff that the successes we describe in this report have been achieved. This is all the more remarkable given the pressure under which they have to operate in today s NHS. We would like to thank them profoundly for all that they have done and continue to do for UCLH and its patients. 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Richard Murley Chairman Professor Marcel Levi Chief Executive Annual Report and Accounts 2016/2017 7

8 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) About UCLH University College London Hospitals NHS Foundation Trust (UCLH) is situated in the heart of London. Our vision is to deliver top-quality patient care, excellent education and world-class research. Our values of safety, kindness, teamwork and improving are at the heart of everything we do, both for our patients and for our staff. UCLH delivers clinical services from five hospital sites: 1. University College Hospital, including: University College Hospital University College Hospital at Westmoreland Street Macmillan Cancer Centre Elizabeth Garrett Anderson Wing Hospital for Tropical Diseases Institute of Sport, Exercise and Health 2. The NHNN, including the National Hospital for Neurology and Neurosurgery at Cleveland Street 3. Eastman Dental Hospital 4. Royal National Throat, Nose and Ear Hospital 5. Royal London Hospital for Integrated Medicine We became one of the first foundation trusts in Giving staff, patients and members of the local community a greater say in how their hospitals are run has been the driving force behind the creation of NHS foundation trusts. As a foundation trust we remain firmly part of the NHS but we manage our own budgets and shape the services we provide to better reflect the needs and priorities of our local community. Through our Council of Governors we are able to listen to the views of patients, local people, staff and partners and by doing so, offer patients faster, better and more responsive healthcare. We provide academically linked acute and specialist services, both to the local population and to patients from across England and Wales. We balance the provision of nationally recognised specialist services with delivering high-quality acute services to our local populations. UCLH is working with clinical commissioning groups, local authorities and NHS providers in Camden, Islington, Haringey, Barnet and Enfield to develop a five year North Central London (NCL) Sustainability and Transformation Plan (STP). We are proud of our close partnership with UCL (University College London) which is consistently reported as one of the best performing universities in the world. UCL s facilities are embedded across much of our hospital campus and the partnership is linked through a large number of joint clinical and academic appointments. We are one of England s 11 Biomedical Research Centres (BRC) and we are a founding partner of UCLPartners, one of the UK s first academic health science centres. We have a turnover of 1,043m and contracts with 106 commissioning bodies. We care for more than one million patients a year and employ more than 8,100 staff across all of our hospital sites, either on a full or part-time basis. 8 University College London Hospitals NHS Foundation Trust

9 1.1.3 Highlights of 2016/17 Farewell to Sir Robert The 30 September marked the final day for Sir Robert Naylor as our Chief Executive after 16 years at the helm. Sir Robert joined UCLH in November 2000 when the contract for the new hospital had been signed and during his tenure he became one of the most admired chief executives in the NHS. Upon his departure, Sir Robert paid tribute to staff: I would like to thank the thousands of staff who have made my time here so memorable. I applaud the commitment, skill and compassion you have shown which has made UCLH such an outstanding success I am enormously proud of our staff for their tireless efforts to be the best that we can be for our patients. Neil Griffiths, Deputy Chief Executive, became interim Chief Executive for three months until the arrival of Sir Robert s permanent successor. Welcome to Professor Marcel Levi Professor Marcel Levi took up his appointment as the new Chief Executive of UCLH on 3 January. Professor Levi who has had a distinguished career as a clinician, academic and clinical leader in the Netherlands joined us from the University of Amsterdam where he was Chairman of the Executive Board of the Academic Medical Center since On his arrival at UCLH, he hosted a series of open forum sessions on all sites to meet colleagues of various disciplines and to answer their questions. The events attracted more than 700 staff. CQC reports that we treat our patients with compassion, dignity and respect UCLH was rated Good by the Care Quality Commission in its inspection report published in August CQC inspectors found that UCLH staff treated and cared for patients with compassion, dignity and respect. The report also praised the innovative environment at UCLH. Lead inspector Professor Ted Baker said: Throughout UCLH we saw areas of outstanding practice. We found all staff to be dedicated, caring and supportive of each other and we found patient feedback to be overwhelmingly positive. While our overall rating was Good, five areas were found to require improvement; three in urgent and emergency services, and two in medical care. We have put measures in place to address these findings (see Quality Report section 3.2). Working with our local partners During 2016/17, UCLH progressed a number of important partnerships to ensure patients receive the best possible care: With commissioners, providers and councils in North Central London (NCL), we helped develop a Sustainability and Transformation Plan (STP) to deliver high quality care to our local communities while living within our financial means. We signed a memorandum of understanding (MoU) with Whittington Health to provide a formal structure for how we work together to improve various acute services for our local population. UCLH is part of the NCL maternity network. During 2016, the network began working with the national programme, Better Births, to improve maternity care. UCLH was awarded the contract to provide a new Camden Integrated Musculoskeletal (MSK) Service. Investing in our digital future There have been three significant ICT developments in 2016/17 as part of our transformation programme, uclh future: The Board has approved a full business case for Epic to provide an electronic health record system (EHRS), subject to external funding. The system will support better patient care and staff experience. We have agreed a 10-year partnership with Atos which will improve our IT infrastructure and services. We signed a contract to develop a digitallyenabled coordination centre programme which will improve patient flow and care at our hospitals. For further information see section Important events affecting our organisation. Annual Report and Accounts 2016/ PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE)

10 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Transforming emergency care Building work to expand our emergency department at University College Hospital is moving forward as part of a 21.7m programme to redevelop and improve the facility, while continuing to provide care to patients. More than 138,000 people come to the emergency department last year. The existing emergency department and clinical decision unit have been improved and a new emergency day unit has been developed. See section Patient care activities for more details about changes to our emergency department. Building work started on our new clinical facility Building work for a 104m clinical facility for services currently provided at the Royal National Throat Nose and Ear Hospital (RNTNEH) and Eastman Dental Hospital started in December Among the guests at the ceremony to mark the start of works in Huntley Street were patients from both hospitals. They included RNTNEH patient and music journalist Nick Coleman who lost his hearing overnight. Mr Coleman, a patient for 10 years, said: I love the people who looked after me. They saved my life. They helped make it worth living. Staff helped him to understand and cope with his complex clinical problems. The facility is expected to open in Proton Beam Therapy one step closer groundwork continues Our new eleven-storey building will be home to one of only two NHS proton beam therapy (PBT) centres in the UK offering an advanced form of radiotherapy for the treatment of complex and hard-to-treat cancers in children and adults. During 2016 a diaphragm wall was constructed around the perimeter of the site, enabling one of London s biggest and most ambitious excavations to start. Eighty thousand cubic metres of earth will be removed. Once the excavation is completed in the summer of 2017, construction of the basement levels will begin. The new clinical centre which has a revised opening date of late summer 2020 will also include facilities for the treatment of blood disorders and short stay surgery. The national Cancer Vanguard is a partnership between the UCLH Cancer Collaborative, Greater Manchester Cancer Vanguard Innovation and Royal Marsden Partners and together we serve a population of more than 10 million. The renewed funding from NHS England will enable us to continue to invest in improving cancer care for our communities and to replicate our work across the country. The following investment in UCLH s cancer services was also announced in 2016/17: NHS England funding for a new linear accelerator to replace a machine that had been in service for ten years Cancer Alliance funding from NHS England s Cancer Policy Programme to provide tailored care to support people to live healthily during and after cancer treatment. New wards, new operating theatres for neurological patients The new John Young Ward has opened at the National Hospital for Neurology and Neurosurgery as part of a wider redevelopment to provide new operating theatres, 22 extra beds, better staff facilities and refurbished neurosurgical theatres by the end of By May 2017, two new theatres and two new wards are due to open. New pain management centre The new National Hospital for Neurology and Neurosurgery at Cleveland Street is now home to the UCLH pain management centre and the integrated pain management service and provides outpatient care for patients with multiple sclerosis and prion disease. It opened on the site of the former Middlesex Hospital. Christmas event This year our popular festive event in December focused on the work of our charities and the services they support. Our VIP guest Lorraine Kelly, a popular TV presenter and supporter of the NHS, switched on our tree lights. The event attracted hundreds of visitors. Investment in cancer services In 2016/17, NHS England announced 6.9m of renewed funding to support and spread the work of the national Cancer Vanguard. 10 University College London Hospitals NHS Foundation Trust

11 1.1.4 Education and training Delivering excellent education is integral to our mission as an organisation and one of our strategic objectives is to support the development of our staff to deliver their potential. UCLH provides postgraduate training to around 700 doctors and dentists over the course of each year. We also provide placements for more than 400 undergraduate medical students annually. We train around 480 student nurses and midwives, as well as allied health professionals on placements each year and aim to recruit as many of them as possible once they have completed their training. The uclh Institute, established as part of our transformation programme uclh future, oversees most of our education and training. This following section outlines some of the key developments in the past year. Induction In 2016/17, 2,028 staff attended our newly designed corporate induction with a focus on improvement and patient safety. Our Improvement Team presents a one hour interactive session A promise to learn, a commitment to improve. The session highlights UCLH s approach to quality improvement and introduces our ethos of learning to new starters. Mandatory training Some 92 per cent of our staff completed mandatory training, one of the highest rates in London, after we created a new dashboard showing real-time information and established a system of automated reminders. Appraisals The highest ever number of UCLH staff had an appraisal (96.4 per cent). Appraisals have been redesigned to initiate meaningful dialogue and support coaching-style discussions. Coaching and mentoring We launched a coaching and mentoring service available to all staff. It includes a programme to nurture our clinical leaders of the future new consultants are supported to transition into the role and to develop their leadership and managerial skills. wider NHS benefited from excellent clinical training facilities at our Education Centre and Learning Hospital, built to replicate a patient s journey from pre-assessment to discharge. It includes a simulation operating theatre, a two-bedded ward, an intensive therapy unit and four clinical skills rooms. It also includes The Chitra Sethia Centre, a surgical training facility equipped with the latest technology in minimal access and robotic surgery to enable our surgical teams to improve existing techniques and learn new ones. Conferences and workshops Our Education Centre hosted 76 large symposia, conferences and courses in the past year. In October it linked up with London s only army hospital to deliver an innovative symposium on trauma care. Consultants, doctors in training, nurses, nursing students, allied health professionals and staff from the London Ambulance Service attended presentations on mass casualty incidents from a range of speakers. In January, our surgeons hosted a three-day event to showcase the latest surgical techniques and robotic technology to treat patients with cancers. Our surgical teams were joined by delegates from across the UK, Europe and America who had the opportunity to try the latest training equipment. They also watched live surgery at University College Hospital via live streaming in our Education Centre. Quality Improvement Colleagues across UCLH are being supported to improve the quality of services they provide on their wards or departments through training in Quality Improvement methodology and After Action Reviews. The Institute Improvement team has been working with colleagues in diagnostics and theatres and on our wards to streamline pathways and make processes more effective for the benefit of our patients. The team retained its accreditation with NHS Improvement to deliver the national Quality, Service Improvement and Redesign (QSIR) programme. New learning hub We launched a new learning hub which enables junior doctors and dentists to study remotely online. 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Training facilities In 2016/17, more than 3,000 staff from UCLH and the Annual Report and Accounts 2016/

12 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Enhanced apprenticeships We continue to develop our apprenticeship programme for new and existing employees. In 2016/17, 90 staff started apprenticeships. As well as undertaking an apprenticeship, these staff have the opportunity to gain a nationally recognised qualification in business administration, clinical healthcare, or leadership and management. In the past year 72 members of staff have signed up to work towards such a qualification. We also offer apprenticeships to people in the local community to work in a variety of our departments such as our workforce, finance and clinical support services. Cancer Academy In 2016/17 we launched our Cancer Academy. This new initiative brings together existing education and training opportunities for both staff and patients into a central hub. This is part of the five-year UCLH Cancer Strategy to improve care and outcomes for people with cancer and to develop staff working in cancer services. Our launch was made possible through philanthropic support from our commercial partner Amplify and through investment by the UCLH Charity Trustees. The Academy has been established with staff and patients. Our philosophy is to empower people through personal development and opportunity. We achieve this by adopting a combination of approaches including quality improvement, coaching and providing access to internationally regarded experts. This is made possible by our collaboration with the UCLH Institute and UCL, our world leading university partner. Our longer-term ambition is to offer education and training beyond UCLH. Other educational programmes outside of The uclh Institute include: Leadership and change Our Organisational Development Team has led a change management and leadership development programme. This year more than 270 managers and clinical leaders have undergone training to increase their confidence and capabilities during periods of service transformation. The course has received excellent staff feedback. Nurse-led research and education The Centre for Nurse and Midwife-led Research continues to provide research skills workshops and one-to-one support for UCLH nurses and midwives who wish to apply for research grants. This year the Centre launched the UCLH/UCL fellowship scheme to support and inspire nurses, midwives and allied health professionals (AHPs) interested in undertaking research to improve patient care. The fellowships help successful applicants to develop competitive applications for a National Institute for Health Research (NIHR) funded Masters, PhD or post-doctorate. AHP and nursing fellowships are in progress. Midwives are also invited to apply for fellowships. 12 University College London Hospitals NHS Foundation Trust

13 1.1.5 Research and development Providing world-class research to improve the quality of patient care remains a major focus for UCLH. Key developments over the past twelve months include: 111m funding boost for biomedical research The UCLH Biomedical Research Centre (BRC) was awarded 111.5m from the National Institute for Health Research (NIHR). Covering five years from April 2017, this represents a significant uplift to the funding granted to the BRC in The BRC s work currently focuses on cancer, neurosciences, dementia, cardiovascular and inflammation, immunity and immunotherapeutics. The new award means the BRC can expand its work into other areas where UCLH and UCL also excel - oral health and disease, deafness and hearing, mental health and obesity. The international panel judging the funding award described the level of integration between the BRC s partnership organisations UCLH and UCL as outstanding and the quality, volume and breadth of research across the partnership as excellent. Clinical Research Facility awarded 6.5m The Clinical Research Facility (CRF) at UCLH was awarded 6.5m in funding from the NIHR towards experimental medicine studies in cancer and dementia. UCLH was one of eight successful CRFs across London to receive NIHR funding for 2017 to 2022 following a competitive bidding process. In April the CRF opened a new purpose-designed space in Tottenham Court Road. It provides bigger clinical spaces, better patient and staff facilities, a laboratory, pharmacy and a dedicated facility for early phase trials and experimental medicine. Major investment for dementia research UCLH and UCL will host the new UK Dementia Research Institute with a 250m investment. It will lead research and develop new treatments to prevent dementia and help those living with the condition. This is a major achievement building on the world leading strengths of UCL in neuroscience and aligns to the BRC dementia theme to help the early translation of new diagnostics and treatments. Cancer Research UK UCL The UCL Cancer Research UK Centre and UCL s Experimental Cancer Medicine Centre (ECMC) successfully secured new funding as part of a 226m UK investment announced by Cancer Research UK. UCLH is one of the major partners in the hub which brings together research teams from universities and hospitals and where promising cancer treatments including small molecule drugs, surgery, immunotherapy, and vaccines are safely tested and monitored for the first time in patients. Prostate research makes headlines around the globe Research involving UCLH doctors and patients has been hailed as the biggest leap in prostate cancer diagnosis in decades with the potential to save many lives (Prostate Cancer UK). The Prostate MRI Imaging Study (PROMIS) study, published in The Lancet, showed that using an advanced form of MRI scans can help men avoid unnecessary biopsies while almost doubling the number of aggressive tumours that are detected. The research was funded by the Department of Health, NIHR, UCLH BRC and the Royal Marsden and Institute of Cancer Research Biomedical Research Centre. It was conducted by scientists from UCL, UCLH, the Royal Marsden Hospital, the Medical Research Council (MRC) Clinical Trials Unit at UCL, the University of York and Hampshire Hospitals NHS Foundation Trust. In a second research trial, a drug activated by laser light was found to successfully destroy early prostate cancer while avoiding side-effects that commonly occur with surgery. The new technique, called vascular-targeted photodynamic therapy (VTP), involves injecting a light-sensitive drug into the bloodstream. The drug is then switched on by laser pulses fired through optical fibres inserted into the prostate. The trial was led by UCLH consultant Professor Mark Emberton and the BRC. The VTP therapy approach was developed by scientists at the Weizmann Institute of Science in Israel in collaboration with STEBA Biotech. Funding for new era of T-cell cancer therapies The UCLH/UCL spin-out company Autolus secured a further 40m investment funding towards developing revolutionary T-cell cancer therapies. The treatments could enable the patient s own immune system to fight the primary cancer and could help the body to better fight secondary cancers. These therapies are based on the work of UCLH consultant Dr Martin Pule. Annual Report and Accounts 2016/ PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE)

14 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Epilepsy drug could prevent nerve damage in MS An epilepsy drug could lead to a new treatment that protects against nerve damage in Multiple Sclerosis (MS) patients, according to research published in The Lancet Neurology. Researchers, led by Dr Raj Kapoor from the National Hospital for Neurology and Neurosurgery, found the anti-convulsant drug phenytoin protected neural tissue in patients with optic neuritis. Optic neuritis is a symptom of MS which causes the nerves carrying information between the eye and the brain to become inflamed and damaged. The findings bring researchers one step closer to establishing neuroprotective drugs for people with MS currently there are none. Decoding our DNA UCLH is one of the major recruiters for a revolutionary project which aims to read the genetic blueprint, or genome, of around 75,000 people. This includes patients with breast, bowel, ovarian and lung cancers and leukaemia, and people with rare genetic diseases and their relatives. After the DNA is decoded, the information will be combined with data from the person s medical records, creating a lifecourse picture of the disease. Results from the 100,000 Genome Project could provide insights leading to new tests and drugs tailored to an individual s DNA, including those that prevent disease rather than merely treat it. UCLH partners with DeepMind to develop pioneering technology UCLH has begun a medical research partnership with DeepMind Health which specialises in using machine learning to solve complex problems. At present, it can take clinicians up to four hours to identify and differentiate between cancerous and healthy tissues on CT and MRI scans of head and neck cancer patients. Open event UCLH hosted its third major summer exhibition dedicated to research and innovation with 50 interactive stands demonstrating the latest technology and techniques for conditions such as cancer, dementia and arthritis. See section Patient care activities for information about recruitment to research studies. 14 University College London Hospitals NHS Foundation Trust

15 1.1.6 Key risks to delivering our strategic objectives The table below identifies some of the risks that could impede us from achieving our five strategic objectives. The table also outlines how we are seeking to mitigate these risks. Strategic objective 1: Provide the highest quality of care within our resources Risk We could fail to provide best care because of weaknesses in patient tracking. The quality of care we provide could deteriorate because we need to save money. Older parts of UCLH are in a state of disrepair which could impact on the quality of our services. Insufficient capacity to deal with the number of patients referred to UCLH. This could result in missed access targets, financial penalties, lost income and activity, and could lead to regulatory or contractual interventions. Mitigation We can now track whether future bookings have been provided to patients marked as needing an appointment. We need to develop regular monitoring of this. Our Clinical Data Repository (CDR) has been updated and abnormal diagnostic test results are now automatically flagged up. This reduces the risk of missing important results requiring action. Work is underway to embed this change throughout the organisation. Our cost improvement plans (CIP) focus on improving patient experience by reducing waste and increasing efficiency. We carry out a quality impact assessment on each saving scheme before committing to it. Medical Directors (and where appropriate, other senior clinical staff) scrutinise cost improvement plans before they are implemented. We use the national Safer Nursing Care Tool to determine ward staffing levels. We undertake regular maintenance, focusing on preventative checks and repairing areas in need. We conduct an annual survey to fully evaluate the condition of our buildings. We work with commissioners to review the demand and capacity for UCLH services. Our new building projects are designed to increase capacity. We continue to determine whether these new buildings have enough room to meet waiting time targets. We will use strategic capacity planning to assess medium term bed and theatre requirements. Our planned new models of care, the uclh future programme and Sustainability and Transformation Plan (STP) workstreams all aim to improve pathways and reduce length of stay. 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

16 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Strategic objective 1: Provide the highest quality of care within our resources Risk UCLH fails to deliver benefits from technology change (lack of investment or implementation failures) leading to quality issues or financial loss. Mitigation We have undertaken a baseline assessment of our digital technology to identify areas of weakness. We have set up a Digital Services Delivery Board. We are leading North Central London (NCL) plans to improve use of digital patient records across GP surgeries, hospitals and mental health trusts. We participate in NHS England s (NHSE) regional and national digital programmes to ensure we are aware of the latest standards and involved in strategic plans nationally. We signed a contract with Atos, our new digital transformation partner in December Service transition started in January 2017 with services due to go live by July The Board has approved a full business case for Epic to provide an electronic health record system (EHRS), subject to satisfying some further financial tests, including securing external funding. Strategic objective 2: Support the development of our staff to deliver their potential Risk The lack of a long-term organisational development plan could affect our continued effectiveness and viability. An estimated per cent of junior doctor posts are vacant at UCLH, which places an additional workload on those in post and impacts on the quality of their training and education. Mitigation Strategic objective 3: Achieve financial sustainability Risk The Sustainability and Transformation Plan (STP) fails to deliver on the pathway and efficiency changes required to deliver sector-wide sustainability, which would impact directly on our financial position. The Deputy Chief Executive is leading on organisational development (OD). We have a clear plan to refine the OD programme. This includes reviewing training to develop our future leaders and assessing our capability to deliver change. We are considering centralising our recruitment for junior doctors to help us plan rotational appointments. We are also considering novel approaches such as mixed clinical, research, education and leadership posts, and sponsoring clinicians to gain additional academic qualifications. Mitigation We are actively engaging with the STP and have focused our clinicians and managers on the workstreams we feel will deliver the biggest benefits. Our Finance Director is leading the finance group. We will therefore maintain a detailed understanding of the STP assumptions and related risks. 16 University College London Hospitals NHS Foundation Trust

17 Strategic objective 3: Achieve financial sustainability Risk UCLH is set efficiency targets that it is unable to achieve. We could lose income due to commissioner-driven changes in models of care and tariff structures. National and local tariffs for specialist work continue to underfund the cost of complex specialist treatment. NHS-wide financial constraints result in non-payment for activity by commissioners. Mitigation Efficiency targets represent a considerable challenge. However, the two-year planning process for 2017/18 and 2018/19 has ensured earlier agreement of financial plans, enabling a focus on delivery and implementation of cost improvement plans well in advance of the start of 2017/18. We are working to maximise potential cost savings through the Carter productivity programme led by the finance director. This links closely with our cost improvement programme. We are closely monitoring the commissioning landscape in order to anticipate any changes to funding streams. We have developed closer working relationships with commissioners and other local providers including Whittington Health NHS Trust in order to find more efficient ways of delivering care. We have a new commercial and contracts function at UCLH which will help design payment models that support improved patient care without passing too much risk to providers. We have raised the issue with NHS Improvement and NHS England that the new tariff does not fully resolve the underlying issues that have resulted in financial deficits for trusts such as UCLH. We will continue to work with NHS Improvement and NHS England to ensure that local prices are not reduced and that control totals are set fairly. We participate in all relevant London specialised commissioning programmes of work. We have a leadership role through the Cancer Vanguard to share best practice to improve quality (for example, through centres of excellence for specific tumour sites) or to reduce costs (for example planning radiotherapy and imaging capacity across North Central London and North East London). We have a stronger approach to cash management internally and will ensure close engagement with commissioners in relation to service developments and activity growth. We are working with commissioners to help find wider solutions to affordability issues. Our framework for negotiating contracts includes clear and defined timescales for agreement, ensuring rigour in assessing and mitigating impacts. A focus on cash flow was secured as part of the 2016/17 contract agreement. 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

18 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Strategic objective 3: Achieve financial sustainability Risk Our efficiency programme may not generate enough savings to meet our long-term financial plan. London property values may decline, so we cannot make as much money as expected when selling our assets in the future. Mitigation We regularly review our long-term financial modelling to ensure we have set realistic efficiency plans for the future. We now track uclh future and cost improvement plans at a detailed level. Our long-term financial planning takes the changing value of London property into account. Strategic objective 4: Improve patient pathways through collaboration with partners Risk The redesign of services under the STP proposals may not be sufficient to accommodate the rise in demand. This could then impact our waiting times. Risk that we are not engaged in the specialised Sustainability and Transformation Plan (STP) and could lose opportunities to develop world class specialist services. Mitigation Strategic objective 5: Generate world-class research Risk Some annual research funding streams will be constrained over time. We have a number of governance arrangements to help develop our role in the local health economy, including an integrated care division, a local services strategy, an urgent care steering group and a system redesign group. We continue to participate in all major STP events. We are leading key pieces of work within the specialist STP. Mitigation We are working with the biomedical research centre (BRC), clinical research facility and wider research community to ensure we achieve the standards needed to generate future income. 18 University College London Hospitals NHS Foundation Trust

19 1.1.7 Going concern disclosure The directors have considered the application of the going concern concept to UCLH based upon the continuation of services provided by the Trust: NHS Improvement (NHSI), the sector regulator for health services in England, states that anticipated continuation of the provision of a service in the future is sufficient evidence of going concern, on the assumption that upon any dissolution of a foundation trust the services will continue to be provided. The directors consider that there will be no material closure of NHS services currently run by UCLH in the next business period (considered to be 12 months) following publication of this report and accounts. For this reason, the directors continue to adopt the going concern basis in preparing the accounts. Given the deteriorating financial context within the wider NHS, and pressures specific to the Trust, the directors have also given serious consideration to the financial sustainability of UCLH as an entity and in relation to UCLH s available resources: In relation to UCLH as an entity, the directors have a reasonable expectation that UCLH has adequate resources to continue to service its debts and run operational activities for at least the next business period (considered to be 12 months) following publication of this report. UCLH has sufficient cash to ensure its obligations are met over this time period given the potential mitigations identified for a downside scenario. There remains significant uncertainty about the Trust s financial sustainability over a longer time period than the 12 months considered here, particularly as a result of underfunding of some specialist services combined with the financial pressure resulting from the current PFI arrangement. 1.2 Performance analysis Finance Director s Report 2016/ /17 was another challenging year for UCLH, reflecting the increasingly difficult economic environment across the public sector and the NHS specifically. We reported an underlying deficit of 5.8m, which was 5.2m better than the 11m deficit planned at the start of the year, and an improvement of 29.8m on the prior year. The underlying deficit, which is the most appropriate measure of our financial performance, is calculated before the impact of exceptional items such as asset sales, oneoff sustainability funding from NHS Improvement, capital donations and impairments arising from the revaluation of land and buildings. Taking these into account UCLH reported a surplus of 34.8m. Our Financial Performance UCLH was set, in common with all other NHS providers, a control total for our overall financial performance in 2016/17 for the first time, which required us to deliver no more than an 11m deficit. This has restricted our ability as a foundation trust to set our own financial plan and take decisions that improve our long term financial sustainability but have a shorter term investment cost. Following a very challenging year in 2015/16 in which our underlying deficit was 35.6m, UCLH agreed a plan to achieve an 11m deficit for 2016/17. Part of this planned improvement was as a result of additional core sustainability funding provided to all NHS trusts by NHS Improvement (NHSI). In UCLH s case this funding amounted to up to 14.7m if all our targets were met. Against this 11m deficit plan we achieved an underlying deficit of 5.8m, which included 14.3m of core sustainability funding, with the remaining 0.4m of sustainability funding withheld as a result of missing a cancer performance target. This was a pleasing result overall given the financial context of UCLH and the NHS more widely, and reflects the huge effort from staff across UCLH in over-achieving our challenging savings target of 36.5m (actual performance against this target was 39.1m), an efficiency gain of nearly 4 per cent. However, it is not sustainable for UCLH to remain in financial Annual Report and Accounts 2016/ PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE)

20 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) deficit, particularly given the need for us to generate sufficient cash from our underlying financial position to make repayments on our loans and invest in our future. There were a number of unplanned, exceptional transactions that were reported in the 2016/17 financial year, which are summarised in the table below: 2016/17 plan m Underlying deficit (11.0) (5.8) Capital donations (less donated asset depreciation) One-off revenue brought forward from Royal Free London for Royal National Throat Nose and Ear Hospital Additional unplanned sustainability funding from NHSI Net profit on disposal of assets Impairments arising from revaluation of assets I&E surplus/(deficit) after exceptional items /17 actual m (9.8) (11.1) 34.8 The revenue brought forward from the Royal Free for the Royal National Throat Nose and Ear Hospital (RNTNEH) relates to an agreement between the two trusts associated with vacating the RNTNEH site and relocating these services in UCLH s new Phase 5 development. The 9.8m impairment arises from the revaluation of our land and buildings in year it is a non-cash, technical accounting change which has no implications for the fitness of our land or buildings to deliver patient care. The additional unplanned sustainability funding from NHSI was received as part of a national scheme to reward NHS organisations that reported a better than planned financial position at the end of the year. Taking these exceptional items into account, UCLH reported a surplus of 34.8m. However, our underlying financial deficit presents a very significant challenge to delivery of 2017/18 and future year financial targets. Total income for UCLH grew by 12 per cent to 1,043m compared to 933m the previous year. This figure incorporates the one-off revenue from the Royal Free, the unplanned sustainability funding from NHSI, along with the full year impact of the move of malignant haematology from the Royal Free London in December 2015 (an increase in income compared to the previous year of around 12m) together with consolidation of specialist cancer services from other trusts. Total non-nhs income represented around 7 per cent of total operating income, significantly lower than the cap laid out in the Health and Social Care Act. Operating expenditure for UCLH grew by 2 per cent to 974m compared to 952m the previous year, including a 9.8m impairment related to revaluation of assets as described above. Within this, pay costs increased by 23m, and the need to deploy staff more efficiently whilst also meeting the requirements of the increasing number of patients being treated at UCLH remains a priority. We have been successful in significantly reducing our expenditure on agency staff, although there remain some areas where agency usage is still higher than we would like where there are national shortages of staff. The Trust s cash balance has increased during the year, from an opening position of 69m to a closing balance of 75m at 31 March This is primarily as a result of faster collection of outstanding debt, together with other factors such as the 2016/17 financial surplus and the timing of loan draw down for capital expenditure. However, our current borrowing of 352m (including the PFI, which is a particularly expensive form of borrowing) remains relatively high and will increase further in the short to medium term as we complete construction of two new hospital sites and manage the financial timing difference between capital expenditure and receipt of disposal proceeds from the existing hospital sites that will be vacated. Whilst UCLH has made progress on collecting outstanding debt we are owed, there remain high balances outstanding with other NHS trusts who are themselves finding the current financial context challenging. Outlook for 2017/18 and beyond UCLH has been set a control total of a 9.8m surplus by NHSI for 2017/18. This represents a 41m required improvement in our underlying financial position from our 2015/16 reported deficit of 31m. It is therefore a very significant challenge and one that we do not currently believe we can achieve without recognition or funding for the excess cost that UCLH faces as a result of its PFI contract. UCLH also faces a number of specific financial challenges for example, our business rates have increased by over 1m, our PFI 20 University College London Hospitals NHS Foundation Trust

21 costs increase in line with the retail prices index each year (which is well in excess of the inflation that we are funded for through the NHS tariff), and we face a further 3m reduction in training and education income with no opportunity to reduce associated costs. Cumulatively, these specific pressures are equivalent to a doubling of the headline 2 per cent efficiency requirement that is built into the NHS tariff and mean that very significant further reductions in unit cost will be required in 2017/18. UCLH is fully committed to working with our partner organisations within the North Central London Sustainability and Transformation Partnership (STP), and as part of this commitment has agreed to a marginal rate contract with local commissioners where we will not be paid the full tariff for growth in local activity to further encourage us to work across the local health economy to reduce the number of admissions to, and attendances at, acute hospitals. We have agreed contracts with commissioners for a two year period to March 2019, which will provide welcome certainty and help both commissioners and providers to focus on delivery of schemes to look after patients in the most appropriate setting and improve the cost effectiveness of the NHS in our area of London. However, this does present additional financial risk if activity levels continue to rise. Within this context, UCLH is planning to deliver our control total of a 9.8m surplus on the condition that PFI funding of at least 4.5m is provided to partially compensate for the high and increasing cost of this facility. Our plan assumes full receipt of the 15m sustainability funding that UCLH has been allocated in 2017/18, although there is some risk to the 4.4m of this funding that depends upon meeting Emergency Department performance targets. There also remain a number of significant risks to delivery of the plan, many of which are outside of UCLH s control. Despite the increasingly short-term focus of the NHS on in-year financial performance, the UCLH Board remains committed to taking a medium-term view of financial sustainability whilst maintaining an absolute focus on maintaining quality and safety, providing the necessary support to all areas of the Trust to meet the challenges ahead. We have approved a business case to invest in a new electronic health record system, based upon receipt of external funding and the requirement for the Trust to remain financially sustainable. We are also progressing our UCLH future programme and are working closely with NHSI to focus on improving productivity as part of the UCLH response to Lord Carter s report earlier this year. UCLH s strategic development programme, together with the opportunity to work more closely with local partners through the STP, provides a strong platform for our world class aspirations to be delivered whilst significantly improving productivity. It will be essential for UCLH, together with other NHS providers, to be appropriately resourced to ensure this can be underpinned by a sustainable financial plan. Tim Jaggard Finance Director 23 May PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

22 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Overview of our performance 2016/17 The following table outlines our performance against our corporate objectives for 2016/17. Progress made Objectives Deliverable Full Good Partial None Provide the highest quality of care within our resources Improve patient pathways through collaboration with partners Improve patient pathways through collaboration with partners Deliver the Sign up to Safety campaign so that we further reduce harm to patients Maintain upper decile Standard Hospital Mortality Index (SHMI) results Maintain patient experience ratings Achieve hospital-acquired infection targets Improve booking and correspondence with patients and GPs Ensure that we check and action all patient test results Meet A&E waiting time targets Meet 18-week and diagnostic waiting times targets Meet cancer waiting times targets Implement the Cancer Vanguard project Deliver phase 4, phase 5, Emergency Department and Queen Square development milestones Develop new pathways for diabetes, Musculoskeletal (MSK) conditions, chronic obstructive pulmonary disease (COPD) and frail elderly patients 22 University College London Hospitals NHS Foundation Trust

23 Progress made Objectives Deliverable Full Good Partial None Support staff to deliver their potential Achieve financial sustainability Generate world class clinical research Improve staff experience Improve development opportunities for staff Achieve targets for staff retention, vacancies and temporary staffing usage Support patient safety by ensuring staff complete mandatory training Improve the quality of appraisals for our staff Improve the UCLH experience for medical and dental trainees Achieve financial targets Contribute to North Central London s (NCL) Sustainability and Transformation Plan (STP) Deliver agreed contracts with commissioners Improve utilisation of beds, theatres, imaging and outpatient services Progress the rationalisation of support services Agree preferred option for future IT infrastructure Achieve re-designation as a National Institute for Health Research (NIHR) Biomedical Research Centre (BRC) Increase recruitment of patients into portfolio studies and early phase trials Support bid for the national Dementia Research Institute and the Cancer Research UK (CRUK) centre Establish clinical research facility (CRF) in new location Deliver on our responsibility for the 100,000 Genomes Project Progress clinical academic appointments with UCL 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

24 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Detailed review of our performance 2016/17 This section presents a summary of our performance in 2016/17 against our corporate objectives. National access standards During the past year we have encountered significant challenges in delivering key access targets, in particular the A&E four-hour wait and the 62-day and 31-day cancer targets. Referral to Treatment (RTT) We have consistently met the standard that 92 per cent of our patients should wait no longer than 18 weeks for treatment. To continue meeting the standard we have: Clear roles and responsibilities to deliver short waiting times Classroom and electronic training across UCLH on all aspects of managing waiting times More proactive management of waiting lists Protocols to deliver shorter waiting times when booking patients Made significant improvements to the way we report patient waiting times. In particular, we have much stronger patient tracking and tighter controls around validating information on patient pathways Specialty level referral to treatment (RTT) demand and capacity modelling and forecasting. However, across the year there were 20 patients who waited more than 52 weeks for their treatment. In most cases this resulted from incidents where patients were wrongly recorded on our systems as having received treatment, and so regrettably we stopped tracking them towards a timely treatment date. We conduct an investigation into all cases of patients who wait longer than 52 weeks. In 2016/17 these investigations found no evidence of detrimental impact on clinical outcomes. Clearly we do not want any of our patients to experience such delays so we are working hard to improve our data quality through improved staff training. Cancer waiting times We have improved cancer waiting times, as measured against the national standards. Since October, we have met the standard that patients who are urgently referred with suspected cancer should have their first appointment within 14 days. In most months we also met the standard that all cancer patients should receive treatment within 31 days of diagnosis. We have consistently achieved this target since December. We missed the standard that patients referred by a GP with suspected cancer should be treated within 62 days of referral. About half of these patients were referred to us for specialist treatment from other trusts, having had the early part of their pathway at their local hospital. Breaches often occur because patients are referred too late in their pathway for us to deliver treatment within 62 days. We are working closely with referring trusts and their commissioners to co-design pathways so patients receive their treatment quickly. We have: Introduced regular review meetings, led by our medical directors, to review the waiting list for all cancer pathways Improved the way we analyse breaches to understand more fully the reasons for delays. We are reviewing our processes in collaboration with commissioners to standardise our approach Re-designed pathways to make them shorter and introduced one-stop clinics. Where possible, patients get all of their diagnostics at the first appointment. These one-stop clinics are now in place in urology, lower GI, upper GI, lung and skin clinic Put in place extra capacity where required, for example in urology robotic surgery, head and neck ultra-sound, skin two-week wait clinics and breast two-week wait clinics Carried out detailed analysis in all two-week wait clinics to ensure they have sufficient capacity to offer patients appointments within seven days of referral Introduced a set of new reports to help managers deliver these standards Worked closely with referring trusts and their commissioners to implement a local referral protocol. This aims to streamline the care and treatment for patients referred to us from other trusts. 24 University College London Hospitals NHS Foundation Trust

25 A&E four-hour wait Along with most other trusts, we have struggled to meet the operational standard that 95 per cent of our patients should be seen in our emergency department within four hours. However, we have performed better than average for London and nationally. We are working with community providers, mental health and social care colleagues as part of the clinical commissioning group s (CCG) efforts to address the system-wide factors affecting where patients receive their care. Bed capacity at University College Hospital continues to impact on performance, as patients have to wait in the emergency department for a bed to become available. A large focus of our work on A&E performance is about improving the flow of patients through the hospital, in particular reducing delays to discharge. Our detailed action plan to improve flow and bed capacity includes new measures introduced in the emergency department, across UCLH and the wider healthcare system. We have: Changed how we allocate our staff across the emergency department to ensure we have the right skill mix Increased the percentage of patients discharged home before midday from 13 per cent to 18 per cent. This means we have more beds available earlier in the day to admit new patients Opened a ward in St Pancras Hospital, providing care for patients that do not need to be in an acute hospital bed but are not yet ready to go home Established weekly senior level meeting with commissioners to review all issues that are causing delays to discharge. We liaise with social services and our hospitalbased social workers, as well as community healthcare colleagues to help reduce delays. We also work with our Pathway homeless and alcohol liaison teams. The CCG supports us when we need to escalate particularly challenging delays. Diagnostic waiting times From December, we met the standard that 99 per cent of our patients should wait less than six weeks for a diagnostic test. This is the first time that we have achieved the standard since In particular, we have made improvements in waits for endoscopy and MRI. Key actions we have taken to shorten waits for patients include: Undertaken demand and capacity modelling in all challenged areas to understand the demand and quantify any capacity shortfalls Improved monitoring of diagnostic waits. Referral to treatment (RTT) waiting lists and how they are managed are reviewed at weekly meetings to ensure all areas have the correct protocols in place Improved capacity by increasing weekend working and using more private sector facilities for patients needing MRI and endoscopy. Quality metrics This section outlines our performance against a number of key quality indicators that were prioritised through the 2016/17 corporate objectives and are reported through UCLH s performance framework. Healthcare associated infections There were 90 Clostridium difficile toxin positive cases reported in 2016/17. Each case is reviewed with the lead clinical commissioning group (CCG) to agree whether it was due to the care they received at UCLH. Our year-end threshold is that no more than 97 cases should be due to lapses in care. Of the 90 cases, seven were assessed to be a result of lapses in care, 57 cases were agreed not to be the result of any lapse in case. There are 26 cases currently under review, which means our worst case position is 33 cases against the threshold of 97. Our current Clostridium difficile reduction plan aims for optimal cleanliness of the healthcare environment, ensuring staff follow infection control practice including hand hygiene and that there are sufficient hand washing facilities. We are also improving testing methods and treatment of cases. There have been two cases of trust-attributable Meticillin Resistant Staphylococcus aureus (MRSA) bacteraemia reported in 2016/17; our lowest number of cases for the second year running. While this is above the national standard of zero, this is below the ceiling set by our regulator of no more than six cases by year end. In 2016/17 we increased training and monitoring around intravenous device insertion and care. Patient feedback We are always looking at ways to improve the experience that patients have of our services. In 2016 we introduced a wider range of tools for monitoring feedback from patients in real-time including paper questionnaires, electronic tablets and text messaging. 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

26 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) We ask patients the nationally set Friends and Family Test: Would you recommend our services to your friends and family? The feedback results for our emergency department were among the highest compared to our peers in the Shelford Group. The Shelford Group, comprising ten leading NHS academic healthcare organisations, was formed in 2011 to benchmark and share best practice. Our results from the national Picker Institute survey showed an improvement for both inpatients and cancer patients, compared to last year. The surveys did highlight areas for improvement, including the need to enhance the patient experience during discharge from hospital. Mortality UCLH has consistently been ranked among the top performing trusts in England for its low mortality rates. We were ranked second in the latest Summary Hospital-level Mortality Indicator (SHMI) performance ratings, compiled by the Health and Social Care Information Centre (HSCIC). We are committed to reducing avoidable mortality among our patients and maintaining SHMI performance. This year we introduced a new governance process to review deaths. Sepsis We have focused on reducing harm from sepsis. New guidelines clearly inform staff how to identify and screen patients at risk, and administer antibiotics swiftly in cases of confirmed sepsis. We audit how well we are doing and 98 per cent of our inpatients are being screened for sepsis. However, we still need to improve the number of patients being screened in our emergency department and receiving antibiotics within an hour of sepsis being confirmed. Monitoring quality and performance We undertake a detailed review of performance against metrics and monitor the effect of recovery action plans. Results are presented to the UCLH Executive Board and Quality and Safety Committee as part of detailed performance and quality packs. This enables monitoring of performance standards, financial performance, and workforce and quality indicators. Our reporting structure is shown in the following diagram: 26 University College London Hospitals NHS Foundation Trust

27 1.2.4 Our corporate objectives for 2017/18 1. Provide the highest quality of care within our resources Align all clinical staff to work towards reducing avoidable harm Improve how we learn from mortality, morbidity and serious incidents to sustain excellent outcomes Improve patient experience Ensure all contact with patients and GPs is timely, accurate and professional including a streamlined booking process Start implementation of an Electronic Health Record System and successfully implement prerequisite systems Achieve hospital acquired infection targets 2. Improve patient pathways through collaboration with partners Work with system partners to shorten waits for patients in our emergency department and avoid admission where possible Improve our patients experience of waiting, both from referral to diagnosis and treatment; and waiting in the building Shorten waiting times at all stages of the pathways for cancer patients Deliver earlier diagnosis for cancer patients across the sector through the Cancer Vanguard Deliver phase 4, phase 5, Emergency Department and Queen Square development milestones Work with local and specialist Sustainability and Transformation (STP) partners to develop new pathways and support preventative care for our local patients 3. Support the development of our staff to deliver their potential Improve staff experience Improve the quality of education and development Demonstrate that we are an employer of choice Improve working conditions for junior doctors and other staff in training Collaborate with STP and others to design and develop the future health and care workforce Develop our staff to achieve transformational change 4. Achieve financial sustainability Achieve financial targets including delivery of a 42m cost improvement programme Deliver clinical productivity efficiencies in line with the Carter agenda Take a leading role within the North Central London (NCL) and specialist STPs to support financial objectives Improve management of commercial relationships Achieve value for money from our assets and estate Deliver more efficient use of non-pay resources 5. Generate world-class clinical research Deliver the promises of the Biomedical Research Centre bid Give as many of our patients as possible the opportunity to be part of research trials Progress clinical academic appointments within UCL and other academic partners Work with partners, including HSL, to develop academically linked, advanced diagnostics and embed genome testing Improve utilisation of our clinical research facilities Develop and encourage research opportunities for junior doctors, nurses and all other staff across UCLH 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

28 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Environmental matters and sustainability UCLH has made excellent progress in improving the environmental impact of our work. Our sustainable development, carbon, and waste management policies, which integrate the latest requirements and guidance from the NHS Sustainable Development Unit, clearly demonstrate our environment-friendly credentials. All UCLH tendering processes and business cases include an assessment on sustainability. Reducing carbon emissions In 2016 we retained our Carbon Trust Standard certification for reducing carbon emissions. This is a mark of excellence, providing independent verification for our carbon footprint management. Our direction is clearly defined by policies for sustainable development, carbon, and waste management which integrate the latest requirements and guidance from the NHS Sustainable Development Unit. UCLH is working hard to cut emissions by more than 28 per cent against our 2007/08 baseline by This represents a target of 0.16 tco2e (carbon dioxide equivalent) per patient contact. In 2016/17 our carbon emissions per patient contact was 0.20 tco2e. Our reported carbon footprint includes those sources where we have a good understanding of emissions. This year UCLH has attempted to include emissions from procurement, our supply chain, waste plus transport and travel which will be integrated into the 2020 reduction target. We are working to quantify and reduce emissions from these sources more thoroughly. Carbon Emissions (tco 2 e) Carbon footprint per Patient contact 2007/ / / / / / / / / /17 Our key achievements in reducing carbon emissions this year included: We received a prestigious Green Apple Award at the Houses of Parliament for environmental improvements at the University College Hospital Macmillan Cancer Centre. Changes made to the building s energy management system reduced energy consumption and carbon emissions and made the environment more pleasant for staff and patients. In the year following the completion of this project, the centre achieved: Energy Travel Commissioning Procurement 10 per cent reduction per month on energy consumption 8 per cent reduction per month on energy costs 15 per cent reduction per month on carbon emissions saved an average 27,000 kwh per month 28 University College London Hospitals NHS Foundation Trust

29 In January 2017, UCLH launched the Green Impact programme, led by the National Union of Students. Teams across UCLH are involved in projects to reduce carbon and make cost savings and are working towards a bronze, silver or gold certificate. UCLH is reducing its carbon footprint by using transport resources more smartly. One supplier now collects our confidential waste for free after they deliver our stationery reducing the number of journeys. The service is currently at four of our sites and is to be expanded. We took part in the annual NHS Sustainability Day in March 2017 to offer advice to patients and staff on how to live more sustainably at work and at home. UCLH has pledged that all its new buildings will comply with standards of excellence laid down by BREEAM (Building Research Establishment Environmental Assessment Method). This is the world s leading sustainability assessment method. UCLH achieved the Silver Mark of achievement from the Camden Climate Change Alliance this year. Our new energy contract has provided us with a dynamic risk management approach to buying out energy and has saved UCLH approximately four per cent this year in comparison to 2015/16. Reducing waste UCLH is one of the first NHS foundation trusts in England to be awarded the Carbon Trust Standard for Waste. This additional certification recognises our achievements in reducing waste each year and our continued efforts to deal with waste more effectively by increasing recovery, recycling and reuse. Feedback from the Carbon Trust has provided a good framework for UCLH to use our resources efficiently, as well as cutting costs. We have revised our Waste Policy to measure our success against waste targets more accurately. Our key achievements in waste reduction this year include: Diverted 100 per cent of our recycled waste from landfill Increased recycling facilities at our hospitals Introduced monthly waste audits to highlight areas for improvement Increased battery recycling facilities on all sites Adopted a kg waste/patient metric for measuring waste targets We now have a secure area to store surplus furniture and equipment for re-use across UCLH. We aim to challenge a disposable culture by encouraging staff to donate unwanted furniture. Staff are also encouraged to enquire what items are in the store before buying new ones to reduce waste, save money and keep our carbon footprint to a minimum. During the financial year 2016/17, 198 items have been re-used. We have identified an aid agency that needs medical equipment and currently have more than a 100 crutches in our re-use store ready for donation. This means we send less waste to landfill, reduce waste costs and make a small contribution of medical aid to those in need. Remaining sustainable UCLH has some challenging carbon reduction targets ahead. By 2050 we aim to reduce our carbon emissions by 78 per cent, with interim targets of 28 per cent by 2020 and 45 per cent by The work of the UCLH Sustainability Steering Group is constantly evolving and remains responsive to new challenges. The group consists of senior managers and clinicians from pharmacy, radiography, procurement, information systems, and estates and facilities management. We continue to work with colleagues across the NHS to reduce the impact and cost of energy, waste, water and transport. We are an advisory board member of the Camden Climate Change Alliance. As a member of the Shelford Group, we are collectively working towards sustainable procurement. We are working to improve energy performance by: Adapting our existing electricity sub-meters so we can monitor the amount of electricity we are using at any given time throughout University College Hospital. This will help us proactively reduce electricity consumption if required Exploring setting up a software package that would allow us to view how much energy we are consuming on a daily basis Introducing an energy efficient LED lighting programme across UCLH Undertaking a feasibility study on how we can generate heat and power more efficiently on site. Water management UCLH has only recently begun looking at water efficiency across the estate. In 2017 we achieved the Carbon Trust Standard for water reduction, becoming the first and only NHS trust to achieve a triple carbon standard for water, waste and carbon. Annual Report and Accounts 2016/ PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE)

30 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Social, community and human rights issues We are committed to ensuring that our services meet the needs of people regardless of their age, disability, ethnicity, gender, race, pregnancy and maternity, religion or belief, sexual orientation and gender reassignment. This is in accordance with the Equality Act (2010) and our public sector equality duties under the NHS Constitution. We recognise the importance of respecting and protecting the human rights of our patients, staff and members, in line with Equality and Human Rights Commission guidance. Our equalities objectives are to improve patient care, staff experience and reduce inequalities among staff and patients. We publish an annual equality report that sets out how UCLH meets specific employment duties and includes monitoring data, achievements and priorities for action. We are committed to safeguarding all our patients, including the most vulnerable adults and children. We participate in our local multi-agency Safeguarding Boards and work with our partners to safeguard vulnerable adults and children. We react promptly to safeguarding issues and our trained safeguarding champions apply our policies and procedures around-the-clock. They are supported by a team of substantive safeguarding child and adult leads who have expert knowledge. There are named executive leaders for child and adult safeguarding and a quarterly report is presented to the Board. Safeguarding training is given to all staff as part of mandatory training. Care and treatment is provided to all patients with their consent or the consent of their parents or nextof-kin. We provide a comprehensive patient information and language support service to meet the needs of our diverse population. A telephone interpreting service is available in most common languages and we provide core information leaflets in an easy read format. A multi-faith spiritual care team is available to support patients and reflects the diverse faiths and beliefs of our local population. We carry out assessments to confirm that our policies, functions and services are not discriminatory. We develop and implement action plans to address any shortcomings. Monitoring data is included in the Annual Equality Report. For further information see section Equality reporting (patients) and section Equality reporting (staff) Important events affecting our organisation Working with our local partners UCLH has been working with clinical commissioning groups, local authorities and NHS providers in Camden, Islington, Haringey, Barnet and Enfield to develop a five year North Central London (NCL) Sustainability and Transformation Plan (STP). A draft plan has been published alongside a case for change. This sets out the challenges that need to be addressed across NCL to improve health and healthcare, to reduce health inequalities, to keep people well and at home and to streamline access to acute services, all while living within our financial means. We are working with our partners across NCL, particularly closely with Camden, Haringey and Islington, to develop proposals to improve services for local residents, particularly for those with long term conditions or who are frail. In Camden this work is part of the Local Care Strategy, and in Haringey and Islington it is part of the Wellbeing Partnership work. We are also part of the NCL maternity network which has begun working with the national programme, Better Births, to improve maternity care. In October 2016, UCLH was awarded the contract to provide a new Camden Integrated Musculoskeletal (MSK) Service, following a comprehensive procurement process. The service has been designed by Camden residents, local GPs and specialist clinicians to deliver better results and experiences for people with conditions related to their joints, muscles or bones. It will launch in spring We are also working with Whittington Health to ensure both hospitals acute services remain resilient and accessible. A memorandum of understanding to formalise this work has been signed by the two trust boards. At an NCL level, plans are underway to make it easier for staff to move between partner organisations and for short term staffing gaps to be addressed collectively. Contracts with commissioners By January 2017, we had successfully signed two-year commissioning contracts for the period April University College London Hospitals NHS Foundation Trust

31 to March 2019 with Camden Clinical Commissioning Group (CCG), NHS England and most of our associate commissioners. This was much earlier than in previous years. uclh future Our transformation programme, uclh future, aims to improve patient and staff experience by embedding a culture of continuous improvement and innovation. The programme delivers this through introducing new ways of working, supported by significant investment in technology and staff development. There have been three significant ICT developments in 2016/17 as part of uclh future. The developments, outlined below, move us closer towards our goal of becoming a digitally enabled healthcare organisation. UCLH s Board has approved the full business case for Epic to provide an electronic health record system (EHRS). The Board s approval is subject to agreeing external funding and we will continue to work closely with NHS Improvement and NHS Digital as we move towards contract signature. The EHRS platform will give UCLH a single, integrated electronic clinical record to support better patient care, research, patient engagement and staff experience. The platform will also enable patients to view a summary of their health records, and book and reschedule appointments online. EHRS is a major step forward in UCLH becoming fully interoperable with our NHS partners, supporting data sharing across the North Central London Sustainability and Transformation Plan (NCL STP). EHRS will also enable us to deliver new models of care, in line with NHS England s Five Year Forward View. We have signed a major new ICT partnership with Atos to transform the way we deliver digital services for staff and patients. The partnership will rapidly improve our use of technology, data analysis capability, resilience and IT availability. The transition phase of the 10-year contract has started with a view to becoming fully operational in summer Over the course of the 10-year contract, Atos will renew end-user technology across UCLH including laptops and desktops. Staff can also expect improvements in the service desk function, including an online chat facility. Our existing contract with CGI will come to an end in mid We signed a contract to develop a coordination centre programme which will transform patient flow at our hospitals by providing staff with the technology and processes needed to better manage the admission, discharge and transfer of patients. It will provide real-time visibility of where patients are in the hospital, enable the tracking of equipment, and highlight those patients ready to be moved from an acute care setting. We will be creating a combined coordination centre for all inpatients at University College Hospital, the National Hospital for Neurology and Neurosurgery and Elizabeth Garrett Anderson Wing. Ward staff will be able to spend more time caring for patients and less time looking for equipment or trying to find available beds. The programme will be implemented using a phased roll-out and the first elements of the programme will go live towards the end of For further information about uclh future developments see section Education and training and section Patient care activities. There have been no events subsequent to financial year end affecting the Foundation Trust. EU referendum Although there appears to be no immediate prospect of a change in immigration policies affecting our European employees, UCLH is closely monitoring the situation following the Brexit result. UCLH, along with the NHS as a whole, relies on staff recruited from abroad. More than 15 per cent of our workforce was born and trained in mainland Europe. For further information see section Staff numbers Overseas operations There were no overseas operations in 2016/17, as per the previous year 2015/ PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

32 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) 1.3 Accounting officer approval This performance report is made up of two parts: an overview of UCLH s performance and our performance analysis. The overview highlights some of our key achievements from the past year, showcasing the best of our recent work in patient care, clinical research, education and partnerships. The performance analysis demonstrates how we measure performance along with any important events that affected us over the past year. UCLH has done its best to ensure that, to my knowledge, the information in these sections is true and accurate. Professor Marcel Levi Chief Executive 23 May University College London Hospitals NHS Foundation Trust

33 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

34 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) 2 Accountability Report 2.1 Directors Report UCLH Board The Board, led by the Chairman, sets the vision and values of UCLH and works to promote the success of the organisation. It is responsible for the organisation s decision-making and performance to ensure that UCLH delivers a high-quality, safe and efficient services. The Board meets six times a year in public, although part of these meetings is held in private to deal with confidential matters. In 2016/17, the Board held four additional meetings wholly in private which included a meeting to approve the annual report and financial statements. The Board comprises the Chairman, seven nonexecutive directors, and eight executive directors, including the Chief Executive. The division of responsibilities between the Chairman and the Chief Executive is as follows: The Chairman leads the Board and ensures its effectiveness The Chief Executive is accountable to the Board for running all aspects of the operational business. The Chairman sets the agenda for the UCLH Board. The agenda includes reports from the standing committees of the Board. During the year, the Board also received presentations including The deteriorating patient and Surgical safety a year on to help assure the Board that the organisation is focused on the key objectives to improve safety, effectiveness, and experience. Board papers for the public meeting are published on the UCLH website and shared with governors. Governors also receive a monthly performance report, the agenda and minutes of confidential meetings, and a summary from the Chairman of the issues discussed. Board members Directors details, together with their committee membership, are given below. Board members are required to declare their interests annually, as well as to confirm they meet the fit and proper person condition as set out in Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulation The register of directors interests is published annually. It can be found on our website on the Board of Directors pages or can be obtained from the Trust Secretary. To contact the Board there is a dedicated address, directors@uclh.nhs.uk, as well as a telephone and postal address, which can be found on the UCLH website. Committee key member of AC audit committee FCC finance and contracting committee IC investment committee RC remuneration committee QSC quality and safety committee WC workforce committee Non-executive directors Richard Murley Chairman RC (chair) Richard Murley was appointed as Chairman of UCLH in July 2010 having previously served as a nonexecutive director. Richard is a qualified solicitor and has worked in the City of London for more than 30 years. He is a Vice-Chairman of Rothschild where he has worked since Between 2003 and 2005, he was Director General of the Panel on Takeovers and Mergers, regulating the conduct of takeovers of public companies in the UK. Richard is also a trustee for Crisis and Macmillan Cancer Support, a co-opted trustee for the Royal Society of Medicine, a member of the Medical Research Council and Chairman of the United Trust Bank. 34 University College London Hospitals NHS Foundation Trust

35 Harry Bush CB Vice-chairman AC/FCC (chair)/ic/rc Harry Bush joined the Board in February He has extensive senior management experience at HM Treasury and in the economic regulation of the aviation industry. He was most recently a member of the Civil Aviation Authority Board with executive responsibility for its economic output. Prior to that, he held a number of senior posts at HM Treasury during a long career there. Harry was appointed vice-chair in March Althea Efunshile CBE AC (from January 2017)/QSC (quarterly from February 2017, focus on patient experience)/rc/wc Althea Efunshile was appointed in May She has had a 30-year career in local and central government, during which she gained extensive senior management experience. She was Deputy Chief Executive of Arts Council England where she was responsible for the national investment strategy, corporate governance and operational delivery. Prior to that she held a number of director level posts within the Department for Education all of which were concerned with improving outcomes for disadvantaged children and young people. She has been the Executive Director for Education and Culture in the London Borough of Lewisham, and Assistant Director of Education in the London Borough of Merton. Althea was awarded a CBE for services to art and culture in the 2016 Queen s birthday honours. David Lomas QSC (chair)/rc David Lomas joined in September He is UCL Vice-Provost (Health), Head of the UCL School of Life and Medical Sciences, head of UCL Medical School, Academic Director of the UCLP Academic Health Sciences Centre and works as a respiratory physician at UCLH. He received his medical degree from the University of Nottingham and undertook his PhD at Trinity College, Cambridge. He was a Medical Research Council (MRC) clinician scientist, university lecturer and Professor of Respiratory Biology in Cambridge before moving to UCL in 2013 to be Chair of Medicine and Dean of the Faculty of Medical Sciences. He is Deputy Chief Executive at the Medical Research Council and previously chaired the Respiratory Therapy Area Unit Board at GlaxoSmithKline. He is also a senior investigator for the National Institute for Health Research (NIHR). Rima Makarem AC (chair)/rc/wc Rima Makarem joined in July Rima has extensive experience in healthcare and the pharmaceutical industry. She currently runs her own interim management and consultancy business and holds a portfolio of non-executive positions. Rima has significant experience as an audit chair. She was previously audit chair at NHS London and NHS Haringey before that, and is currently audit chair of the National Institute for Health and Care Excellence. Previously, Rima was Director of Competitive Excellence at GlaxoSmithKline and prior to that, a management consultant. Rima holds a PhD in biochemistry and an MBA from INSEAD Business School. Kieran Murphy AC (member until December)/FCC/IC (chair)/qsc (from January 2017)/RC Kieran Murphy was appointed in January He graduated from Cambridge and began his career as a civil servant at HM Treasury. Subsequently he joined Kleinwort Benson where he spent 15 years as a senior corporate finance adviser, culminating in leadership of the worldwide industrial sector investment banking business. Kieran joined the corporate finance advisory firm Gleacher Shacklock as a partner in He became a senior adviser prior to his retirement from the firm in December He has developed an extensive career as a board member and chairman in both the public and private sectors. He is currently chairman at Ordnance Survey, and a non-executive director at the University of London and at Aliaxis SA. He has also been a board member at City, University of London. Diana Walford AC/ QSC/RC Diana Walford joined in December She has a distinguished record at the highest level in the civil service, NHS and higher education. During her career she served the NHS as Deputy Chief Medical Officer for England, director of healthcare for the NHS Management Executive, Director of the Public Health Laboratory Service and non-executive director of the NHS Blood and Transplant Authority. Diana is also a qualified haematologist and epidemiologist and was an honorary consultant haematologist at the Central Middlesex Hospital. Most recently, she was the Principal of Mansfield College, Oxford University. Annual Report and Accounts 2016/ PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE)

36 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Caspar Woolley FCC/IC/RC/WC (chair) Caspar Woolley joined in January Caspar is a Cambridge University graduate who started his career as a design engineer. He founded and is a Board member at Hailo Network Ltd, the taxi app. He also served as the Chief Executive Officer of E-Courier (UK) Ltd and led the ecourier.co.uk management team. He was also Vice President for Fleet at Avis. Previously, he served as the Head of Business Development for The John Lewis Partnership. He served as Vice President of Operations at buy.com (UK) Ltd. He has been an independent non-executive director of GAME Digital plc since 16 May He has also been a governor at a foundation trust. Executive directors The remuneration committee of the Board appoints executive directors on permanent contracts. Professor Marcel Levi Chief Executive FCC/IC/QSC Marcel Levi joined UCLH as Chief Executive in January Marcel has had a distinguished career as a clinician, academic, educator and clinical leader. Prior to joining UCLH he was Chairman of the executive board of the Academic Medical Center, University of Amsterdam, for six years and before that, he was Chairman of its Department of Medicine and Division of Medical Specialisms for ten years. Marcel is a practising consultant physician at UCLH, specialising in haemostasis, thrombosis and vascular medicine. He was named the best specialist in internal medicine in the Netherlands for three consecutive years. Marcel obtained his PhD in 1991 and was appointed a Member by the Royal Netherlands Academy of Science. Professor Geoff Bellingan Medical Director, Surgery and Cancer Board FCC/QSC Geoff Bellingan was appointed Medical Director in September He previously held posts as Clinical Director and Divisional Clinical Director between 2006 and He trained as a chest physician and then in intensive care in which he has been a consultant at UCLH since He was appointed as a professor in intensive care medicine at UCL in As Medical Director for Surgery and Cancer, Geoff has a particular interest in cancer care across North and East London and West Essex, working closely with London Cancer, Macmillan and a number of other major partners. This led to the successful UCLH Cancer Collaborative application and the award of the national Cancer Vanguard in partnership with Greater Manchester Cancer Vanguard Innovation and Royal Marsden Partners. Geoff is also the senior responsible officer for the development which incorporates one of the UK s first two NHS Proton Beam Therapy units, and a short stay surgical centre. Dr Gill Gaskin Medical Director, Specialist Hospitals Board FCC/QSC Gill Gaskin was appointed Medical Director of the Specialist Hospitals Board in January Gill graduated from Cambridge and trained in renal and general medicine at Hammersmith Hospital and the Royal Postgraduate Medical School, completing a PhD on the biology of systemic vasculitis. Between 1995 and 2010 she held consultant-level posts at Imperial College, Hammersmith Hospitals and Imperial College Healthcare Trusts, with additional responsibilities as Director of Postgraduate Medical Education and Professional Development, Clinical Director and latterly Director for the Medicine Clinical Programme Group. Gill is a member of the Faculty of Medical Leadership and Management. Neil Griffiths Deputy Chief Executive FCC Neil Griffiths joined the Board as Deputy Chief Executive in June Neil has more than 20 years hospital experience having joined the NHS from Bristol University in He has a background in operational, commercial and strategic management having previously worked at Lewisham, St Mary s (now part of Imperial), East Kent, and the Royal National Orthopaedic Hospitals. Neil also previously worked at UCLH between 2003 and Before his current post Neil spent six years working in the private healthcare sector, most recently as a member of the healthcare management consultancy McKinsey & Company, where he helped develop the McKinsey Hospital Institute in the UK. 36 University College London Hospitals NHS Foundation Trust

37 Dr Charles House Interim Medical Director, Medicine Board FCC/QSC/WC Charles House took up the post of interim Medical Director in March He studied medicine at St Mary s Hospital Medical School and trained in radiology at UCLH, being appointed here as consultant radiologist in 2005, with subspecialist interests in bone and soft tissue sarcoma, myeloma and orthopaedic imaging. After spells as College Tutor for the UCLH radiology training scheme and clinical lead in radiology, Charles had previously held posts as Divisional Clinical Director of Imaging and Associate Medical Director. Charles has a keen interest in clinical leadership and evolving models of healthcare, with focus on collaboration between organisations and across sectors. Tim Jaggard Finance Director FCC/IC Tim Jaggard was appointed Finance Director in April 2016 having previously held the posts of Interim Finance Director and Deputy Finance Director at UCLH. He joined from the Whittington in 2010 where he was Deputy Finance Director for two years. Prior to this Tim held senior finance positions in service line reporting, patient level costing, commissioning and financial management. He graduated from the NHS graduate training scheme in He has a degree in Psychology from Cambridge which was followed by further study at the Judge Business School. Professor Tony Mundy Medical Director, Corporate QSC/WC Tony Mundy has been a Medical Director since Since November 2006 he has been the Corporate Medical Director with UCLH-wide responsibility for quality and safety and for research and development. He is the UCLH responsible officer for the revalidation of doctors under the GMC registration regulations. He was previously Clinical Director of Urology and Nephrology and then Medical Director for Medicine and Surgery from 2001 to Tony is a professor of urology at the University of London and Director of the Institute of Urology. Flo Panel-Coates Chief Nurse QSC/WC Flo Panel-Coates was appointed UCLH Chief Nurse in April 2015, coming to the organisation from Barking, Havering and Redbridge University NHS Trust where she was Chief Nurse for two and a half years. Prior to that she was Director of Nursing and Quality at Maidstone and Tunbridge Wells NHS Trust from August 2008 until September She also held positions of Director of Nursing and Midwifery, and Director of Infection Prevention and Control at the North Middlesex University Hospital NHS Trust from September 2005 to August She has a keen interest in organisational culture and in creating different ways of working to release more time to care. Ben Morrin Director of Workforce WC Ben Morrin joined UCLH as the Director of Workforce in September In the preceding decade he worked across the Department of Health and within the Prime Minister s Delivery Unit. Ben is a Fellow of the Chartered Institute for Personnel and Development. Board members who stood down during the year Sir Robert Naylor Chief Executive Sir Robert Naylor retired in October He had been the Chief Executive since November Sir Robert oversaw the development of one of the largest building projects in the NHS to create the world-class University College Hospital. Robert was awarded a knighthood for services to healthcare by Her Majesty the Queen in the New Year Honours List PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

38 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Board committees The Board committee structure is set out below. Terms of reference set out the responsibilities of each committee and this structure monitors and provides assurance to the Board on the delivery of our objectives and other key priorities. Audit Committee Investment Committee Board of Directors Remuneration Committee Quality & Safety Committee *UCLH also has a treasury advisory group that meets as and when required Directors attendance at the Board and the Council: Member Board Council Non-executive directors Richard Murley 10/10 4/4 Harry Bush 8/10 2/4 Althea Efunshile 8/9 2/3 David Lomas 9/10 1/4 Rima Makarem 9/10 3/4 Kieran Murphy 10/10 4/4 Diana Walford 8/10 3/4 Caspar Woolley 10/10 3/4 Executive directors Marcel Levi 2/3 1/1 Geoff Bellingan 9/10 3/4 Council of Governors Finance & Contracting Committee Workforce Committee Member Board Council Charles House 10/10 4/4 Tim Jaggard 10/10 4/4 Flo Panel-Coates 9/10 4/4 Tony Mundy 6/10 0/4 Ben Morrin* 9/10 4/4 Robert Naylor 4/5 2/2 * The Director of Workforce regularly attends Board meetings but has no voting rights. Gill Gaskin 10/10 3/4 Neil Griffiths 10/10 4/4 38 University College London Hospitals NHS Foundation Trust

39 Audit committee Membership comprises four independent nonexecutive directors (including the committee chair) selected for their skills and experience. The audit chair has significant audit committee experience. One member has substantial financial expertise and one is a distinguished medical expert. All meetings are normally attended by our external auditors, Deloitte LLP, and local counterfraud specialists RSM Risk Assurance Services LLP, the UCLH Finance Director, and Deputy Chief Executive and our Trust Secretary. KPMG were appointed as internal auditors in 2016/17 replacing TIAA. The Head of Internal Audit and other internal audit representatives also attend the meetings. Other executive directors and senior managers are invited to attend when necessary and the Chief Executive attends annually when the committee reviews the financial statements. The committee meets seven times a year to discharge its duties. It reviews the adequacy and effectiveness of the systems of integrated governance (corporate, clinical and financial) and ensures internal control and risk management is in place to support the achievement of the UCLH objectives. Its responsibilities are set out in its terms of reference which can be found on our website. Members attendance at audit committee: Member Attendance Rima Makarem 7/7 Harry Bush 7/7 Althea Efunshile 2/2 Kieran Murphy 4/5 Diana Walford 6/7 The committee is well-placed to fulfil its assurance role. The finance, investment, quality and safety, and workforce committees include audit committee members. This broad coverage of knowledge strengthens its effectiveness. The audit committee provides the Board with an independent view of financial and corporate governance and risk management. During the year the committee approved the internal audit plan for 2016/17 and received audit reports from KPMG. The reports covered risk management, financial control, data quality, clinical governance (for example serious incidents), and compliance issues including cyber security. The committee reviewed the appropriateness and implementation of management s response to the findings. The committee monitored counter fraud arrangements through the review of quarterly progress reports, including fraud risk assessments. It also received regular updates from management on the financial metrics in place to meet the better payment practice standards. The head of internal audit opinion is one of significant assurance with minor improvements required. External auditors Deloitte LLP presented quarterly reports on the financial statements. The committee reviewed key areas of judgement in both financial and non-financial reports, including revenue recognition and related bad debt provisions, capital expenditure, valuation of land and buildings, financial performance including going concern and value for money areas. The committee received Deloitte s conclusions from its audits of the 2016/17 quality report and annual accounts and considered the annual report and annual governance statement before submission to the Board for approval. The committee monitored the performance and independence of the external auditors and the effectiveness of both internal audit and local counter fraud. It also reviewed its own effectiveness. The committee held two workshops to gain a deeper understanding of the management of private patients and overseas visitors and the UCLH leadership development programme. In March 2017 it held an annual risk session with other Board members. The external and internal audit partners and the local counter-fraud specialists have direct access to the committee. The committee members held private meetings with both the external audit partner and the head of internal audit during the year. External auditors The Council of Governors appointed Deloitte LLP as external auditors for three years commencing with the 2016/17 audit, with an option to extend for a further two years. The auditors opinion and report on the financial statements is the Annual Accounts. Deloitte may also provide non-audit services with the agreement of the committee and the Council of Governors. No non-audit work was provided during 2016/17. The total cost of the external audit of the financial statements and quality report for the year was 199,000 ( 153,600 in 2015/16). Annual Report and Accounts 2016/ PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE)

40 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Remuneration committee The remuneration committee sets pay and employment policy for the executive directors and other senior staff designated by the Board, and considers the performance of the executive directors. The committee sets remuneration with due regard to benchmarking information and survey data of other comparative senior posts within the NHS sector. All non-executive directors listed under Board of Directors are members. It is chaired by Richard Murley, Chairman of the Board. The remuneration committee met on two occasions in 2016/17 (11 May and 8 June) All non-executives attended both meetings. Ben Morrin, Director of Workforce, and Sir Robert Naylor, the Chief Executive attended both meetings in an advisory capacity. Details of salary and pension entitlements for the directors of UCLH are set out in the Remuneration Report section 2.2.3:Senior manager remuneration. Finance and contracting committee The finance and contracting committee provides oversight and scrutiny of all aspects of financial management and assurance to the Board on the management of financial risk. To achieve its aims, the committee examines financial performance and reviews costing and benchmarking work. It also oversees UCLH s approach to contracting and considers longer-term financial performance and planning issues. The FCC met nine times in 2016/17. Investment committee The investment committee advises the Board on investment decisions. It reviews the annual capital programme and reports to the Board on major capital investment proposals. In conducting an independent review of investment proposals, it considers strategic fit and ensures business cases have been appropriately assessed with regard to risk. In addition, it reviews medium-term investment strategy, including the financial and economic aspects of the estate strategy. The committee met eight times during the year. Quality and safety committee The quality and safety committee (QSC) is responsible for ensuring that effective arrangements are in place for the oversight and monitoring of all aspects of quality i.e. safety, effectiveness and patient experience. The Board relies on the committee to provide advice on clinical quality, patient safety and risk and for assurance on areas of clinical governance, audit and patient experience. It focuses on promoting a culture of openness and organisational learning. 40 University College London Hospitals NHS Foundation Trust On behalf of the Board, it reviews compliance and receives assurance in meeting regulatory standards set by the Care Quality Commission (CQC). The QSC met 11 times in 2016/17. Workforce committee A new workforce committee was established in September It is responsible for ensuring effective oversight of one of our strategic priorities to support staff to deliver their potential. The committee met on two occasions before the end of 2016/17. Board, committee and directors evaluation The Board considers that its Board of Directors and its committees have sufficient knowledge and experience to fulfil its statutory duties. The balance of skills and expertise on the Board is appropriate to the requirements of UCLH. To help the Board assure itself in this regard it undertakes a self-assessment of its governance practices. Last year it undertook an external review of its governance and actions from that review were implemented in 2016/17. All directors have an annual appraisal. The Council of Governors nomination and remuneration committee conduct the Chairman s appraisal. This is done jointly in May by a governor and the Vice-Chair of the Board following consultation with governors and Board members. The outcome was presented to the Council in July The Chairman assesses the performance of the non-executive directors and reports the outcome to the nomination and remuneration committee. The Chief Executive reviews the performance of the executive directors and, following discussion with the non-executive directors, the Chief Executive is appraised by the chairman. The outcome of these appraisals is reported to the Board s remuneration committee. Director expenses For 2016/17 the total amount of expenses claimed by five directors was 3,

41 2.1.2 Governors and members Being a member gives people interested in UCLH the opportunity to find out more about UCLH and the services it provides and get involved. We have three membership constituencies and anyone aged 14 or over can become a member of UCLH. The membership has three constituencies, patient, public and staff, as defined in the Trust constitution and summarised below: The public membership includes individuals living in one of the 32 London boroughs or the City of London. The patient membership is divided into three groups. Patients living in one of the 32 London boroughs or the City of London (London) and patients from elsewhere in England or further afield (non- London). There is also a carer group which is open to individuals who are unpaid carers of patients of UCLH. Anyone who joins as a patient or carer member must have attended a UCLH hospital within the last three years. The staff membership comprises individuals who have a contract to work with UCLH for more than 12 months. This includes employees of UCLH, employees of UCL who have an honorary contract with UCLH, and contractors who provide services to UCLH. There are four staff groups: clinical support, doctors and dentists, non-clinical support, and nurses and midwives. When staff join UCLH they become members unless they choose to opt out. This right is explained to staff. No staff are currently opted out. Staff cannot be members of the public or patient constituencies. Our membership At 31 March 2017, UCLH had 21,796 members as follows: 12,000 10,000 8,000 6,000 4,000 2,000 - Our membership 2016/17 9,023 Our overall public and patient membership increased from 11,686 to 11,819 in the past year despite our focus being on improving engagement and involvement with existing members. Demographic information provided by public members shows our membership is broadly representative of the population we serve. However, we need to actively increase our membership from black communities and also those members aged between 14 to 29. Twenty-eight per cent of our public members are under 40, compared to 47 per cent of the local population and nine per cent of our public members identify themselves as black, compared to 13 per cent of the local population (2011 Census data). During 2017/18 we will carry out more detailed analysis to support our membership development work by working closely with the voluntary and community sectors and with our public and patient involvement partners at UCLH. 2,796 9,977 Patient and carer Public Staff Number of members 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

42 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Membership engagement and strategy The membership strategy making a difference together centres on recruitment, communication and engagement with members. This year, in line with other trusts, the membership manager has focused on developing the communication and engagement with members rather than increasing membership numbers. Some of the work undertaken during 2016 to aid this includes: Surveying members for their views on their magazine UCLH News Recruiting members to join UCLH groups looking at improving patient experience and how we plan and manage our cancer and haematology services Evaluating the contact information already held for members; increasing communication via Patient-Led Assessments of the Care Environment (PLACE) Involvement in UCLH s summer school Governors chaired five MembersMeet health seminars on a range of topics influenced by members interests including migraines, sleep disorders and arthritis. There was also a seminar on the UCLH forward plan for 2017/18. The seminars allow members to talk about matters of interest to them and for governors to meet with members, follow up concerns and communicate any issues to the Board. Once an individual becomes a member they have the option to vote for or stand to become a governor. There is an annual session for interested members to ask questions about the role. A group of governors and members will review our membership strategy and report the outcome to the Council in April Our Council of Governors UCLH is accountable to the communities it serves through the Council of Governors which represents the views of patients, public members of UCLH and its staff. The Council works closely with UCLH to help shape and support its future strategy and ensure that we focus on issues that benefit patients. With the support of the governors on the Council, UCLH can take into account the views of members and stakeholders in the wider community. Who are the Council? The Council has 33 governors; comprising 23 elected governors who represent the public, patients, carers and staff; and 10 appointed stakeholder and partner governors. As at 31 March there were 31 seats occupied. The following table gives details of the governors, their terms in office during 2016/17 and attendance at council meetings. Governors normally hold office for three years and are eligible for re-election or re-appointment at the end of their first term. Governors may not hold office for more than six consecutive years. The council also elects one of its members to be the lead governor. Diana Scarrott has held the position since April Name Constituency Current term Term end David Coulter Public second 31 August Maggie Gormley Public first 31 August /2 Frances Lefford Public first 31 August Meetings attended (out of a total of 4 unless otherwise stated) Diana Scarrott Public second 31 August Veronica Beechey Patient London second 31 August John Bird Patient London second 31 August University College London Hospitals NHS Foundation Trust

43 Name Constituency Current term Term end Graham Cooper Patient London first 31 August /2 Emma Dalton Patient London second 31 August Adam Elliot Patient London first 31 August John Green Patient London first 31 August John Knight Patient London second 31 August Christine Mackenzie Patient London first 31 August Jo Wagerman Patient London first 31 August /2 Leslie Brantingham Patient non-london first 31 August Annabel Kanabus Patient non-london first 31 August Gareth Long Patient London first 31 August /2 Rosalind Jacobs Patient Carer second 31 August Janet Clarke Staff first 31 August /2 Caroline Dux Staff first 31 August /4 Josie Gladney Staff first 31 August /2 Kathryn Harley Staff first 31 August Jessica Lipman Staff first 31 August /2 Wayne Sexton Staff first 31 August Danny Beales Camden Council first 31 August Claudia Webbe Islington Council second 30 June Warren Turner Mike Hanna London South Bank University University College London first 14 October second 6 November Claire Williams Friends of UCLH first 29 June Philip Brading UCLH Charities Committee second 14 October Charlotte Williams UCLPartners first 31 July /2 Ammara Hughes GP Commissioning Consortia Vacant NHSE (London) - - first 1 October Meetings attended (out of a total of 4 unless otherwise stated) 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Vacant Camden/Islington CCGs - - Annual Report and Accounts 2016/

44 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Governors who stood down in 2016/17 Name Constituency Current term Term end Fiona Henderson Staff first 31 August /2 Tom Hughes Staff second 31 August /2 Stephen Rowley Staff first 31 August /2 Fazlul Chowdhury Public first 31 August /2 Andrew Todd-Pokropek Patient London first 31 August /2 Fiona McKenzie Patient London second 31 August /2 Stuart Shurlock Patient non-london second 31 August /2 James Mountford UCLPartners second Stood down 30 June 2016 Role of the Council The Council has a number of statutory responsibilities, which include but are not limited to: holding the non-executive directors to account for the performance of the Board, appointing or removing the chairman and nonexecutive directors deciding the remuneration of non-executive directors appointing or removing UCLH s auditors. The Council also has the final decision on significant transactions, receives the annual report, quality report, accounts and auditors report; approves changes to the constitution; and gives its views on the development of our forward plan. How the Council works The Chairman of the Board of Directors is also Chairman of the Council. This establishes an important link between the two bodies and helps governors to fulfil their statutory responsibilities. Other Board members, both executive and non-executive, also attend meetings. Board members attendance at council meetings can be found in Section table: Directors attendance at the Board and the Council. The Council receives regular reports from the Board on clinical and financial performance and service strategy and is presented with a report from the chair of the audit committee annually. It also Meetings attended (out of a total of 4 unless otherwise stated) 0/1 receives reports from governors who contribute to our sub-committees: arts and heritage, nursing and midwifery, patient experience and quality and safety. It considers reports from the council s nomination and remuneration committee and a governors group with a focus on high-quality patient care. The chairman and the lead governor also seek the views of governors when preparing the agendas for meetings and during the year the council had presentations on specific topics, including the delivery of the CQC action plan. The link between the Board and the governors is further strengthened through a series of seminars to support governors in their role. In 2016/17 six were held. Sessions included the North Central London Sustainability and Transformation Plan (NCL STP) and digital services and informatics. The lead governor also holds regular meetings with governors to keep in touch with opinion and further enhance communication between the Council and Board members. Governors also meet separately with the non-executives to hear first-hand how they have sought assurance from the executive on areas of performance and for the non-executives to hear the views of the governors. This year s meeting covered progressing capital projects and operational performance. Governors and Board members also undertake walkarounds to keep in touch with patients. Papers for the council meetings are published on the UCLH website. 44 University College London Hospitals NHS Foundation Trust

45 Training On joining UCLH each governor attends an induction session and meets with the Membership Manager, Chairman and lead governor respectively. Externally facilitated training is also provided to help governors gain an improved appreciation and understanding of their role in specific areas. These sessions are run jointly with Camden and Islington NHS Foundation Trust and this year covered governor core skills, accountability, finance and business skills and membership and engagement. Governor expenses Governors can claim reasonable expenses for carrying out their duties. For the year 2016/17 the total amount claimed by seven governors was 8, Register of interests Governors sign a code of conduct and declare any interests that are relevant and material. The register of governors interests is published annually and can be found on our website on our council of governors page or by ing foundation.trust@uclh.nhs.uk or calling Committees of the Council The Council of Governors has responsibility for approving the reappointment or appointment of non-executive directors as recommended by the nomination and remuneration committee or a nonexecutive appointment panel. Non-executive directors are appointed by the Council for an initial period of three years; this may be extended for a further three years. In exceptional circumstances a non-executive director can serve for a further year. The Council may also remove the Chairman or another non-executive director: this requires the approval of at least three-quarters of the members of the council. Nomination and remuneration committee The nomination and remuneration committee is chaired by David Coulter, who is a public governor. The committee comprises nine governors (including the committee chair). It is responsible for reviewing the remuneration of non-executive directors and contributes to the appraisal of the Chairman. It also acts as the appointment committee for the nonexecutive director nominated by UCL and for those non-executive directors seeking reappointment. The committee met five times during the year. The Chairman attended three meetings. In June the committee recommended a change to the UCLH Constitution to allow the Council to extend a non-executive director s period in post beyond the maximum term in office, in exceptional circumstances. In parallel, the committee considered extending the Chairman s appointment for a further six months from July 2017 so that he could work alongside and support the new Chief Executive for a full year. In July, the Council approved the revision to the Constitution and the extension of Chairman s appointment for a further six months. In July, the Board also approved the revision to the Constitution. In June the committee considered the reappointment of two non-executive directors Rima Makarem and Kieran Murphy. In July the committee recommended to the Council that they be reappointed. This was agreed. Membership of the committee is reviewed each year in October. Members and attendance at the committee is set out below. Meeting dates were 19 May, 9 June, 22 June, 27 June, and 3 November Nomination and remuneration committee membership and attendance Member Attendance David Coulter (Chair) 3/5 John Bird 4/5 Philip Brading 1/5 Emma Dalton 1/5 John Green 4/5 John Knight 4/5 James Mountford* 1/2 Wayne Sexton 3/5 Claire Williams 5/5 *stood down 30 June Non-Executive Appointment Panel In February 2016, a Non-Executive Appointment Panel was established to appoint to a vacant position on the Board. Membership of the panel comprised the Chairman, three Governors, and two Non- Executive Directors. External search advisors Green Park supported the process. The panel met on two occasions: 5 and 11 April. All panel members attended the meetings. The panel recommended to the Council that Althea Efunshile be appointed. 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

46 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Contacting the Governors The UCLH membership office is the point of contact for members, patients and the public who wish to contact Governors. foundation.trust@uclh.nhs.uk Post: Membership Office, University College London Hospitals NHS Foundation Trust, 2nd Floor Central, 250 Euston Road, London NW1 2PG Phone: Statement of compliance with cost allocation and charging guidance UCLH has complied with all costing guidance issued by NHS Improvement Details of political and charitable donations UCLH has not made any political or charitable donations this year Statement on the better payment practice code UCLH aims to pay its suppliers within 30 days of receipt of goods or a valid invoice (whichever is later) in line with the Better Payment Practice code and monitors performance against this target. In 2016/17 we paid 72 per cent by value of invoices within this target (2015/16-61 per cent) Quality governance disclosures Quality governance framework We consider we have robust structures and processes in place to ensure required standards are met. We address sub-standard performance, make continuous improvements based on best practice and identify and manage any risks to the quality of care we provide. The quality and safety committee has oversight of clinical risks and provides assurance on the quality of clinical care. It reviews feedback, complaints, claims and incidents. It also monitors compliance with Care Quality Commission (CQC) standards. The Quality and Safety team, led by the Director for Quality and Safety, shares learning across UCLH to promote and maintain patient safety. This is delivered through a monthly quality and safety bulletin and also a regular update on serious incidents which includes root causes, key learning and actions arising. We have a programme of improving care walk rounds conducted by a multidisciplinary team who act as fresh eyes to encourage improvement to care and services. UCLH produces an annual Quality Report which includes details of our objectives to improve safety, experience and effectiveness, as well as our quality performance measures and assurances. Further information is also provided in the annual governance statement. During our review of the 2016/17 quality governance framework, we noted progress on actions identified last year and agreed to: continue work to improve our risk management practices by increasing training in this area publish performance indicators in quality and safety packs to improve risk monitoring undertake a review of the quality and safety committee s effectiveness continue to focus on improving data quality Patient care activities Care Quality Commission (CQC) inspection In March 2016 the Care Quality Commission (CQC) carried out its first inspection of our core services which resulted in a rating. UCLH was rated good in the inspection report published in August CQC inspectors found that UCLH staff treated and cared for patients with compassion, dignity and respect. The report also praised the innovative environment at UCLH. While our overall rating was Good, five areas were found to require improvement; three in urgent and emergency services, and two in medical care. Following the inspection report, UCLH embarked on an action plan to address the recommendations made by the inspection team. The UCLH CQC executive steering group is responsible for monitoring the plans on a quarterly basis. For detailed information about how we are responding to recommendations made by the CQC see section 3 Quality Report. Inpatient survey 2016 We have once again achieved excellent results in the national inpatient survey. The 2016 Picker Institute results show we scored significantly better on 27 of the 67 questions compared to the Picker national average, and only significantly worse on two. In the survey, 89 per cent of inpatients at UCLH rated 46 University College London Hospitals NHS Foundation Trust

47 their overall experience as seven out of 10 or higher. This puts us among the top acute London teaching hospitals. For more information, see the Quality Report. Responding to staff and patient feedback We have strengthened and developed our approach to patient experience since it was first introduced in The patient experience committee is now chaired by a non-executive director, and the role of the site experience groups and content of our quarterly report have been developed further. Our work on patient/customer experience standards is ongoing. The standards aim to provide clear guidance on what people should expect to experience during their time as a patient at UCLH. The standards are broad and elements include the physical environment of the ward, waiting times, length of stay and safe discharge. The metrics have been tested with the director of planning and performance and uclh future programme leads, as well as by the patient experience committee and the Executive Board. New patient feedback system We have introduced a new way of collecting feedback from patients to monitor their experiences in real time. The new system allows a greater range of patients to give us their comments as it includes different languages, formats and text-to-speech options. We have adapted our surveys for children and young people and are developing an Easy Read version suitable for patients with a learning disability or dementia. We will soon be contacting patients via text and automated phone calls to capture responses from those who were treated in the Emergency Department, Outpatients or as day cases. Improvements to parking for disabled patients We have made it simpler and more convenient for patients with a disability and their carers to park at University College Hospital and have simplified the process for applying and collecting dispensation notices. This is in response to reports of difficulties with parking. The permit allows blue badge holders to park on the site. People can now apply for a notice in advance. Previously, they had to collect a permit from reception staff, and then park their car and return to the hospital. This improvement means that patients now need only make one journey to the hospital, as they can simply park with the permit and go straight to their appointment. A UCLH parking address has been introduced so our patients with disabilities have a contact for any enquiries. We have also updated our maps to show the availability of disabled parking spaces. As a result, our Patient Advice and Liaison Service (PALS) has reported a 93 per cent reduction in contacts about parking for patients with a disability. Disabled Go guides In November, we introduced new guides for patients and visitors with special access needs to help them plan their hospital visits. The guides are available for University College Hospital (including the Elizabeth Garratt Anderson Wing), the University College Hospital Macmillan Cancer Centre and the National Hospital for Neurology and Neurosurgery. The guides have been designed for anyone who might find getting around less easy than others, for example older visitors, those with young children or those coming to hospital with an injury. Each site was assessed by a team of surveyors, and the guides can be accessed via our website. The guides received 1,195 views in the first eight weeks. We will evaluate the impact of the guides and may introduce them for our other hospitals. The UCLH website also links to the Disabled Go web-based service which provides detailed information about the accessibility of different venues. The Disabled Go site can be viewed in 64 different languages, in different formats, and features a read aloud mode. Annual Report and Accounts 2016/ PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE)

48 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Accessible Information Standard written patient information We have been working to meet the requirements of the national standards for accessible information. We want to make sure our patients, their family and carers can access and understand the information they are given. We provide printed patient information in formats such as easy read, audio and braille, and have produced improved guidance for staff on how to provide alternative formats. Inpatient welcome packs We have continued to roll out our welcome pack across UCLH. In the last year 28,700 packs were delivered to wards to improve the experience of our patients during their stay at UCLH. The packs give patients useful information about what they can expect during their stay, including information on safety and wellbeing, and include practical items such as a toothbrush and toothpaste, eye mask and non-slip socks. These items are particularly useful to patients who are admitted to UCLH as an emergency. The packs continue to receive positive feedback from staff and patients and this year we will be taking part in an evaluation project working with Giving World, the charity which supplies the packs. uclh future (patients) We have made a number of improvements to patient experience through our transformation programme, uclh future, in the past year including: Introducing an exemplar ward accreditation system which recognises and supports teams that continuously improve every element of ward activity and care. Introducing enhanced training for nursing assistants through our exemplar ward programme. They receive specialist training and support to help look after our most vulnerable patients. Improving coordination and planning ahead for discharge at daily ward huddles. We have introduced a simple escalation procedure and improved standards for ward huddles to reduce any unnecessary delays. This means more patients are ready to be discharged as soon as they are medically fit to be moved from an acute setting. Maximising efficiency and performance of diagnostic services by streamlining and integrating patient pathways. A new electronic system has been introduced enabling staff to request pathology tests more efficiently. Introducing new staff rostering methods which offers more predictable and regular shift patterns for nurses, leading to better staff and patient experience. Increasing the number of phone consultations by 20 per cent so these patients did not have to travel for follow-up appointments when it was not necessary to see a clinician in person. In 2016/17 there were 26,143 phone consultations. Recruitment to research studies In 2016/17, approval was given to 320 new research studies to begin recruiting at UCLH. These range from clinical trials of medicinal products and devices, to studies on service and patient satisfaction. There are currently 1,482 studies involving UCLH patients that are open to recruitment or follow-up. Of these, approximately 64 per cent of studies are adopted onto the National Institute of Health Research Clinical Research Network (NIHR CRN) portfolio of research. There were 19,986 participants recruited to research studies at UCLH this year. The Research Patient Flag allows clinicians to flag electronic notes when a patient is participating in a research project. We have 218 UCLH staff who have been trained to use the system to log studies and patients, and 126 new studies have been added to the research flag function. Handling complaints UCLH asks complainants how they want their complaint to be handled. A formal complaint is one in which the complainant asks for an investigation and written response. Individual divisions work closely with the complaints team to resolve other concerns which do not require a full formal investigation. Monthly figures on complaints are shared and monitored via performance reports. The patient experience quarterly report uses data from complaints, Patient Advice and Liaison Service (PALS), feedback, surveys and Friends and Family Test (FFT) results. UCLH produces an annual complaints report. The UCLH complaints manager produces ad hoc reports for the divisions and boards as required, and quarterly reports for the Improving Experience Group, the Patient Experience Committee and the Quality and Safety Committee to identify any trends or themes. Lessons learnt are shared through the quality and safety newsletter, site experience groups and divisional governance groups. For more information about the number of complaints received and the outcome see section 3 The Quality Report. 48 University College London Hospitals NHS Foundation Trust

49 Stakeholder relations Patient and public involvement activities We actively involve our patients, carers and the local community when making decisions about the services we provide. Patient and Public Involvement (PPI) is one of the ways in which we can engage patients and the local community to help us deliver the highest quality care within our resources. In the last year a range of PPI activities have led to a number of changes. We have listened to feedback from 466 patients and worked closely with a further 46 patients to develop ideas. We held two engagement events and run 23 user groups across UCLH. The Improving Experience Group has recruited two new patient representatives to attend monthly meetings and work with staff at a strategic and local level. Patient feedback has helped shape the redevelopment of our Emergency Department (ED). Patients have been consulted on the signage and new route from the ED to the Elizabeth Garrett Anderson maternity wing. The National Hospital for Neurology and Neurosurgery piloted a number of productive support groups for patients and carers, and the Cancer Patient and Public Advisory Group has continued to run successful bi-monthly meetings. A Whose Shoes? event held by our Maternity Services in July encouraged patients and staff (through using a board game) to gain insight into the concerns, challenges and opportunities of others. The Paediatric and Adolescent Division hold weekly breakfast clubs on the wards, so patients can give their feedback in a relaxed, informal environment. Feedback postcards are collected each month and the themes are included on the You Said, We Did boards in our wards. Over the past year, six young patients have helped to interview new staff and their personal insights have proved invaluable for helping us recruit the best candidate. The team was shortlisted in the final of the Patient Experience National Network awards, held in March 2017, for their work involving young people in staff recruitment. UCLH Cancer Collaborative and the national Cancer Vanguard Our aim to produce world class cancer outcomes is only possible if we work as part of a wider healthcare system, with colleagues across London and the country. The UCLH Cancer Collaborative brings together healthcare organisations across North Central and North East London, and West Essex to improve cancer outcomes through earlier diagnosis, with a particular focus on lung and colorectal cancers. We are developing new models of care through partnerships with industry, academia, the third sector and pharma companies that benefit patients. We are also working to improve the way that data on cancer outcomes is recorded and used. London Cancer became part of the UCLH Cancer Collaborative in September 2016 and continues its work across the region in partnership with Macmillan and others to deliver comprehensive and seamless cancer care to patients from diagnosis, through treatment, to living with and beyond cancer. The national Cancer Vanguard is a partnership between the UCLH Cancer Collaborative, Greater Manchester Cancer Vanguard Innovation and Royal Marsden Partners. Together we serve a population of over 10 million and we are working to change the way that cancer care is provided. Working with our local partners See section Important events affecting our organisation Equality reporting (patients) In 2016, we worked with different communities to deliver patient care that is inclusive, accessible and fair. This includes improving treatment for people living in vulnerable circumstances such sheltered and supported accommodation, the homeless, patients with learning, physical, mental and social difficulties and disabilities. We have continued to enhance our specialist services, including our African Women s Clinic, and a wide range of services for children and young people. We have created action plans to further improve services for patients with protected characteristics in line with the Equality Act (2010). Our priorities include to: make more areas of our hospitals and services dementia-friendly and accessible for patients collect data on all protected characteristics and ensure multiple disabilities are recorded fulfil the needs of patients with specific communication requirements, in line with NHS England s accessible information legislation (part of the Health and Social Care Act (2012)) develop the teenage and young adult page on the UCLH website, including establishing a closed Facebook page 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

50 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) improve access and information for our disabled patients by implementing recommendations from Disabled Go develop the maternity website to include links to information leaflets for pregnant women whose first language is not English explore in more detail why our inpatient survey shows patients aged are less satisfied with our services than other age groups. Our action plans will be monitored by our Diversity and Equality Group and regular progress reported to the Executive Board. We are also committed to the principles of equality and fairness for our staff. See section Equality reporting (staff) Income disclosures Total non-nhs income represented around 7 per cent of total operating income, significantly lower than permitted in the Health and Social Care Act Section 43(2A) of the NHS Act 2006 (as amended by the Health and Social Care Act 2012). The threshold is 50 per cent. The Health and Social Care Act states that a foundation trust will not fulfil its principal purpose if, in each financial year, its total income from the provision of goods and services for the purpose of health service is exceeded by the total income from any other purposes Statement of disclosure of information to auditors So far as UCLH s directors are aware, there is no relevant audit information of which the auditors are unaware. The directors have taken all of the steps that they ought to have taken as directors in order to make themselves aware of any audit information and to establish that the auditors are aware of that information. Signed on behalf of the Board of Directors Professor Marcel Levi Chief Executive 23 May University College London Hospitals NHS Foundation Trust

51 2.2 Remuneration Report Annual Statement on Remuneration Chair of Remuneration Committee All decisions regarding the pay of senior managers are made by the Remuneration Committee. The Committee is responsible for determining and agreeing, on behalf of the Board, the broad policy for the remuneration of our very senior managers. The Committee are also responsible for considering the performance of the Chief Executive and Executive Directors including the setting of objectives and regular review of performance against them. In the financial year 2016/17 a one per cent increase was afforded to base salaries for senior managers whose terms and conditions were not covered by nationally determined contracts. The Medical Directors basic salaries are defined through national agreements for Medical and Dental staff. In the financial year 2016/17, three Medical Directors received an uplift of one per cent to base salary in line with the national agreement for medical and dental staff whose terms and conditions are covered by nationally determined contracts. A fourth medical director is an employee of University College London. In January 2017 we welcomed our new Chief Executive, Professor Marcel Levi. No other appointments were made to Executive Director posts. UCLH is aware of recent media attention given to the levels of remuneration of senior managers within the NHS. UCLH has always strived to operate with openness and transparency when reviewing and setting the pay levels for senior management and we will continue to do this going forward. Richard Murley Chairman University College London Hospitals NHS Foundation Trust Chair of the Remuneration Committee 23 May Annual Report and Policy on Remuneration The Remuneration Committee (RC) sets pay and employment policy for the executive directors and other senior staff designated by the Board. The Committee sets basic salary remuneration with due regard to benchmarking information and survey data of other comparative senior posts within the NHS sector. Although NHS foundation trusts are free to determine their own rates of pay for Very Senior Managers (VSMs), benchmarking is informed by the VSM pay framework as published by NHS Employers and updated in July Although there is no local consultation with affected employees on VSM pay, the framework takes account of the Will Hutton Fair Pay Review and the Senior Salaries Review Body (SSRB) report on pay, which involved wide consultation. Decisions on any annual uplift to basic salary are informed by government decisions in respect of the recommendations from the SSRB including any government recommendation on non-consolidated basic pay increases. UCLH does not operate a performance bonus scheme and the sole component of VSM pay is the basic salary determined as set out above. There is, therefore, no performance related pay component to VSM salary. All of the staff we employ are afforded remuneration that is subject to annual performance review. The majority of our staff are remunerated in line with the national terms and conditions of the agenda for change or medical and dental contracts. Our most senior managers (VSMs) are employed through trust specific contracts and their individual performance and the case for any pay award are annually reviewed by our remuneration committee. UCLH have developed a Leader Model against which it has begun the task of assessing management capability in order to assess performance. Implementation of this model and assessment will continue to support the short and long term strategic objectives of UCLH. The other elements of pay listed in the table below are only applicable to Medical Directors and are determined in line with national terms and conditions for medical and dental staff. The salary and pension entitlements for senior managers and directors for the financial year are shown in tables Senior Manager Remuneration and Senior Manager Total Pension Entitlement respectively. The remuneration table also shows the notional increase in pension benefits that have accrued during the year, calculated in line with Annual Report and Accounts 2016/ PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE)

52 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Monitor and HMRC guidance. The pensions table includes the real increase of pensions during the reporting year, the value of accrued pension at the end of the reporting year, the value of cash equivalent transfer value (CETV) and the real increase of that value during the financial year. The remuneration and expenses for the UCLH Chairman and non-executive directors are determined by the Council of Governors, taking account of the guidance issued by organisations such as the NHS Confederation and the NHS Appointments Commission. Remuneration for UCLH s most senior managers (executive directors who are members of the Board of Directors, and other directors) is determined by UCLH s remuneration subcommittee, which consists of the chairman and the non-executive directors. The following table Description of components of Senior Manager Remuneration includes a description of each component of the Senior Manager Remuneration. The only non-cash element of senior managers remuneration packages are pension-related benefits accrued under the NHS Pensions Scheme. Contributions are made by both the employer and employee in accordance with the rules of the national scheme which applies to all NHS staff in the scheme. Pay levels are informed by executive salary surveys conducted by independent management consultants and by the salary levels in the wider market place. Affordability, determined by corporate performance and individual performance, are also taken into account. Terms and conditions are consistent with the new NHS pay arrangements. Description of components of Senior Manager Remuneration Component Applicable Description Basic salary inclusive of London weighting Non consolidation Payment Clinical Excellence Award (CEA) Additional Programme Activity Clinical Director Responsibility Medical On Call All senior managers Applicable to Medical Directors only Applicable to Medical Directors only Applicable to Medical Directors only Applicable to all Medical Directors Applicable to Medical Directors only Agreed at appointment by the Remuneration Committee. In April 2016, 1 Medical Director received an unconsolidated, non-pensionable uplift of 1 per cent to base salary in line with the national agreement for medical and dental staff whose terms and conditions are covered by nationally determined contracts. The Clinical Excellence Awards (CEA) scheme is intended to recognise and reward those consultants who contribute most towards the delivery of safe and high quality care to patients and to the continuous improvement of NHS services including those who do so through their contribution to academic medicine The remuneration for this is covered by Schedules 13 and 14 of the Terms and Conditions Consultants (England) Recognises the increased responsibilities associated with the role of Medical Director. The on-call availability supplement recognises the time spent being available while on call. It does not recognise the work actually done while on call. Senior managers are employed on contracts of employment, with a standard six month notice period, and are substantive employees of UCLH. UCLH s disciplinary policies apply to senior managers, including the sanction of dismissal for gross misconduct. UCLH s redundancy policy is consistent with NHS redundancy terms for all staff. Details of the Remuneration Committees which determine the remuneration of board members can be found in Section Details of the appointments committees can be found in Section (non-executive panel). No compensation for early termination was paid during this financial year. No early terminations are expected and no provisions are required accordingly. No awards have been made to any past senior managers or directors. There were no benefits in kind or non-cash elements of remuneration paid to directors in the year. 52 University College London Hospitals NHS Foundation Trust

53 In , 8 senior managers were paid in excess of the threshold of 142,500. UCLH has taken the following steps to satisfy itself that this remuneration is reasonable: The Remuneration Committee sets pay and employment policy for the executive directors and other senior staff designated by the Board. The Committee sets remuneration with due regard to benchmarking information and survey data of other comparative senior posts within the NHS sector. All non-executive directors are members of the Committee and provide objective scrutiny to salaries set in excess of the threshold. A substantial part of the Medical Directors remuneration is made up of a NHS Consultant s basic salary determined in accordance with NHS national terms and conditions. The salaries and pension entitlements of the directors for 2016/17 and 2015/16 are shown on the following pages. Accounting policies for pensions and other retirement benefits are set out in note 7 of the accounts. Professor Marcel Levi Chief Executive 23 May PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

54 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Senior Manager Remuneration Senior Manager Remuneration Note: all salary paid in the year is reflected in the first column. The table also shows the notional increase / (decrease) in pension-related benefits (see note below). Therefore the final column should not be interpreted as the total salary paid in the year. Year ended 31 March 2017 Name and title R Murley Chairman Sir A Breckenridge Non-Executive Director H Bush Non-Executive Director R Makarem Non-Executive Director K Murphy Non-Executive Director C Woolley Non-Executive Director From 1 January 2015 Sir J Tooke Non-Executive Director D.Walford Non-Executive Director D Lomas Non-Executive Director From Sep 2015 A Efunshile Non-Executive Director From May 2016 M Levi* Chief Executive From Jan 2017 Sir R Naylor Chief Executive To Sep 16 N Griffiths Deputy Chief Executive Acting Chief Executive Sep 16 to Jan 17 TOTAL Salary and Fees (bands of 5000) 000 Taxable Benefits and Bonuses (bands of 5000) 000 Notional Increase / (Decrease) in Pension-Related Benefits (see note below) (bands of 2500) 000 Total Including Notional Increase in Pension-Related Benefits (bands of 5000) University College London Hospitals NHS Foundation Trust

55 Name and title R Alexander Finance Director To July 2015 T Jaggard Finance Director From July 2015 G Bellingan Medical Director C House Interim Medical Director From Apr 2016 J Fielden Medical Director To March 2016 G Gaskin Medical Director A Mundy Medical Director F Panel-Coates Chief Nurse B Morrin Director of Workforce Year ended 31 March 2016 Name and title R Murley Chairman Sir A Breckenridge Non-Executive Director H Bush Non-Executive Director R Makarem Non-Executive Director TOTAL Salary and Fees (bands of 5000) 000 Taxable Benefits and Bonuses (bands of 5000) 000 Notional Increase / (Decrease) in Pension-Related Benefits (see note below) (bands of 2500) 000 Total Including Notional Increase in Pension-Related Benefits (bands of 5000) TOTAL Salary and Fees (bands of 5000) 000 Taxable Benefits and Bonuses (bands of 5000) 000 Notional Increase / (Decrease) in Pension-Related Benefits (see note below) (bands of 2500) 000 Total Including Notional Increase in Pension-Related Benefits (bands of 5000) PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

56 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Name and title K Murphy Non-Executive Director C Woolley Non-Executive Director From 1 January 2015 Sir J Tooke Non-Executive Director D.Walford Non-Executive Director D Lomas Non-Executive Director From Sep 2015 A Efunshile Non-Executive Director From May 2016 M Levi* Chief Executive From Jan 2017 Sir R Naylor Chief Executive To Sep 16 N Griffiths Deputy Chief Executive Acting Chief Executive Sep 16 to Jan 17 R Alexander Finance Director To July 2015 T Jaggard Finance Director From July 2015 G Bellingan Medical Director C House Interim Medical Director From Apr 2016 J Fielden Medical Director To March 2016 G Gaskin Medical Director TOTAL Salary and Fees (bands of 5000) 000 Taxable Benefits and Bonuses (bands of 5000) 000 Notional Increase / (Decrease) in Pension-Related Benefits (see note below) (bands of 2500) 000 Total Including Notional Increase in Pension-Related Benefits (bands of 5000) (2.5-0) ( ) ( ) University College London Hospitals NHS Foundation Trust

57 Name and title A Mundy Medical Director F Panel-Coates Chief Nurse B Morrin Director of Workforce TOTAL Salary and Fees (bands of 5000) 000 Taxable Benefits and Bonuses (bands of 5000) 000 Notional Increase / (Decrease) in Pension-Related Benefits (see note below) (bands of 2500) 000 Total Including Notional Increase in Pension-Related Benefits (bands of 5000) * M Levi is provided with accommodation by UCLH Charity. This is not included in the disclosures above. Pension-related benefits are intended to show the notional increase or decrease in the value of directors pensions, assuming the pension is drawn for 20 years after retirement. It is calculated as 20 x annual pension increase + lump sum increase, less any employees pension contributions paid in the year. These increases are then adjusted for inflation to show the real increase in pension-related benefits this may be negative where the inflation adjustment is greater than the underlying increase. Medical Director salaries include payment for both their Director role and NHS clinical work. Senior managers are not paid any taxable benefits, annual performance-related bonuses or long-term performance-related bonuses. Details of expenses paid to Directors and Governors is included in the Directors report. 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

58 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Senior Manager Total Pension Entitlement Real increase/ (decrease) in pension and related lump sum at age 60 (bands of 2500) Total accrued lump sum at age 60 at 31 March 2017 (bands of 5000) Total accrued pension at 31 March 2017 (bands of 5000) Cash equivalent transfer value (CETV) at 31 March 2016 Cash equivalent transfer value (CETV) at 31 March 2017 Name and title Sir R Naylor Chief Executive G Bellingan Medical Director N Griffiths Deputy Chief Executive G Gaskin Medical Director C House Interim Medical Director T Jaggard Finance Director F Panel-Coates Chief Nurse B Morrin Workforce Director ,461 1, Real increase/ (decrease) in cash equivalent value The information above is based on that provided by the NHS Pension Agency. CETVs are stated as actual values, with the increase / (decrease) figure adjusted for inflation. CETVs are shown as zero for directors aged over 60 at the end of the year, as these directors are not permitted to transfer their pensions. Real increase / (decrease) in pension and related lump sum is the increase / (decrease) in annual pension compared to 31 March 2016, adjusted for inflation. Total accrued pension at 31 March 2017 is the annual pension that each director has accrued, including any purchase of added years and transferred-in benefits from other employments. No additional benefit is payable in the event that a director retires early and no director is a member of a separate pension scheme in relation to this employment. 58 University College London Hospitals NHS Foundation Trust

59 Lord Hutton Report Fair Pay Multiple Reporting bodies are required to disclose the relationship between the remuneration of the highest-paid director in their organisation and the median remuneration of the organisation s workforce Band of the Highest Paid Director s Total Remuneration ( 000) Median Pay Remuneration ( ) 37,826 37, The banded remuneration of the highest-paid director in the Trust in the financial year 2016/17 was in the band k (2015/16, 265k- 270k). This was 7.3 times (2015/16, 7.1) the median remuneration of the workforce, which was 37,826 (2015/16, 37,651). In 2016/17, no employees (2015/16, none) received remuneration in excess of the highest-paid director. Total remuneration includes salary and non-consolidated performance-related payments. It does not include employer pension contributions and the cash equivalent transfer value of pensions Accounting officer approval to be signed by CEO Professor Marcel Levi Chief Executive 23 May PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

60 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) 2.3 Staff report Staff costs 2016/17 Year Ended 31 March 2015/16 Year Ended 31 March Salaries and wages 402, ,956 Employers' National Insurance Contributions 37,248 29,534 Employer contributions to NHS Pension scheme 40,370 38,926 Pension Cost - other contributions 0 17 Total excluding Agency staff 480, ,433 Salary cost recharges (5,028) (3,339) Agency staff 9,268 14,579 Employee benefits expense 484, ,673 Less: Employee Costs Charged to Capital 1,783 1,934 Total Employee Costs as per Note 4 482, , Staff numbers Average number of employees (WTE basis) 2016/ /16 Medical and dental 1,293 1,257 Ambulance staff 6 6 Administration and estates 1,694 1,655 Healthcare assistants and other support staff Nursing, midwifery and health visiting staff 2,612 2,528 Nursing, midwifery and health visiting learners Scientific, therapeutic and technical staff 1, Healthcare science staff Total 7,673 7,468 Agency and contract staff Bank staff Total average number of non-permanent employees Total average number of employees 8,576 8,403 Of which Number of employees (WTE) engaged on capital projects Note: We have reviewed staff classifications in 2016/17 and revised the 2015/16 staff numbers for comparison. 60 University College London Hospitals NHS Foundation Trust

61 Gender analysis Male Female Total (headcount) Directors Other senior managers Other staff 2,352 5,827 8,179 Sickness absence data Sickness absence rate % Medical and dental 0.52 Administration and estates 3.74 Healthcare assistants and other support staff 5.20 Nursing, midwifery and health visiting staff/ learners Scientific, therapeutic and technical staff 2.39 Healthcare science staff 3.16 Total 3.16 Recruitment and retention The Chartered Institute of Personnel and Development presented UCLH with the national award for recruitment and talent management in 2016 following a highly successful campaign to recruit and retain staff. We face the same challenges as other trusts to recruit and retain nurses and midwives. However, following our success in 2015/16 we have maintained a low vacancy rate across all staff groups. At the end of 2016/17, out vacancy rate had fallen to 6.5 per cent. Our sustained recruitment drive has included targeted social media campaigns featuring our staff, jobs fairs and open days across the UK and quicker and more efficient recruitment processes. Reducing agency spend is a top strategic priority for the NHS and we have made good progress over the last year, eliminating agency usage in all but a handful of professional areas within UCLH. Our use of agency staff has more than halved. Our performance under the NHS Improvement agency rules is unparalleled in London. Our staff retention rate has also improved in the past year: turnover has reduced from 14.7 per cent to 12.8 per cent. We have introduced career clinics to encourage existing staff to transfer to other job posts within UCLH, rather than seek promotion elsewhere. Our 3.61 strategy has enabled us to find and keep the best staff in a competitive national and international market. EU referendum UCLH, along with the NHS as a whole, relies on staff recruited from abroad. Over 15 per cent of our workforce were born and trained in mainland Europe. The day following the EU referendum result, our former Chief Executive wrote to all our staff to offer reassurance and commitment. It was viewed by more than 3,000 staff in just two days who reacted positively to the message. Although there appears to be no immediate prospect of a change in the immigration policies affecting our European employees, UCLH is closely monitoring the situation following the referendum. Staff from 121 nationalities work at UCLH and we believe it is vital to support an international workforce in order to continue to provide high quality care to our patients Staff policies and actions Health and safety Our Health and Safety Committee meets bi-monthly to review information on incidents and injuries and ensures learning is shared across the organisation. Incidents and injuries involving exposure to bloodborne viruses (i.e. sharps injuries and splashes) are Annual Report and Accounts 2016/ PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE)

62 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) reviewed by the UCLH Infection Control Committee which meets quarterly. Key policies have been reviewed and revised during We have undertaken the seventh audit which included staff, outpatient and visitor slips, trips and falls, manual handling, violence and aggression, control of substances hazardous to health, lone working and stress. The audit checked whether risk assessments were up-to-date, had been risk rated and placed on the appropriate risk register. Detailed feedback was provided to each division. The Health and Safety Committee is currently focusing on the most significant risks to safe working as a central London trust. Reducing assaults and violence is a priority and we are bolstering preventative and response measures to address the risk and incidence of such events. Counter fraud and corruption UCLH takes a zero-tolerance towards fraud. Our counter fraud team works constantly to investigate, prevent and deter fraud. The team also gives advice to staff on how to be on the alert for fraud and how to report suspected fraud or corruption as quickly as possible. It is UCLH policy to prosecute wherever possible when a fraud has been committed. Raising Concerns: (Whistleblowing) We encourage staff to raise concerns with senior managers about patient safety, criminal offences, breaches of legal obligations, miscarriages of justice, damage to the environment or the deliberate concealment of information. Our Raising Concerns Policy guides this process. This year we launched an external Guardian Service which offers independent and confidential advice to support staff to raise issues with senior management. Equality and diversity See section Equality reporting (staff) Staff engagement Staff communication As well as keeping staff updated about news and developments we are always keen to actively engage staff and ensure their views are listened to, and where appropriate, acted upon. Staff are given the opportunity to feedback their comments and suggestions to colleagues, managers and senior leaders, via our staff survey and staff suggestion scheme. There is also a mechanism for staff to comment and engage in online conversation about our intranet articles. UCLH-wide communications include: Team Brief: the Chief Executive s monthly briefing delivered by local managers to their teams who are encouraged to discuss any concerns or issues Inside Story: our monthly staff magazine Insight: our intranet, updated daily with stories Chief Executive s roadshows/q&a forum: open to all staff and held on each site Team meetings: where staff are kept informed and can discuss matters at a local level Social media: Twitter, Facebook, Instagram and YouTube. Staff surveys Staff suggestion scheme Celebrating Excellence Awards More than 700 staff were nominated by colleagues for our annual awards which celebrate those employees who go above and beyond to demonstrate the UCLH values of kindness, safety, improving and teamwork. Whether they are kind and caring to patients and colleagues, an inspiring mentor, dedicated to safety or an outstanding leader, our awards ceremony celebrates their success. A panel of judges selected 44 finalists from a broad spectrum of job roles including nurses, doctors, therapists, researchers and administrative staff. The ceremony was held at the Landmark Hotel in London and hosted by news broadcaster Sian Williams. In another event, staff that went above and beyond during the flu and norovirus outbreaks were thanked at a special afternoon tea at the Savoy Hotel. It was hosted by actress Laura Main. Both events were funded by UCLH Charity. Staff partnership Our partnerships with unions and representative bodies are important to us. UCLH s management and staff representatives meet monthly to review policies and staff experience. Our joint partnership forum has used our active staff suggestion scheme to design and introduce new staff initiatives. Over the past year staff and management representatives have been working on streamlining of the internal process and procedures of the Joint Negotiating Committee (JNC) and Joint Partnership Forum (JPF). The changes mean meetings are now more productive which releases time for committee members. We have worked with the pan-london NHS Social Partnership Group to discuss recruitment and retention challenges forecast for the next decade. 62 University College London Hospitals NHS Foundation Trust

63 Staff health and wellbeing Over the past 12 months our Occupational Health team has encouraged staff to improve their health and wellbeing. Our programmes for health and wellbeing have focused on the main causes of premature mortality and ill health, encouraging physical exercise and balanced diets, tackling smoking and focusing on threats to the mental health and resilience of our staff. Hundreds of staff took part in the annual pedometer challenge, a 100 staff signed up for free slimming club vouchers and on average lost half a stone each, and many staff increased their daily activity as part of Healthy Living Week. Healthy living roadshows visited various hospital sites and encouraged staff to increase their physical activity, stop smoking, reduce their alcohol intake, and access staff psychological and welfare services. Food services were improved and more initiatives are planned for next year. Occupational Health and a team of peer vaccinators delivered the most successful flu vaccine campaign to date Education and training See section Education and training NHS Staff Survey: results and actions The results of the 2016 NHS Staff Survey revealed that UCLH remains a place that the majority of our staff would recommend as a place to work or be treated. A total of 44.6 per cent of the UCLH workforce completed the 2016 NHS staff survey. Some 84 per cent of staff said they would be happy for a friend or relative to be treated here up from 82 per cent last year (the national average is 70 per cent). And 70 per cent of staff would recommend UCLH as a place to work up from 66 per cent (the national average is 62 per cent). Plus, 83 per cent of staff agreed that the care of patients is UCLH s top priority (the national average is 76 per cent). Overall, UCLH is in the top 20 per cent of acute trusts for staff engagement, a measure closely linked to patient experience. We improved in 32 of the 88 questions and saw no deterioration in any. Areas with significant improvements include the number of staff who feel well supported and valued, and action on health and wellbeing. There were less favourable responses to questions on working extra hours (paid and/or unpaid), workrelated stress, equal opportunities for career progression, discrimination, and bullying and abuse by other staff. The following tables detail some of the key finding in the 2016 NHS Staff Survey: Staff survey response rate: UCLH National average UCLH National average UCLH % change Response rate 35.8% 38% 44.6% 43% 8.8% Staff survey results top five ranking scores: % experiencing physical violence from patients, relatives or the public in the last 12 months UCLH National average UCLH National average 12% 14% 12% 15% 0% UCLH % change 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) % staff appraised in the last 12 months 89% 86% 93% 87% 4% Annual Report and Accounts 2016/

64 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Quality of appraisals (Score out of 5) Recommendation of the organisation as a place to work or receive treatment (Score out of 5) Effective use of patient feedback (Score out of 5) UCLH National average UCLH National average UCLH % change % Staff survey results bottom ranking scores: % working extra hours % believing UCLH provides equal opportunities for career progression or promotion % experiencing discrimination at work in last 12 months % experiencing harassment, bullying or abuse from staff in last 12 months % experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months 1.6% UCLH National average UCLH National average 80% 72% 77% 72% 3% 78% 87% 78% 87% 0% 17% 10% 18% 11% 1% 31% 26% 31% 25% 0% 31% 26% 32% 27% 1% 0.6% UCLH % change 64 University College London Hospitals NHS Foundation Trust

65 We are addressing some of the key findings from the Staff Survey as follows: Improved line management: We have improved our appraisal processes and now provide more inhouse coaching and support to staff to promote constructive conversations between managers and colleagues. Backed by UCLH Charity, a pilot project called Winning Through Teams helps colleagues diagnose and tackle issues at a local level and work more effectively as a team. The uclh Institute is developing a new suite of training for line managers. Mediation: Supported by UCLH Charity, we are working with an external provider to train around 300 senior managers to resolve conflict swiftly and informally at a local level, where possible. Guardian Service: An independent and confidential Guardian Service was launched in June to complement the existing support services. The service is available to all staff to discuss matters relating to patient care and safety, whistleblowing, bullying and harassment, and work grievances. Formal employee relations processes: We re working with Staffside to develop a resolution pathway. It will provide detailed advice on how to tackle issues of conflict and where to access the right support. It will promote early and informal resolution, steering staff away from over-reliance on formal processes. Bullying and harassment: We established a new campaign to encourage open and honest discussion around uncomfortable behaviours, and to create a clear set of standards to which all staff can be held accountable. The Where do you draw the line? campaign is funded by UCLH Charity and was designed by staff at a series of focus groups. In the next phase of the campaign, individual members of staff will feature in communications materials across UCLH talking about how they tackled poor staff experience. An animation video will also be presented at induction in late summer Staff well-being: The Staff Psychology and Welfare service has introduced workshops for managers to help them understand mental health issues and to support colleagues. The Occupational Health team, working with the 52 Club (staff gym), has also introduced a series of projects to improve staff s physical fitness. Discrimination: Along with partner organisations across our Sustainability and Transformation Programme (STP), we are reviewing our processes for redeployment, promotion, internal transfers and career advice. We want to ensure that opportunities within UCLH and with our partners are truly inclusive and consistent Expenditure on consultancy In 2016/17 expenditure on consultancy was 2.68m, compared to 4.6m in 2015/ Off-payroll engagements The following table details off-payroll engagements as of 31 March 2017, for more than 220 per day and that last longer than six months Number of existing engagements as of 31 March 2017 of which: Number that have existed for less than one year at the time of reporting Number that have existed for between one and two years at the time of reporting Number that have existed for between two and three years at the time of reporting Number that have existed for between three and four years at the time of reporting Number that have existed for four or more years at the time of reporting PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

66 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) The following table details all new off-payroll engagements, or those that reached six months in duration between 1 April 2016 and 31 March 2017, for more than 220 per day and that last longer than six months Number of existing engagements as of 31 March 2017 of which: Number that have existed for less than one year at the time of reporting Number that have existed for between one and two years at the time of reporting Number that have existed for between two and three years at the time of reporting Number that have existed for between three and four years at the time of reporting Number that have existed for four or more years at the time of reporting Exit packages During the year UCLH agreed the following number exit packages within the cost bands shown below: Number of existing engagements as of 31 March 2017 of which: 2016/17 other agreed packages: Under 10, ,000-25, ,001-50, , , , , Total number /16 other agreed packages: Total cost 1,351, , Equality reporting (staff) We are committed to the principles of equality and fairness for our staff and have made good progress in the past year in promoting diversity, equality and inclusion. The characteristics of our workforce are broadly consistent with our local communities in terms of religion and ethnicity. We have more female employees and staff from black and minority ethnic (BME) backgrounds compared to the local population. We have improved the way we record data on our Electronic Staff Record (ESR) system and have asked all staff to update their information held on ESR. We have raised awareness of the importance of equality, diversity and inclusion by including new information in staff induction and we now regularly audit data on new starters. We need to make more progress to capture data to support transgender individuals and that continues to be a priority. We have made preparations for the introduction of the Workforce Disability Equality Standard (WDES) in April The Starting at UCLH Policy sets out how we give full and fair consideration to job applications made by disabled people. UCLH is a Disability Confident Employer and guarantees that suitable disabled employees will be interviewed. We regularly analyse applications for employment, shortlisting and appointment and the data is reviewed. We make reasonable adjustments to working arrangements for disabled staff and new recruits, as well as offering appropriate training. We provide our disabled staff with suitable opportunities for training, career development and promotion, in line with our Training, Development and Study Leave Policy. We want to reduce the variations between the disability data recorded on ESR and the data reported by staff in the annual NHS Staff Survey. UCLH publishes the Workforce Race Equality Scheme (WRES) annually in line with the requirements of NHS England and publishes a mid-year update to monitor progress. There is a detailed action plan which is monitored by the Diversity and Equality Steering Group and the WRES is included in the Annual Equality Report for University College London Hospitals NHS Foundation Trust

67 Our priorities are to: Encourage, support and develop women and members of BME communities to put themselves forward for more senior roles. Undertake research to understand why our BME staff say we could do more to offer equal opportunities for career progression. Plus, analyse our recruitment data to understand whether our BME candidates are less likely to be appointed to certain roles or grades and take action to address this. Roll out updated interview skills training to increase the proportion of BME staff that are offered a post, compared to white applicants and review whether BME staff are well-represented on recruitment panels. Investigate whether there is a disproportionate number of BME staff going through a formal disciplinary process. Improve the experience of our lesbian, gay, bisexual and transsexual staff to improve our performance in the Stonewall Top 100 Employers Index. Reduce discrimination and continue to roll out our staff campaign to reduce levels of bullying and harassment. Continue to offer mentoring and coaching support to staff with protected characteristics to improve their opportunities for promotion including to director level positions. Implement any actions arising from the audit of ESR staff demographics. Review the Equality Impact Assessment process, policy documentation and service reviews. Improve the experience of our disabled staff: in our staff survey they report a significantly worse experience at work in most key findings. We are committed to the principles of equality and fairness for our patients and work with different communities to deliver better patient care that is inclusive, accessible and fair. See section Equality reporting (patients). 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

68 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) 2.4 Code of Governance disclosures The NHS Foundation Trust Code of Governance contains recommendations to help trusts improve their governance practices, relating to directors, governors, audit, effectiveness and relationships. UCLH has applied the principles of the NHS Foundation Trust Code of Governance on a comply or explain basis. The NHS Foundation Trust Code of Governance, most recently revised in July 2014, is based on the principles of the UK Corporate Governance Code issued in Throughout our annual report we describe how we meet the Code. A summary of where detail can be found on the issues we are required to disclose is given in the following table. Where further explanations on the items listed in the table are needed these are given underneath. Code reference A.1.1. A.1.2 Section Set out in Trust Board and Role of the Council and in A.4.1 below Set out in Board members and Board meetings and committees, and in Nomination and remuneration committee Sections/s and the table titled Directors attendance at the Board and Council and section A.5.3 Set out in who are the Council? the table titled Governors on the Council and the table titled Governors who stood down in 2016/17 Additional requirement Set out in board meetings and governors on the council B.1.1 Set out in Board members B.1.4 Additional requirement B.2.10 Additional requirement Set out in Board members, and Board, committee and directors evaluation the table titled Directors attendance at the Board and Council the table titled Governors on the Council and the table titled Governors who stood down in 2016/ Set out in Board members and Committees of the Council and Set out in Remuneration committee and Nomination and remuneration committee Set out in Non-Executive Appointment Panel Not applicable, the Trust used external search consultancy and open competition for vacant Non-Executive Director post and B.3.1 Set out in Richard Murley s biography B.5.6 Set out in Membership engagement and strategy B.6.1/6.2 Set out in Board, committee and directors evaluation C.1.1 Set out in Statement of directors responsibility University College London Hospitals NHS Foundation Trust

69 Code reference C.2.1 Section Set out in Key risks to delivering our strategic priorities and in the Annual governance statement C.2.2 Set out in Audit committee C.3.5 Set out in audit committee Not applicable, the Council accepted the Audit Committee recommendation Sections/s and C.3.9 Set out in Audit committee and External auditors D.1.3 Set out in Board members and Remuneration report and 2.2 E.1.4 Set out in Contacting the board and Contacting the governors and E.1.5 Set out in How the Council works E.1.6 Set out in Our membership Additional requirement Additional requirement Set out in Our membership and Membership engagement strategy Set out in Register of interests (available on UCLH website) A.4.1 The Board has not appointed a Senior Independent Director (SID). It considers it has effective processes in place to raise issues of concern other than through the normal route of chairman or chief executive. UCLH has a vice-chairman and an elected lead governor to act with independence of mind, both of whom provide a channel through which directors and governors would be able to express concerns. The lead governor also acts as the main point of contact between NHS Improvement and the other governors for any communication that might, in very specific circumstances, be necessary. B.1.2 The Board considers all its non-executive directors to be independent in character and judgement. They are also all independent of management, with the exception of Professor David Lomas, Vice Provost of UCL, who holds an honorary contract with UCLH. B.6.3 See Section A.4.1 above, the Board has not appointed a SID. The Chairman s annual evaluation is undertaken jointly by a governor (chair of the council s nomination and remuneration committee) and the vice chairman (a non-executive director). UCLH partially meets the provision in D.2.3 relating to the market-testing of remuneration levels for nonexecutive directors and the chairman. UCLH participates in NHS Providers remuneration surveys and other industry benchmarking exercises. However, it would approach advisors were it to consider a material change to remuneration. 2.5 Single Oversight Framework In the first two quarters of 2016/17 we were assessed under the Monitor Risk Assessment Framework. Each quarter, we were assigned two ratings: a financial sustainability risk rating and a governance rating. For financial sustainability, the rating is on a scale of one to four, where four is best. In quarter one and quarter two we were rated as two. This was due to our being behind on our income and expenditure plan, although we scored strongly against the liquidity measure (this is the level of cash in the organisation). The governance rating assesses UCLH against national access and quality standards and takes account of the results of investigations by other organisations, such as the Care Quality Commission (QCC). Governance is measured on a three point scale; green (no concerns), under review, or red (significant concerns and immediate actions are being taken). We were rated green in both quarters. 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

70 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Half way through 2016/17 Monitor and the Trust Development Authority (TDA) merged to become NHS Improvement (NHSI). NHSI launched the Single Oversight Framework (SoF) to replace the Monitor Risk Assessment Framework. Within this framework trusts are assessed against a range of elements (financial, operational and quality performance, as well as leadership capability) to be placed into one of four segments. Segment one is best performance whilst segment four is worst performing. The segment that trusts are placed in determines the level of support or intervention that is put in place. In quarter three we were placed in segment two. This recognised our good rating from the CQC, our strong financial position and our strong position in relation to national 18- week waiting time standards. We were not placed in segment one because we did not achieve the A&E four hour waiting time standards or a number of the national cancer waiting times standards. 2.6 Statement of accounting officer s responsibilities Statement of the Chief Executive s Responsibilities as the Accounting Officer of University College London Hospitals NHS Foundation Trust. The NHS Act 2006 states that the chief executive is the accounting officer of the NHS foundation trust. The relevant responsibilities of the accounting officer, including their responsibility for the propriety and regularity of public finances for which they are answerable, and for the keeping of proper accounts, are set out in the NHS Foundation Trust Accounting Officer Memorandum issued by NHS Improvement. NHS Improvement, in exercise of the powers conferred on Monitor by the NHS Act 2006, has given Accounts Directions which require University College London Hospitals NHS Foundation Trust to prepare for each financial year a statement of accounts in the form and on the basis required by those Directions. The accounts are prepared on an accruals basis and must give a true and fair view of the state of affairs of University College London Hospitals NHS foundation Trust and of its income and expenditure, total recognised gains and losses and cash flows for the financial year. In preparing the accounts, the Accounting Officer is required to comply with the requirements of the Department of Health Group Accounting Manual and in particular to: observe the Accounts Direction issued by NHS Improvement, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis; make judgements and estimates on a reasonable basis; state whether applicable accounting standards as set out in the NHS Foundation Trust Annual Reporting Manual (and the Department of Health Group Accounting Manual) have been followed, and disclose and explain any material departures in the financial statements ensure that the use of public funds complies with the relevant legislation, delegated authorities and guidance and prepare the financial statements on a going concern basis. The accounting officer is responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the NHS Foundation Trust and to enable him/her to ensure that the accounts comply with requirements outlined in the above mentioned Act. The Accounting Officer is also responsible for safeguarding the assets of the NHS Foundation Trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities. To the best of my knowledge and belief, I have properly discharged the responsibilities set out in the NHS Foundation Trust Accounting Officer Memorandum. Marcel Levi Chief Executive 23 May University College London Hospitals NHS Foundation Trust

71 2.7 Annual governance statement Scope of responsibility As Accounting Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the NHS Foundation Trust s policies, aims and objectives, whilst safeguarding the public funds and departmental assets for which I am personally responsible, in accordance with the responsibilities assigned to me. I am also responsible for ensuring that the NHS Foundation Trust is administered prudently and economically and that resources are applied efficiently and effectively. I also acknowledge my responsibilities as set out in the NHS Foundation Trust Accounting Officer Memorandum. The Board of Directors (Board) is accountable for internal control. I have overall accountability for risk management in the Trust. The control of risk is defined in the management roles of the Executive Directors, particularly the Corporate Medical Director who leads on clinical risk and the Medical Directors of the Medicine, Surgery & Cancer, and Specialist Hospitals Boards, who have responsibility for the delivery of operational services. Levels of accountability and responsibility are set out in the UCLH Risk Management policy and procedure. The risk register and risk process is overseen by the Risk Coordination Board (RCB), an executive subcommittee chaired by the Deputy Chief Executive, reporting to the Executive Board. To ensure that risk management is not seen only as an issue to be addressed within UCLH, working arrangements are in place with stakeholders and partner organisations, including with Clinical Commissioning Groups (CCGs) and NHS England (together our commissioners), University College London and other key partner organisations to provide a comprehensive range of clinical and nonclinical support services. These cover both operational and strategic issues such as service planning, performance management, research, education and clinical governance. The Risk Management policy / procedure define the process for capturing risks both locally and strategically, it also defines the Trust s risk appetite. A Board Assurance Framework (BAF) has been used in UCLH for eight years. The central purpose is to set out the strategic themes of UCLH for the year, identify principal risks against them, the controls and any gaps in control, the assurances and gaps in assurances, and the action plans to remedy such gaps. The BAF is reviewed quarterly by the RCB, Executive Board and the Board. Processes for auditing and monitoring clinical activity are in place in all the clinical divisions. Clinical processes are updated when national guidance is published or in response to adverse events and national safety notices, the latter via the Central Alerting System (CAS), Subcommittees of the Quality and Safety Committee (QSC) monitor implementation of NICE guidance and recommendations by NCEPOD and the corporate clinical audit programme. Standard clinical data sets are established, including areas of performance such as emergency readmissions these are assessed on a monthly basis by the QSC to provide assurance on clinical outcomes and to identify any emerging risks for further investigation and action. The Audit Committee reviews risk and controlrelated disclosure statements prior to endorsement by the Board, and the effectiveness of the management of the principal strategic risks identified by UCLH. The purpose of the system of internal control The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only provide reasonable and not absolute assurance of effectiveness. The system of internal control is based on an ongoing process designed to identify and prioritise the risks to the achievement of the policies, aims and objectives of University College London Hospitals NHS Foundation Trust (UCLH), to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically. The system of internal control has been in place in UCLH for the year ended 31 March 2017 and up to the date of approval of the annual report and accounts. The system of internal control is based upon a number of individual controls for example, policies and procedures covering important business activities, how staff are appointed and managed, the Standing Orders, Standing Financial Instructions and Scheme of Delegation that are used to govern UCLH. In addition there are checks and balances inherent in internal and external audit reviews, Executive Board and UCLH Board oversight. Capacity to Handle Risk The Executive Board brings together the corporate, financial, workforce, clinical, information and Annual Report and Accounts 2016/ PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE)

72 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) research governance risk agendas. The BAF ensures that there is clarity over the risks that may impact UCLH s ability to deliver its strategic themes together with any gaps in control or assurance. There are internal processes to ensure that incidents which fit the national criteria for serious incidents are reported on the Department of Health Strategic Executive Information System (STEIS). The QSC has oversight of serious incidents and receives a monthly report on serious incidents declared and reports completed that month. A quarterly report on serious incidents is provided to the Board and a monthly update and quarterly report to commissioners. Board members receive training in risk management awareness and an overview of the risk systems. Staff receive online training in risk at induction. The risk manager also provides one to one and group training as required. Guidance on risk management is available on our intranet. Good practice is shared through the RCB. The Risk and Control Framework The Risk Management Policy and Procedure is available to all staff on the UCLH intranet. UCLH uses Datix risk management software as a repository for risks. Datix assists in the production of risk reports and helps staff manage local risk registers. Risk reports, including the top risks, are reviewed quarterly by the RCB and EB with oversight from the Audit Committee. UCLH reviews the most significant risks and the associated risk management plans based on the highest graded risks on the risk register. The RCB reports to the Executive Board after each meeting. The Audit Committee and the Board consider a BAF report on a quarterly basis and a risk report three times a year. The UCLH Board holds a risk awareness session every year. The Audit Committee oversees and monitors the performance of the risk management system. Internal Audit (KPMG) and External Audit (Deloitte) work closely with this committee and undertake reviews and provide assurances on the systems of control operating within UCLH. Internal Audit reviewed the Assurance Framework in place throughout 2016/17 and concluded that UCLH has had a well-functioning framework with suitable management and committee scrutiny of the risks, controls and assurances contained within it. The risk management policy and procedure defines what risks need to be escalated to the next management level as well as defining the level of risk which must be referred to the RCB and the UCLH Board. Risks are classified as low, moderate, high and very high, based on a consequence and likelihood matrix approved by the Board. The risk appetite is such that any very high risks are managed at clinical board level or by the Board and high risks are managed at divisional level. The Quality and Safety Committee (QSC) is responsible for ensuring that effective arrangements are in place for the oversight and monitoring of all aspects of clinical quality and safety, including identifying potential risks to the quality of clinical care. The Board relies on the committee to provide advice on clinical quality, patient safety and risk and for assurance on areas of clinical governance and audit. It focuses on promoting a culture of openness and organisational learning. On behalf of the Board, it reviews compliance and receives assurance in meeting regulatory standards set by the Care Quality Commission (CQC). In compliance with the regulations of the Health and Social Care Act, UCLH has registered eleven locations and nine registerable activities, approved by the Board. Internal Audit and Counter Fraud Activities The results of Internal Audit reviews are reported to the Audit Committee which takes a close interest in ensuring system weaknesses are addressed. Improved procedures are in place to monitor the implementation of control improvements and to undertake follow up reviews where systems were deemed less than adequate. An internal audit tracking system is in place which records progress in implementing the agreed recommendations. Progress in implementing corrective action is reported to the Audit Committee, and the Executive Board also receives regular reports on outstanding high and medium rated actions. The counter fraud programme is led by the Finance Director and monitored by the Audit Committee. Information Governance UCLH has a Records and Information Governance Group (RIGG) which is chaired by the Caldicott Guardian. This group reports to the Digital Services Delivery Board (DSDB). The DSDB reports to the Executive Board and is chaired by the Deputy Chief Executive who is the Senior Information Risk Officer (SIRO) for UCLH. The RIGG and DSDB oversee our Information Governance Toolkit annual assessment and action plan. Through this governance structure the UCLH Information Governance Statement of Compliance (IGSoC) is assessed on an ongoing and annual basis. UCLH is compliant with the IGSoC 72 University College London Hospitals NHS Foundation Trust

73 control requirements. The toolkit includes a requirement to undertake an annual data mapping exercise to assess all routine data flows within UCLH and between UCLH and any third party. UCLH is making good progress on improving its overall IG Toolkit attainment. Specific focus has been given to improving our Cyber Security controls and systems. The IG Toolkit overall assessment score for version 14 is 80 per cent (compliant). Data security risks are managed via an Information Governance Framework, which comprises an Information Governance Policy, related policies and guidance and the RIGG. In particular, the Information Risk Policy sets out a structured approach to information risk management which is integrated with our broader risk management arrangements. This includes the appointment of the SIRO, Information Asset Owners and Information Asset Administrators. Information risk identification is supported by the maintenance of an Information Asset Register and regular information mapping exercises. Any significant risks identified from these processes are included in our risk register and will be subject to formal management attention. UCLH operates in a complex environment and exchanges data with a number of organisations and we continue to prioritise activities to reduce the risk of data loss or accidental disclosure of personal data. Information Governance Policy and guidance is continually reviewed and training and awareness raising programmes target all our staff. Information Governance training includes an assessment of understanding of key aspects of policy and assessment scores indicate the success of awareness raising activities. Strengthened technical controls will result in a reduction of risk of specific types of data loss. There have been three Level 2 serious incidents reported through the Information Governance Incident Reporting Tool 2016/17. Of those reported, three have been considered by the Information Commissioner s Office (ICO) and a decision made to take no further action. Major risks UCLH has described the principal strategic risks that it faces in the annual report. The most serious strategic risks relate predominantly to financial sustainability, in particular the risk that unachievable efficiency targets or control totals are imposed on UCLH and are greater than can be achieved through our cost improvement programmes, together with the risk that the tariff will not appropriately compensate UCLH for the complex, specialist work that is undertaken and the risk of non-payment for activity by commissioners. With regard to operational risks the principal current risks are identified as follows: Emergency Department flow - risk of insufficient capacity (in terms of beds, outpatient and diagnostic resources) to meet the 4 hour Accident and Emergency target. Despite the pressures UCLH has performed well compared to other trusts but this will continue to be an area that is closely monitored. Providing cancer treatments within 62 days of referral - risk of not meeting the 62 day cancer waiting times standard because of a combination of the following: some pathways are not fully optimised to deliver the 62 day standard for all patients; higher levels of complexity in the patients seen at UCLH compared to the national average; referrals of patients by other providers too late in the pathway for the standard to be met. UCLH has an improvement plan which tracks the key actions that will shorten the waiting time for treatment for cancer patients; the plan is being refreshed for May All the above are current risks to UCLH, but are also expected to continue into the future. The risks associated with financial pressures in the NHS are expected to increase, and in particular there is a risk that planned developments, including new hospital buildings and investment in a new electronic health records system to support UCLH s plan to improve efficiency, have a short to medium term financial impact that risks the Trust s achievement of its control total and other financial targets. Foundation Trust Governance Requirements The Board of Directors sets the strategic direction of UCLH and is collectively responsible for the performance of the Trust. The Board agrees its strategy and objectives annually, which are set out in the annual report. The Council of Governors receive regular updates on clinical and financial performance and reports relating to service delivery. Governors input to the annual forward plan and met separately with the non-executive directors four times during the year. This enables the governors to discharge their duties. The Board is supported by six oversight committees: audit, finance and contracting, investment, QSC, remuneration, and workforce, each chaired by a non-executive director. Relevant reports are submitted to the Board. More detailed information on the coverage of these oversight committees and the attendance records of members of each can be found in the Directors Report: Annual Report and Accounts 2016/ PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE)

74 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) of the annual report. The Board also reviews the risk register and BAF (previously described above) and it receives a report from an Executive Board, through the Chief Executive. This Executive Board oversees delivery of the operational service and reviews performance against financial, workforce and clinical indicators monthly. UCLH has a clinical leadership model delivered through four medical directors and its chief nurse. Three of the medical directors manage the operational service through three clinical boards and 17 divisions supported by corporate functions such as finance and workforce. UCLH has a well-established performance management framework that ensures that key indicators across a range of the business are scrutinised on a monthly basis, with key exceptions analysed further at clinical team, clinical board and UCLH Board level as appropriate. Each of the key issues (governance measures, quality, activity levels and efficiency) is discussed at specific sub-board meetings and form sections within the Board performance report. Quality, waiting times and data quality are all reviewed at the performance board, membership of which includes senior leaders from all clinical boards, nursing and midwifery, workforce, quality and safety and performance. The Board receives the Board performance pack at its meetings. The QSC also receives a monthly performance report focussed on quality issues. Performance metrics are reviewed on an annual basis to ensure that all national and local priority indicators are included. The Board can self-certify the validity of its Corporate Governance Statement. The process for reviewing the effectiveness of the system of internal control has been reviewed by: The Board, who have considered the risk report and the management of risks to the delivery of the objectives set out in the BAF. The Audit Committee, which has reviewed governance and risk management policies and monitored the implementation of these. The QSC which has reviewed compliance against the CQC standards, reviewed clinical audit and clinical governance arrangements. A number of compliance self-assessments including from the finance director which provide assurance on financial performance and the opinions and reports of both internal and external audit. Stakeholder involvement in risk management UCLH actively works with key partner organisations across the local health economy. Wherever possible, and where appropriate, it works closely with the partner organisations to identify and mitigate risks that might impact upon them. These include: UCLPartners The UCLH Cancer Collaborative Our joint venture partners Our partners in the STP UCLH also has well established arrangements in place for engaging with a diverse public, patient and stakeholder community in a number of ways (see below): Council of Governors: governor representatives on each of the following committees (Patient Experience Committee, Nursing and Midwifery Board and QSC) and Care Quality Review Group (CQRG) Governors: participation in walkrounds and PLACE inspection; carers events; Public and Patients: Annual Members Meetings; Members Meets; Annual Research Open event; patient focus groups; residents meetings about our capital developments; patient surveys; Overview and Scrutiny Committees Healthwatch National and local patient surveys; exhibitions and mail outs; patient advisory liaison service and UCLH News (members magazine) Staff: annual staff survey; CEO roadshow; joint staff forum; executive and non-executive walkrounds; Health Partners: CQRG; integrated care board; GP practice relationship visits and GP newsletter; GP engagement events and seminars, joint strategic and service planning meetings; Other Control Measures As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer obligations contained within the Scheme regulations are complied with. This includes ensuring that deductions from salary, employer s contributions and payments into the Scheme are in accordance with the Scheme rules, and that member Pension Scheme records are accurately updated in accordance with the timescales detailed in the regulations. 74 University College London Hospitals NHS Foundation Trust

75 Control measures are in place to ensure that our obligations under equality, diversity and human rights legislation are complied with. Equality Impact Assessments are carried out for all new service developments and when reviewing policies. Risk assessments are undertaken and Carbon Reduction Delivery Plans are in place in accordance with emergency preparedness and civil contingency requirements, as based on UKCIP 2009 weather projects, to ensure that this organisation s obligations under the Climate Change Act and the Adaptation Reporting requirements are complied with. Economy, efficiency and effectiveness of the use of resources Monthly finance and performance reports are presented to the Finance and Contracting Committee, Executive Board and to the Board. UCLH has reported a financial position significantly better than plan in 2016/17, as a result of a number of non-recurrent benefits combined with central matched funding for over-performance against plan. Internal Audit reports consider value for money and Deloitte are required as part of their annual audit to satisfy themselves that UCLH has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources and report by exception if in their opinion UCLH has not. All significant cost improvement plans (CIP) are required to have a quality impact assessment (QIA) undertaken which assesses the potential impact of the plans against three criteria: Patient safety & experience Clinical effectiveness & performance Staff experience The QIA process uses the risk management methodology in place at UCLH in order to consider and rank the impact of proposed changes. Once satisfied that all risks have been appropriately considered, authorisation to proceed with the CIP is required from the clinical lead, chief nurse, and relevant medical director. Quality Report The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 (as amended) to prepare Quality Accounts for each financial year. NHS Improvement (in exercise of the powers conferred on Monitor) has issued guidance to NHS foundation trust boards on the form and content of annual Quality Reports which incorporate the above legal requirements in the NHS Foundation Trust Annual Reporting Manual. There are a number of assurances and controls in place to ensure the quality of data within the quality report, which includes: Clearly defined corporate indicators for data quality. Data quality indicators and reports monitored, validated and provided to clinical divisions. Guidance on data quality in the Data Capture Policy and Access Policy. Performance is monitored at Executive Board and QSC. Clinical Boards monitor and manage performance. Clinical and quality data is reported to the Board and scrutinised and challenged at Board subcommittees, including an annual review of controls and assurances for CEO performance report metrics. The annual data quality assurance report to the Audit Committee includes a kite mark dial assessment for each performance indicator. Each year we have a programme of actions that we implement to improve our data quality. Data quality is audited internally and externally. Data quality is scrutinised routinely by commissioners. External assurance statements on the Quality Report are provided by our local commissioners, OSC and our local Healthwatch as required by Quality Account Regulations. The Board has regularly reviewed the performance on RTT, diagnostics, A&E and cancer access standards. It has also discussed the findings of previous internal and external audit reports and the plans in response to them. The Audit Committee reviews, on behalf of the Board, data quality issues to give the Board assurance that performance can be understood and managed, whilst recognising the need for data and its sources to be constantly reviewed and ongoing improvements needed, for example those set out above. Elective Access Board (EAB) reports to EB on a monthly basis and oversees improvement in relation to elective waiting time data quality for RTT, diagnostics and cancer. Key areas of focus include: Weekly monitoring of data quality indicator trends for RTT. These are circulated to divisions on a weekly basis with priority areas of focus highlighted for action. Review of the monthly internal sample audit outcome, which alternates between RTT and Annual Report and Accounts 2016/ PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE)

76 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) diagnostics. Individual and aggregate findings are shared with divisional managers and front-line staff. Tracking delivery of our RTT and diagnostics training plan. The programme formally launched in September 2016 with the aim to ensure staff have the knowledge and capability to record pathways correctly at source and thus reduce the risk of data quality errors. elearning modules are essential for role for all staff involved in the administration of pathway pathways and require annual refresher. The current phase is to progress clinic outcome form training to improve completion and accuracy rates among clinicians. Our quality report external audit has shown that we need to do more work to improve how we document and provide assurance on waiting times in ED. We have improved validation processes and introduced monthly audits of how staff are documenting waiting times. While these have demonstrated no systematic inaccuracies in the waiting times that we report for individual patients, this year s external audit has again shown that we don t consistently have documented evidence for the waiting times that we have reported. We will need to make further improvements to our record keeping and validation mechanisms so that we can provide full assurance on the accuracy of our recorded waiting times. The Foundation Trust is fully compliant with the registration requirements of the Care Quality Commission. Review of effectiveness As Accounting Officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review of the effectiveness of the system of internal control is informed primarily by those managers and clinical leads within the NHS Foundation Trust who have responsibility for the development and maintenance of the internal control framework, supplemented by the work of the internal auditors and clinical audit. I have drawn on the content of the quality report attached to this annual report and other performance information available to me. My review is also informed by comments made by the external auditors in their management letter and other reports. I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by The Board, the Audit Committee and the Quality and Safety Committee and a plan to address weaknesses and ensure continuous improvement of the system is in place. UCLH reviews the effectiveness of the system of internal control through Executive Directors and managers within the organisation, who have responsibility for the development and maintenance of the system of internal control and the Board Assurance Framework. The responsibility for compliance with the Care Quality Commission standards is allocated to lead Executive Directors who are responsible for maintaining evidence of compliance. The assessment of compliance and the work of Internal Audit through the year have assisted the Trust in gaining assurance on its system of internal control. The results of External Audit s work on the UCLH annual accounts and quality account are a key assurance together with the results of patient and staff surveys. I have been advised on effectiveness of the system of internal control through reports produced for the Quality and Safety Committee, Corporate Medical Director and the Audit Committee, and plans to address weaknesses and ensure continuous improvement of the system are in place. The Board has played a key role in reviewing risks to the delivery of our performance objectives through monthly monitoring and discussion of the performance dashboard which reports performance in the key areas of finance, activity, national targets, patient safety and quality and workforce. This enables the Executive Board and the Board to focus on key issues as they arise and address them. The Board request specific in depth reports on areas of underperformance as required. The Audit Committee has overseen the effectiveness of the UCLH risk management arrangements and has taken part in a review of its role and responsibilities. The Audit Committee is supported in this oversight role by the work of the QSC and the Clinical Audit and Quality Improvement Committee which reports to the QSC. The Head of Internal Audit Opinion has given a reasonable assurance that there is adequate and effective management and internal control processes to manage the achievement of the organisation s objectives. Emergency Department (ED) four hour waits UCLH did not achieve the standard that 95 per cent of patients should spend less than four hours in A&E in any month of the year. However, we consistently achieved above both the London and National average for performance against this standard. Performance over 2016/17 as a whole for total time in A&E under four hours is 88.3 per cent against the University College London Hospitals NHS Foundation Trust

77 per cent standard (up to end February). There is a comprehensive action plan in place which is monitored at UCLH s Emergency Care Recovery Board and includes both A&E, wider UCLH and wider system actions. Bed capacity pressures continue to be the main drivers of delays. One of the key achievements of the plan is securing consistent delivery of the standard in our urgent treatment centre. This was achieved through changing the skill mix of staff within the department. We have also put in place a primary care service in the department, staffed by a team of local Camden GPs. We have made some progress improving flow through the department and hospital for more complex patients. We have improved the percentage of patients discharged before midday, and also developed plans to ensure that patients that require specialty review are seen within 30 minutes. Bed capacity continues to be the main cause of breaches. We are working with CCG and other partners to improve discharge, and have set up a weekly senior review of extended delayed transfers of care (DToCs). In the coming year, we have a number of significant developments that should support emergency flow: Phase 5 and 6 of the ED redevelopment will be complete by Q4, therefore providing more treatment rooms and more capacity for ambulatory care The co-ordination centre will go live in November 2017, which will help us manage flow more effectively across UCLH The CCG have committed to implementing discharge to assess and trusted assessor models of care, these will significantly reduce length of stay for those patients requiring social and continuing care assessments. 62 day cancer wait UCLH did not achieve the 62 day wait for cancer treatment following GP referral in any quarter. The main reasons for delays continue to be late referrals from other trusts. However, we also did not achieve the standard internally (i.e. just for those pathways that started with a GP referral to us) other than in one month. In response UCLH agreed a full recovery plan with CCG commissioners which tackles all issues that are having an impact on performance. A key risk remains the relative dependence on the performance of other providers in sending referrals to UCLH in a timescale that enables it to treat patients within the 62 day standard. Actions in the improvement plan include: Undertaking demand and capacity analysis across all two week wait pathways in order to bring down waits to first appointment to 7 days. This has been achieved in most pathways Development of a new suite of cancer reports that gives us better patient tracking capability and can monitor how frequently pathways are being tracked We have put additional capacity into a range of areas including most two week wait clinics, CT colon, endoscopy, oncology, breast radiology, urology prostate surgery We have provided training to MDT co-ordinators and operational teams on cancer waits. UCLH have successfully recovered both two week wait and 31 day performance both of which demonstrate improved grip and management of cancer waits. Next steps are to continue to work with the sector to improve inter-trust pathways, and to work with our most complex pathways to understand and reduce delays. We also need to work more to understand and tackle patient choice delays on the prostate pathway, Never events During the year five serious incidents occurred under the definition set in the Revised Never Event Policy Framework (2015) by the Department of Health. There were two incidents involving feeding through misplaced nasogastric tubes. UCLH became aware of the first one (which actually occurred in January 2016) as a result of an inquest in July The X-ray was unclear and in hindsight should have been repeated. The coroner report noted that the misplaced NG tube did not contribute to the death. In the second one the NG tube placement was checked in accordance with UCLH guidance including following the correct ph checking procedures. It is believed the tube may have migrated from the stomach. The patient was subsequently discharged after six weeks. There has been substantial review of the nasogastric tube placement policy and associated training requirements There were three incidents involving wrong site surgery in dental patients. In the first one the patient attended for a dental procedure for removal of the Lower Right 8 wisdom tooth root. The local anaesthetic and raising of the muco-periosteal flap to initiate the dental surgery occurred on the Lower Left 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

78 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) 8 tooth. There was no harm to the patient. In the second dental never event, the patient attended for multiple dental extractions under general anaesthetic including a tooth for which the patient had not been consented. In the third dental never event the patient attended for removal of the retained root of the lower right wisdom tooth however the lower right second molar tooth was removed instead. The latter two events are still being investigated. A number of additional safety processes have been implemented in dental practice including in-situ coaching on the use of the WHO checklist and how to implement these checks. In addition to the above never events a serious incident involving the electronic prescribing system on our critical care units has identified a number of significant control issues in relation to the control of certain drugs on the system. Immediate actions have been taken to address the risk. The incident is still being investigated and further actions may be put in place once the report is complete. UCLH takes all such incidents extremely seriously. Each serious incident is individually and carefully reviewed to establish what has happened and if/how controls failed to prevent them occurring. Immediate actions are taken where needed and lessons to be learnt are established and circulated to strengthen controls in future. Conclusion No significant internal control issues other than those mentioned above were identified in the year. Professor Marcel Levi Chief Executive 23 May Accounting officer approval The Accountability Report brings together information on our directors, workforce, governance and membership, as well as reports on our work in equality. UCLH has done its best to ensure that, to my knowledge, the information in these sections is true and accurate. Professor Marcel Levi Chief Executive 23 May University College London Hospitals NHS Foundation Trust

79 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

80 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) 3 Quality Report Statement on quality from the Chief Executive Our vision is to deliver top-quality patient care, excellent education and world-class research. We are proud that our mortality rate as measured by the Summary Hospital Level Mortality Indicator is the second lowest in England. A further example of our commitment to safety is the work we have been doing to improve surgical safety. Our philosophy is to educate our theatre teams about what goes right (good catches, strong leadership etc.) as well as what could be improved. Providing world-class research to improve the quality of patient care remains a major focus for us. In the past year, there have been major funding awards to the University College London Hospitals NHS Foundation Trust (UCLH) Biomedical Research Centre ( 111.5m) and our Clinical Research Facility ( 6.5m). UCLH and University College London (UCL) will host the new UK Dementia Research Institute to develop new treatments to prevent dementia and help those living with the condition. All these successes build on the strong and expanding collaboration between UCLH and UCL. But we are not complacent. Our patients, their families and carers rightly ask for evidence of our continuing commitment to quality, and expect us to report with honesty where we do not reach a target as well as pride when our services are as good as we plan. Quality reports use data and measurement but charts and tables do not tell the whole quality story. High quality patient care comes from our hearts and from our values - safety, kindness, teamwork, improving. Our values may not always be precisely measurable, but in the short time I have been at UCLH I have seen them being lived every day. The latest annual survey of NHS staff shows UCLH staff are more likely than most to recommend their hospital as a place to work or receive treatment. Their answers also show us leading in the coverage and quality of appraisal an essential tool for developing, motivating and focusing the people working here. Our staff have better than average confidence in reporting unsafe practices, are better than average at reporting errors, near misses and incidents, are more likely than average to believe in the fairness of procedures for reporting errors, near misses and incidents and to feel able to contribute towards improvements at work. A high proportion of our staff also believe that we make good use of patient and service user feedback. Quality care depends on staff but is also a partnership with patients. We work hard to ensure that we learn from our patients. The theme of learning from patients runs through this report. 80 University College London Hospitals NHS Foundation Trust

81 The Care Quality Commission (CQC) inspected our core services in March 2016 and published their report in August The inspection covered University College Hospital including the Elizabeth Garrett Anderson Wing (EGA) and University College Hospital at Westmoreland Street. Whilst some areas for improvement were identified, we were rated as good overall and outstanding for well led in surgery. We face challenges balancing the priority services for our local community with our activities as a specialist centre. Our external stakeholders told us that to be rated as good overall was a real achievement. Nevertheless, we believe we can still do better. Our ambition is for all our hospitals and services is to be rated as outstanding. This drives our work in acting on the CQC s inspection findings. This report shows how we performed against our 2016/17 priorities, then sets out our priorities for the coming year, followed by an overview of all our key performance indicators and assurance statements The report has been written with our clinical teams. The text has been scrutinised by a group representing our governors and by the board including our non-executive directors to ensure that it paints a fair picture. Measures of quality and performance are, by their nature, less precise than our financial information, with less internal and external scrutiny than the financial information presented in our annual report and accounts. But I believe this report gives an accurate account of quality at UCLH and I hope it will be read widely, by staff as well as by the people who use our services. With this in mind UCLH has done its best to ensure that, to my knowledge, the information in the document is accurate recognising the matters identified in the report including in respect of the 18 weeks referral to treatment incomplete pathway indicator and the A&E maximum waiting time for four hours indicator as described in section 3.5. Professor Marcel Levi Chief Executive 23 May PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

82 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) 3.1 About this report What is a quality report? Every year all NHS hospitals in England must write a report for the public about the quality of their services. This is called the quality report. A quality report makes your hospital more accountable to you and drives improvement in the quality of our services. We look at our performance over the previous year, identify areas for improvement and publish that information. We make a commitment to you about how those improvements will be made and checked over the next year. In the report year means April to March (2016/17 or 2017/18). Quality in healthcare is made up of three dimensions: Patient safety - keeping patients safe from harm Clinical effectiveness - how successful is the care provided? Patient experience - how patients experience the care they receive What is in our quality report? This report tells you how well we did against the quality priorities and goals we set ourselves for 2016/17 (this year). It also sets out the priorities we have agreed for 2017/18 (next year), and how we plan to achieve them. Terms and abbreviations denoted by in the report are explained in the glossary. The report begins with the statement on quality from the chief executive. Thereafter it contains six sections and four appendices: Part 3.1 An introduction to the report and explains why we publish it and what it is about. Part 3.2 Sets out how we want to improve in 2017/18. Part 3.3 Sets out our progress against our 2016/17 priorities. Part 3.4 Sets out our priorities for improvement in 2017/18. Part 3.5 Describes how we review and evaluate the quality of the services we provide, including information and data quality. It also describes audits we have carried out, and how we have responded to our stakeholders comments from last year s quality report. Part 3.6 Contains mandated statements of assurance from the board. Annex 1 Provides statements from our commissioners and Healthwatch Camden Annex 2 Provides our statement of directors responsibilities Annex 3 Provides the Independent Auditor s report to the council of governors of UCLH on this quality report Annex 4 Provides a glossary of terms and abbreviations denoted by in the report 3.2. Where we want to improve Care Quality Commission Inspection We underwent the first CQC inspection of our core services that provided a rating for UCLH in March The CQC assessed the safety of our care, how effective our care is, how caring, responsive and well led we are, with services rated as Good overall. Professor Sir Mike Richards, chief inspector of hospitals, said: My team saw many examples of good care, and were impressed by the dedication shown by staff, the support provided to staff, and the clear emphasis UCLH places on putting patients first. The vast majority of patients spoken to were very positive about the care they received, and staff were proud to work at UCLH and of the level of care they were able to deliver. The CQC made many positive comments about our care and services in the report, some of which can be found in Table Q1 opposite. Our overall rating was good. However, five areas were found to require improvement, three in urgent and emergency services, and two in medical care. 82 University College London Hospitals NHS Foundation Trust

83 Table Q1: CQC 2016 rating of UCLH 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

84 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) What the CQC said about us Some extracts from our inspection report In maternity and gynaecology we saw examples of outstanding practice. We saw high levels of support given to staff in an innovative environment with good examples of innovation and best practice. There was outstanding local leadership in the critical care unit with high levels of staff and patient engagement. The majority of patients we spoke with were positive about the care they received. Patients told us staff were excellent and highly professional. Patients told us they were always treated with compassion. One patient reported she had complete confidence in the care she had received. All levels of staff, from the cleaners to the consultants, treated her in a caring way. In outpatients and diagnostic Imaging patients were treated with compassion, dignity and respect; they were fully involved in decisions about their care and treatment Throughout the hospital we saw areas of outstanding practice. We found all staff to be dedicated, caring and supportive of each other and we found patient feedback to be overwhelmingly positive. Patients we spoke with were positive about the care they received. Patients told us staff were excellent and highly professional. Patients told us they were always treated with compassion. One patient reported she had complete confidence in the care she had received. All levels of staff, from the cleaners to the consultants, treated her in a caring way. Staff recognised the changing needs of the local people and wider population and used a task force to identify and address any gaps in services. A range of support teams, such as translators and the drug and alcohol support team, were available to meet patients individual needs. There was a strong focus on improvement from all levels of staff when results were less them (sic) optimum (Surgery) Interactions between staff and patients were individual and delivered in a caring and compassionate way. We saw that staff were caring and demonstrated compassion towards patients in one to one interactions. In quieter periods, we observed nurses and doctors welcome patients who were distressed into the acute assessment area calmly and by introducing themselves. We also saw other examples of similarly positive interactions elsewhere in the department. One patient told us that they were very happy with how staff engaged them and said, Staff have been very nice to me. Children were cared for in a caring and compassionate manner. Their privacy and dignity was maintained throughout their hospital stay. Fully trained and registered children s nurses and neonatal nurses throughout the service ensured that children and their families were informed about their care and were fully involved in any treatment decisions. 84 University College London Hospitals NHS Foundation Trust

85 CQC Recommendations: Emergency Department & medical care CQC recommended that we check the streaming process in the Emergency Department (ED) and work with our staff to develop a system that shortens the time to assess patients, and the time they have to stay in ED. They said we should make sure we always record early warning scores, sepsis screening and pain management. They recommended that we check emergency cover in the ED to ensure it meets the Royal College of Emergency Medicine (RCEM) recommendations. In the areas relating to Medical Care they recommended that we improve record keeping and ensure all our risks are noted on risk registers. What have we achieved so far in the Emergency Department? We have introduced a new ED day unit to treat and assess patients who require further tests and treatment, by specialist teams, but do not require admission to a ward. We have increased GP resource for patients presenting with primary care conditions during core hours, utilising them to redirect patients to appropriate primary care or community services, supplementing the existing see and treat GP provision within the ED. We have introduced a rapid assessment and treatment function to reduce the time it takes to hand over patients arriving by ambulance. We have introduced a clinical navigator at the front of the ED to direct patients to the best area and clinician for their condition. We have improved how we communicate with patients. The nurse lead for each area updates patients at least every hour on potential waiting times. We are testing alternative ways of sharing lessons learnt from incidents. For example, discussing them at daily ward huddle meetings and in monthly bulletins. Although we provide significantly better consultant cover than any other non-major trauma centre in our sector, the RCEM recommend that there is consultant level cover in the ED 16 hours a day on seven days of the week. We achieve this target Monday to Friday. At the weekend, we currently provide 14.5 hours per day and we are working to close that gap. Improving care walk rounds (ICRs) in the Emergency Department The ICR team is made up of nurses, hospital volunteers, students, governors, managers, doctors, pharmacists, therapists and dieticians. They act as fresh eyes and a critical friend to help our staff to improve by identifying areas of concern and good practice and by sharing good practice from other parts of our hospitals. We have carried out three ICRs in the ED since the CQC inspected in March These have confirmed steady improvement in the areas recommended by CQC for action. For example it was noted that patient flow has improved and the management of medicines is better. Staff gave good feedback about learning from incidents and the ICR team could see that the clinical navigator role is having a positive effect on the patient journey. The staff reported improved staff morale, better culture, good teamwork and improved leadership and that nurses and doctors have a better rapport. Staff were aware of the duty of candour and knew what to do if a relevant incident occurred. We still have work to do We have around 140,000 attendances at our ED each year. We are transforming our urgent and emergency care services by expanding and improving our ED footprint at University College Hospital. This is moving forward as part of a 21.7 million programme to redevelop and improve the facility, while continuing to provide care to patients. As part of this programme of works, the paediatric (children s) emergency department will be redesigned to improve the experience of families attending the ED. We will be piloting a new 24-hour Mental Health Liaison service, with a mental health nurse specialist to triage (sort) patients and redirect them to appropriate community services. CQC recommendations trust-wide - other key areas we are working to improve are: Care of patients with dementia: Although we flag (identify) patients with dementia, the CQC said that this did not appear to be reflected in plans for their care. We are now ensuring that patient needs associated with dementia are included in the nursing assessment and care record. Where the patient or family agree, a This is me card is placed on the patient s bedside table which details what the patients preferences are if they are unable to communicate them to staff. We aim for at least 90 per cent of ward-based staff to have completed dementia training this year. 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

86 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Care of patients with learning disabilities (LD): Although we flag (identify) patients with a learning disability (LD), the CQC said that this did not appear to be reflected in plans for their care. We now have thirty trained LD champions across our hospitals. When registered with UCLH patients are flagged on CDR if they have a LD. When a patient with LD is admitted, they are routinely offered a Hospital Passport, if they do not already have one. This is designed to help hospital staff understand each patient s needs, likes, dislikes and interests. We monitor this by audit; currently 77 per cent of patients flagged with a learning disability received a Hospital Passport. Mandatory training: We have developed systems to give our managers up to date reports on the training records of their teams. We are working to ensure suitable and sufficient capacity for classroom training to improve mandatory training compliance. Pain management: The CQC recommended that we improve pain scoring and documentation. We are building pain recording into vital signs monitoring, with training for nursing staff and nursing assistants. Monitoring and assurance of our CQC action plans There is a lead for each area and action from the CQC report. We take assurance from the data in our quality and safety performance book, Exemplar Ward and Essence of Care audits, matrons walk rounds, ICRs and audits, e.g. the sepsis CQUIN. We are developing an approach to bring the different types of assurances together in one report When things do not go well How we are implementing the duty of candour However hard we try, sometimes complications happen, or things do not go as planned. We make sure that if patient safety incidents happen where the harm is moderate or greater, patients or their families are told about them. We ensure that the patient or relative receives an apology and is kept informed of the investigation. We also share learning from such incidents to help prevent stop them happening again. We have worked hard to make sure that our staff are aware of their responsibilities under the duty of candour. We provide extensive training and support to help them to do this and there are named clinicians in each area that our staff can go to for advice. 86 University College London Hospitals NHS Foundation Trust We measure our success by regularly checking that duty of candour is being applied for relevant incidents, using completion of the relevant fields on our incident reporting system, Datix. Our monitoring shows that we have made further progress in the last year. Recording the initial apology has risen from 82 per cent (measured in April 2016) to 85 per cent (measured in March 2017) and compliance with sharing the investigation findings has risen from 68 per cent to 80 per cent for the same periods. We share learning about duty of candour through our quality and safety bulletins. A story published in the July 2016 bulletin described the experiences of a lead investigator sharing the outcome of a serious incident (SI) investigation with a family. The incident involved a patient who had suffered a fall and needed significant ongoing hospital care. The meeting involved an explanation of the SI process and the findings of the report, an opportunity for the family to ask questions and the offer of further support for the family as well as further apologies on behalf of UCLH. Whilst the meeting was very emotional for the family, they thanked the staff, both the ward sister for the care she had provided while the patient was an inpatient and the lead investigator for undertaking the investigation. On reflection the lead investigator described the experience as humbling; it reinforced that the impact of an incident is deeply personal for the people directly affected and that duty of candour is about openness and compassion. Complaints The Picker National results scores for the question Did not receive any information about how to complain were 45/100 for 2015 and 48/100 for 2016 (lower scores are better) but we were significantly better in 2016 compared to our peers in the Shelford Group (58/100), London acute teaching hospitals (61/100) and the Picker national average (60/100). Complainants are asked how they would like their complaint to be handled. Our staff make every effort to respond at the time to things that patients are unhappy about. For example, if the complaints team receive a contact about a current inpatient, the matron, manager or ward sister will visit the patient/ family at the earliest opportunity, and will be able to resolve most issues straight away. Internal auditors looked at the complaints process this year. The audit found significant assurance with minor improvement opportunities. It highlighted that there were processes for learning lessons in place at divisional and trust-wide level. For example, the quality and safety bulletin was used to share lessons from complaints and good complaints handling

87 practice. Areas for improvement included improving response times and communication with complainants if delay occurred. An aim in 2016/17 was to improve training in complaint handling and early resolution of concerns. We held six training sessions for staff from all divisions and two forums, which were attended by over 300 staff. We hope this will promote prompt intervention to resolve a concern and more efficient response times. Our target for the number of complaints responded to within the time frame agreed with the complainant this year was 85 per cent. We responded to 75 per cent in time, an improvement of three per cent on last year; but this requires further attention. A formal complaint is one in which the patient or relative asks for an investigation and a written response. Where possible, divisions work with the complaints team to resolve issues without a full investigation. For example, concerns about appointments can often be resolved quickly, by the local teams. In addition to complaints, the complaints team received a further 1122 contacts, an increase of 52 per cent (737) on last year. Contacts can range from someone wanting to know who to speak to about a concern to staff seeking advice on how best to resolve a patient s concern. In 2016/17, we received 771 formal complaints Chart Q1: Complaints per 1000 patient contacts in comparison to 712 in 2015/16 (an increase of 59). Chart Q1 shows that while there has been a longterm downward trend in complaints per 1000 patient contacts, there was an upturn in the final quarter of 2016/17 following changes to our patient transport service. 2016/17 saw 64 complaints about patient transport compared with 14 in 2015/16 (an increase of 50), so this accounts for almost all of the increase in total complaints. We were very concerned to see this increase, which included some very poor patient experiences. This was linked to the new transport provider taking longer than expected to deliver the full service to the quality we required. We are working closely with them to improve the quality of this service. Measures already taken have included working with clinical areas to reduce transport bookings at short notice. The transport team has also been proactive in talking to patients who have had problems and ensuring future travel plans have been checked to avoid similar problems occurring. We have yet to see the impact of this work on the number of complaints In 2016/17, 739 complaints were closed. Of these 28 per cent were not upheld (not agreed), 47 per cent partially upheld (partly agreed) and 25 per cent upheld (fully agreed) at the time of this report. This is determined by our complaints team. See the glossary on complaints for more detail. 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) 0 Qtr1 Qtr2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr / / / /17 Annual Report and Accounts 2016/

88 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Examples of learning from complaints: A relative bringing a patient with a disability to the hospital complained about disabled parking availability. Blue badge holders wishing to park on the UCLH site must have a dispensation notice. We changed the rules to enable patients with a disability to obtain a dispensation notice before coming to the hospital. Previously, they would have to make three journeys from their car to the hospital - one to get a notice from reception staff, one to park their car and one to go back to the hospital. Now, visitors with a disability can simply park and get to their appointment. We also now employ parking attendants to ensure that disabled spaces at the hospital are used correctly at all times. Providing a chaperone In response to a small number of complaints about the need for a chaperone, we have provided a new policy for staff to follow. We expect staff to explain the nature of any examinations at the earliest point possible in the visit, to ensure that the patient is offered a chaperone and to highlight any difficulties in obtaining a chaperone to the nurse in charge/ matron/manager. Patients with a learning disability A patient with a LD recently complained that the complaint response from us was hard to read and inaccessible. In response, we are now offering an easy to read version of complaint responses along with the original letter for these patients. We expect our staff when writing a complaint response to use easy-tounderstand language and to write medical terms in full. All complaints involving a patient with a LD are shared with our clinical nurse specialist for learning disabilities. This is so that support can be given to the patient and if required, expert advice on any actions required to improve future care, such as additional education for staff, use of the Hospital Passport, help to make an initial complaint or provide support at complaint resolution meetings. A patient with a rare condition had a number of problems with nurses and doctors during their care pathway The matron met with the patient and apologised and explained how they had fed back her experience through a series of safety huddles on the ward, and presented an anonymised (confidential) version of her pathway and experience at the local governance 88 University College London Hospitals NHS Foundation Trust group, so that the whole team became aware of the impact on the patient. Formal educational sessions on the patient s rare condition were also arranged for key medical and nursing staff so that future patients would not have the same experience. The patient was very happy with this resolution. Early response to patient worries We shared this message with our staff as an example of a patient s response when the division responded quickly to her concerns with a telephone call. This may have averted a formal complaint. Morning, I did receive a phone call last night from a senior member of staff from endoscopy which I m very thankful for, I was able to explain the issues that occurred during my test which was all I needed to do, so it can help with further treatment. I really appreciate everything that yourself and the senior member of staff from the Endoscopy Department have done for me, thank you so much. Complaints to the Parliamentary and Health Service Ombudsman Patients unhappy with the outcome of our complaints processes can ask for their complaint to be reviewed by the Parliamentary and Health Service Ombudsman (PHSO). In 2016/17 there were 96* contacts by patients or their relatives with the PHSO. Most of these were considered premature by the PHSO; the complainant had either not made a complaint to us or their concerns were still under investigation. This is a slight increase on the previous year (91 for 2015/6). Of the 96 contacts received by the PHSO, 30 proceeded to investigation, compared to 24 in the previous year, an increase of 25 per cent. Over the past year, 12 PHSO investigations (some relating to previous years) were partially upheld (partly agreed), with the outcome being an apology, an action plan to rectify the failures that were identified and in some cases a financial settlement. Sixteen cases remain open from 2015/16 and one from 2014/15 at the time of this report. *Figure based on local data as PHSO official end of year data not available at time of report Ombudsman s cases A patient complained to the ombudsman about the results given to them by UCLH, when a different diagnosis was made overseas The PHSO investigated and concluded that we had carried out tests recognised in the UK as the gold standard for making a diagnosis and these had been negative. The complaint was therefore not upheld (not agreed).

89 A relative was unhappy with a number of aspects of their relative s care. UCLH s investigation had already partially upheld their concerns. The PHSO case looked at the consent process for the complex surgical procedure and recommended a review of some of the pre-operative tests and how these were documented. They also recommended improving written patient information and documentation during ward rounds. The consent process had originally been considered appropriate by UCLH. The overall case was upheld (agreed). A payment was provided to recognise the failures identified and an action plan is being developed. This will also feed into the improvement work on consent planned for next year. Please see the UCLH Annual Complaints reports available on our website for further information Supporting our staff Staff survey 2016 We take part in the annual national staff survey every year and we use the results to help review and improve the experience of our staff. This year responses were received from 44.6 per cent of our eligible staff, compared to 35.8 per cent in This represented an additional 651 responses, which is a 24 per cent increase on Staff engagement The overall staff engagement score is calculated by NHS England and compares us with other similar hospitals. It is a key indicator for us, taking in how staff feel about being able to contribute to improvements at work; their willingness to recommend the organisation as a place to work or receive treatment; and the extent to which they feel motivated and engaged with their work. It is measured as a score out of five. Our staff engagement score for 2016 was 3.89 against the national average score for acute trusts of Our 2016 score was higher than our 2015 score of Amongst London trusts, we had the second highest score for staff engagement and we were fourth amongst UK trusts. Overall results Our results offer us a guide to staff performance, and given the increased response rate, are more likely to represent the view of the majority of our workforce than in previous years. When ranked against all acute trusts, our results place us in the highest 20 per cent for the following key findings: Staff recommendation of the organisation as a place to work or receive treatment (3.99 out of 5 compared to a national average of 3.76 out of 5) Percentage of staff who have not experienced physical violence from patients, relatives or service users (88 per cent compared to a national average of 85 per cent) Percentage of staff who have been appraised in the last 12 months (93 per cent compared to a national average of 87 per cent) Quality of appraisals (3.29/5 compared to a national average of 3.11/5) Fairness and effectiveness of procedures for reporting errors, near misses and incidents (3.79/5compared to a national average of 3.72/5) Percentage of staff reporting good communication between senior management and staff (39 per cent compared to a national average of 33 per cent) Effective use of patient/service user feedback (3.82/5 compared to a national average of 3.72/5) When ranked against all acute trusts, our results place us in the bottom 20 per cent for the following key findings: Percentage of staff working extra hours (77 per cent compared to a national average of 72 per cent) Percentage of staff believing the trust provides equal opportunities for career progression or promotion (78 per cent compared to a national average of 87 per cent) Percentage of staff experiencing discrimination at 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

90 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) work in last 12 months (18 per cent compared to a national average of 11 per cent) Percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months (31 per cent compared to a national average of 25 per cent) Percentage of staff witnessing potentially harmful errors, near misses or incidents in the last month (32 per cent compared to a national average of 27 per cent) Percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public in the last 12 months (33 per cent compared to a national average of 31 per cent) Percentage of staff feeling unwell due to work related stress in the last 12 months (39 per cent) compared to a national average of 35 per cent Our 2016 results show a significant improvement in 14 key findings with no significant change in 18 key findings. Our results have not significantly worsened in relation to any key finding. Where have we improved In comparison with the 2015 survey, staff experience has improved most in relation to the following key findings: Organisation and management interest in and action on health and wellbeing (3.67/5 in 2016 compared to 3.54/5 in 2015) Quality of appraisals (3.29/5 in 2016 compared to 3.13/5 in 2015) Percentage of staff satisfied with the opportunities for flexible working patterns (52 per cent in 2016 compared to 48 per cent in 2015) Staff satisfaction with level of responsibility and involvement (3.90/5 in 2016 compared to 3.84/5 in 2015) Percentage of staff reporting good communication between senior management and staff, which increased from 33 per cent in 2015 to 39 per cent in 2016 We have also seen improvement in relation to a key finding, which we note as an area for concern in 2015; staff confidence and security in reporting unsafe clinical practice has increased to 3.71/5 in 2016 compared to 3.65/5 in What are we paying attention to? There are two key areas where we want to see improvement: The percentage of our staff who said they experienced harassment, bullying or abuse from other staff has remained at 31 per cent in 2016, the same as We are providing in-house coaching and support for our leaders to promote teamwork that is more effective. We are training managers in each division to carry out local conflict resolution supported by an external company with a successful track record. We are one of the first NHS trusts to introduce an independent Guardian Service (external and independent support) which provides a safe route for staff to raise concerns. We are also investing in aftercare following a formal employee relations exercise, so that any colleague who experiences bullying and harassment over a prolonged period is proactively supported by trained specialists. The percentage of our staff who said they believed that UCLH provides equal opportunities for career progression or promotion was 78 per cent the same as in Our 2016 Annual Equality Report identifies our objectives and priorities for 2017/18. These include additional research amongst current Black and Minority Ethnic (BME) staff to better understand the results of the staff survey. We need to know their reasons for feeling that we do not provide equal opportunities for career progression/promotion, before we can consider the further action to be taken. We will also be undertaking further analysis of recruitment data to understand whether there are specific areas, bands or staff groups within which a BME candidate is less likely to be appointed and implement actions to address this. We also plan to offer mentoring and coaching support to staff with protected characteristics to enhance their promotion opportunities, roll out unconscious bias training and further improve the recording of staff demographics relating to disability, sexual orientation and religion/ belief. We have continued the wider rollout of what is discrimination? In partnership with the Royal College of Nursing (RCN) with five additional sessions held in 2016 that were well attended by staff. The first session, which focused on unconscious bias, was filmed and made available to colleagues who were not able to attend the sessions. We are considering how we may further partner with the RCN as we continue our work to tackle discrimination in 2017/ University College London Hospitals NHS Foundation Trust

91 3.3 How did we do? Progress against 2016/17 priorities This section of our quality report provides a look back over the 2016/17 quality priorities at UCLH. We put in place action plans and developed measures for each of the priorities and our performance has been monitored throughout the year by our clinical teams and hospital committees Priority 1: Patient experience In 2016/17, our aims were to maintain our high overall experience ratings (Table Q2) and to improve on seven specific areas detailed in Tables Q3, Q4 and Q Maintain our overall patient experience scores as measured by the Friends and Family Test (FFT) questions A new feedback system was introduced in 2016 to allow us to reach a wider range of patients and ensure we are able to capture a representative view of our services. The new system allows patients to complete surveys in any language and has a read aloud function in both English and other languages. A text resizer, a text simplifier and a screen ruler as well as different colour contrast options are also available. We also now collect feedback via mobile phone and voice calls as well as electronic and paper methods. We are developing easy read paper survey options to suit both patients with learning disabilities and those with dementia. 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

92 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Table Q2. Progress against FFT priorities Friends and Family Test area Inpatients and day-case patients Patients recommending UCLH 2015/16 score Target for 2016/ /17 Score Performance+ 97% 97% 95% Outpatients 92% 92% 91% Transport 94% 94% 85%* A&E 95% 95% 95% no change *Based on responses from April-June 2016 and January-March Direction of arrows indicates performance compared with previous year. Our FFT target for 2016/17 was to match 2015/16 performance in four priority areas. We achieved this in A&E despite the challenges faced by our staff with increasing demand and limited space. There were small decreases in our inpatient, day case and outpatient scores and a larger drop in the transport score. The inpatient/day case patient score was exceptionally high in 2015/16 and the 2016/17 score remains very high at 95 per cent. Small year-to-year fluctuations are to be expected in FFT scores, reflecting not just changes in patient response but also the level of response. Our average response rate for inpatient/day case patient score in 2015/16 was 24.6 per cent per month, whereas our average for 2016/17 was 16.7 per cent. We expected a slight drop in response rates during the switch from the previous feedback system to the new one as staff became familiarised. However, response rates did not return to the previous levels as quickly as expected. In addition, we changed transport providers in It was agreed that it would be their responsibility to collect the transport FFT data. However, no data were collected between May and December Collection resumed in January 2017 and continues. The scores are low however, as there have been a number of issues during the transition - please see complaints section (section 3.2.2) Improve patient experience in priority areas as measured by local and national surveys We use three survey sources to measure patient experience. The CQC s annual National Inpatient Survey shows how we compare to all other NHS trusts but is only available later in the year. The Picker Institute carries out the patient survey programmes on behalf of the CQC for some trusts which allows us to compare ourselves with other trusts using Picker (83 trusts out of 150 surveyed for 2016/17). We also have an internal patient feedback system, which helps us track our performance continuously through the year. In 2016/17, our aims were to improve in five specific inpatient areas, one outpatient specific area and one cancer specific area. Tables Q2-Q5 show these performance measures using Picker and local feedback data. 92 University College London Hospitals NHS Foundation Trust

93 Table Q3. Progress against specific inpatient priorities National Inpatient survey questions Bothered by noise at night from hospital staff Rating the hospital food as fair or poor** Not always getting enough help from staff to eat meals Not given any written/ printed information about what they should or should not do after leaving hospital Hospital staff did not discuss need for further health or social care services after leaving hospital *Problem scores see glossary for more information on how these are calculated. ** Range = Poor, fair, good and very good + Direction of arrows indicates performance compared with previous year. National survey results (Picker) lower scores are better* 2015 result 2016 target 2016 result Performance+ 20% 17% 20% no change 40% 36% 40% no change 35% 30% 38% 32% 29% 32% no change 19% 14% 18% We have maintained performance in the three of our inpatient priorities, but have fallen short of our improvement targets in all priorities. This is disappointing, as much work has been carried out in the last year. We recognise that some of this has taken place after patients responded to the national survey and so we will continue to monitor progress. A more detailed look at noise at night was carried out to understand the source of disturbances. Individual areas were given a detailed list of what patients were saying about their area and have developed local action plans. Patient experience is monitored through the Patient Experience Committee (PEC) supported by the Improving Experience Group (IEG) and site-specific sub groups. This means sites can look at, and take action, on local patient experience feedback that is specific to their environment and processes. Other experiences that may occur in a number of areas or across UCLH can be looked at collectively at the IEG. We have a number of catering suppliers providing food to our patients in our hospitals so improvements are developed and acted on locally. A number of our site-based experience groups have worked to improve hospital food this year. At University College Hospital at Westmoreland Street, a working group was set up with both catering and dietetics to involve patients in the reviewing of menus and making adjustments in response to the feedback. The Royal National Throat, Nose and Ear Hospital (RNTNEH) undertook a review of wardbased food provision with staff and governors, and used Patient Led Assessments of the Care Environment (PLACE) inspections to review the quality of the food. This information was used to make changes to the menu e.g. to remove items that become soggy when microwaved. At the National Hospital for Neurology and Neurosurgery (NHNN), more detailed patient surveys on food provision were carried out and an action plan was developed by the catering supplier. This included raising the awareness of alternative ethnic menus. To improve patients getting help with their meals, a number of non-clinical staff now volunteer as dining companions on the care of the elderly wards. This has increased the capacity of these wards to help patients with meals where this is most needed. We aim to have volunteers supporting on all wards in the future but have prioritised areas of need, for example with our more elderly patients, and where ward teams have 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

94 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) requested input. To further understand what is important to patients regarding help with meals, we carried out a listen at lunchtime exercise across our hospitals in February We gathered more detailed feedback about what we needed to do differently at mealtimes to ensure we better understand what help is required, including from those patients who do not need help with being fed. What we heard from patients is how important meal times are and the range of support that is required. We will use this information to improve help with meals in the coming year. We are looking at standardising and improving the discharge process across UCLH by ensuring adequate information and planning for health and social care post discharge. This has been done in various ways including daily huddles of key staff on the wards to discuss discharge and the use of a comprehensive discharge guide. Table Q4. Progress against specific outpatient priorities - measured using the UCLH feedback system. Question higher scores are better How long after the stated appointment time did the appointment start? (Percentage of patients who waited 30 minutes or less for appointment to start). + Direction of arrows indicates performance compared with previous year result Target result Performance+ 71% 76% 73% Our real time score for patient reported outpatient waiting times has improved though we did not meet our target. We have been taking action to improve waiting times. This has been driven locally based on patient feedback or where clinic capacity needs to be reviewed. At the University College Hospital Macmillan Cancer Centre, a system called check and track has been used to improve the use of clinic rooms and help bring down waiting times. At the EGA, staff looked at demand and capacity and reviewed the way clinics are organised. They also introduced regular updates about waiting times for patients on the day. The RNTNEH set up an outpatient group to identify opportunities for improving waiting times and developed a process to inform waiting patients of delays. Table Q5. Progress against specific cancer priorities from the CQC National Cancer Patient Experience survey 2016 Question higher scores are better How easy is it for you to contact your clinical nurse specialist (CNS)? (Percentage of patients who said they found it easy to contact their CNS.) 2015 result Target result Performance+ 63% 68% 80% However, while the response to this question has improved we remain lower than other London peer trusts and the results are not consistent for each group of patients with different cancers. We aspire to the same high standard for all patients and this will continue to be a focus for 2017/18. Please note that the national survey questions have been changed based on wider engagement with 94 University College London Hospitals NHS Foundation Trust

95 patients. There are fewer questions and many of the response options to questions changed. This has made comparison with previous years data difficult. Our improvement initiatives include an increase in the number of lead CNS posts. We have increased the number of Macmillan support worker posts who work as part of the CNS teams and who triage (sort and prioritise) phone calls and messages Priority 2: Patient Safety: Continue our focus on reducing avoidable harm Reduce surgery related harm Our aim was to make surgery safer through better use of the 5 Steps to Safer Surgery (5SSS) a checking process including use of the WHO Surgical Safety Checklist. We wanted to reduce risk and encourage a safer culture by improving teamwork and communication, with every team member feeling confident to speak up and raise concerns. We also wanted to see more incidents and near misses being reported, as an indicator of safety awareness. This diagram shows the project activity to reduce surgery-related harm, described more fully below: Surgical safety walkarounds: These follow the successful model of Improving care walk rounds used at UCLH since They focus on improvements across theatres and areas where procedures are carried out outside of theatres such as endoscopy and neuroradiology. Staff taking part come from all areas of UCLH and different disciplines. Walk round teams observe, talk to staff, coach teams, measure practice and help identify improvements, all in one visit. Measuring practice may be quantitative or qualitative. One example is noting whether questions are missed during any of the safety checks (no questions should be missed out). If this occurs, instead of recording it as non-compliance, we would explore why it may have been missed. As a result, the last year has seen targeted coaching and training, staff engagement activities, redesign of checklists and creation of other materials to assist best practice. In 2016/17 there were 23 surgical safety Annual Report and Accounts 2016/ PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE)

96 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) walkarounds across 11 geographical areas performing surgery or procedures, with 44 participants ranging from directors to theatre assistants, from anaesthetists to scrub nurses. Ninety-eight patient procedures were observed. When the CQC inspected our surgical services in March 2014 they issued us with a compliance notice to improve use of the WHO surgical checklist. Since then we have moved it from being a tick box exercise to changing the whole culture around safety in surgery, based on human factors interventions. When the CQC inspected our surgical service in March 2016 they commented that UCLH was well ahead of other trusts in improving the safety culture. As a result of this work we have been nominated for a Health Service Journal patient safety award. Education and training: We had aimed to create an e-learning module on the 5SSS by the end of 2016/17. We decided to do some real life filming instead of using simulation and this, together with key administrative and specialist staff changes, meant that there were some delays. The work is now making good progress and will be completed in 2017/18. Multidisciplinary face-to-face training is still being provided, as needed. Processes: We widened the scope of the 5SSS in 2016/17 to areas carrying out invasive procedures outside of theatres such as endoscopy, dentistry, neuroradiology, radiotherapy, pain management and dermatology. We helped to create and review safety checklists and provide custom-made training for these areas. Safety governance, learning and sharing: Locally, all surgery related incidents and near misses are reviewed by governance leads, and themes are presented at monthly governance meetings. These include a more detailed review of the incidents that led to harm. Monthly governance updates are provided to all theatre staff, including information on incidents, themes and actions taken. Safety culture surveys have been distributed to staff in theatres and areas doing procedures every six months, looking for improvements against the 2015 baseline. They have not shown an improvement so far, but the number of responses is small and the survey goes to a wide group of staff with differing roles. Results of each survey are fed back to the relevant divisions to discuss and act on, and the free text responses give us useful information about what staff think about safety in their area. Themes and examples of learning from incidents, near misses, safety culture surveys and observations during Surgical safety walkarounds are fed back 96 University College London Hospitals NHS Foundation Trust

97 to staff using At the Sharp End, a surgical safety bulletin distributed to all staff working in theatres and procedures. We published seven of these this year. External Impact: This year our approach was shared with seven other NHS trusts and we provided advice on putting it into practice. The project team also published an article on our approach to reducing surgical harm in the Journal of Perioperative Practice. Carthey et al, Implementing an integrated in-situ coaching, observational audit, and story-telling intervention to support safe surgery, Journal of Perioperative Practice, Volume 26, Number 12, December 2016, pp (7) The charts below show progress against our targets for last year. The green line shows the average (mean) number of incidents over time, and the red line shows the control limits that represent the limits of normal variation. When the red and green lines move upwards or downwards this means there has been a significant change. Progress against targets Target: 10 per cent increase in reporting surgical incidents in theatres Chart Q2 shows a statistically significant increase of 60 per cent in reporting of incidents per month from the 2014/15 baseline of 5.3, to 8.5 in August This improvement has been sustained over the past year. Chart Q2: Number of surgery-related incidents reported over time Number of incidents Mean Upper control limit (For definitions of harm and the specific selection of incident classification please see glossary). Target: 10 per cent increase in near misses being reported (within the 10 per cent increase) The number of near misses reported more than doubled between 2014/15 and 2016/17. Taking into account the 60 per cent increase in incident reporting, we have seen a 62 per cent statistically significant increase in reporting of near misses within the same group of incidents since August This has since been sustained - see Chart Q3. Reporting of near misses indicates a better safety culture as people are reporting to learn for next time, as well as when things go wrong. 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

98 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Chart Q3: Number of surgery-related near misses reported over time Number of near misses Mean Upper control limit Lower control limit Target: 50 per cent reduction in incidents leading to harm Even though there has been an increase in reporting of all incidents, we have seen a statistically significant decrease in reported incidents leading to harm per month. The number of incidents reduced from a baseline of 0.68 incidents per month prior to February 2016 to 0.14 incidents per month in March 2016, which has been sustained throughout this year. Chart Q4: Number of surgery-related incidents leading to harm over time Number of incidents leading to harm Mean Upper control limit Lower control limit Use of observational audits to measure use of the checklist, which over time identify improvements in the use of the checklist and associated behaviour in all our theatres Unannounced surgical safety walkarounds take place twice a month. During these, participants use an observational measurement tool to measure both process reliability (whether elements of the 5SSS were carried out), and behavioural reliability (whether they demonstrate teamwork, leadership, communication, 98 University College London Hospitals NHS Foundation Trust

99 situational awareness etc.). They then provide feedback, both in theatre to encourage reflection and improvement, and to local leads via hot debriefs on the same day. A written summary of learning is also provided, for later distribution and discussion. Our philosophy is that teams can learn as much from what goes well as from what needs to improve. Over time, we expect to see a general improvement in safety behaviours, though it is difficult to measure progress when observing different surgical teams, working in different situations on different procedures. Table Q6 and Q7 illustrate the sort of observations being noted. Table Q6: Good catches observed at sign-in during surgical safety walkarounds Observation There was no marking on the patient. This was noticed by the anaesthetist and the surgeon called to mark the correct side. The date of birth was incorrect on the consent form (written 10 Oct instead of 01 Oct). This was picked up in the Sign In and a new consent form resigned by the surgeon and patient. Why is this important? Marking the correct side reduces the risk of wrong site surgery by providing a visual prompt to staff during the procedure. It is vital that the right patient has consented for the right procedure being carried out. If any details are incorrect the identity of the patient and the procedure to be performed needs to be checked and the consent form re-signed. Table Q7: Other safety behaviours observed during surgical safety walkarounds Observation The operating department practitioner asked two people to stop and pay attention as they were holding a loud conversation during the checks which was distracting. The Time Out was led by a dental nurse. She made a clear announcement, Is everyone ready for a Time Out? and confirmed the whole team s readiness before starting. Every item in the Time Out on the WHO Safer Surgery Checklist was read out loud and was clear. The whole team stopped and focused on the Time Out. Open-ended questions were used to confirm the patient s identity. There was verbal and visual confirmation that the throat pack was in place and this information was immediately written onto the theatre white board so all could see. Why is this important? Distractions and interruptions must be kept to a minimum during the checks to so that everyone can pay attention, hear all the information and contribute as needed. This observation comes from a theatre team where one of the nurse s feels supported and empowered to lead the Time Out. The dental nurse who led the Time Out understands the importance of checking other team members readiness to start. She also understands that using open-ended questions, tell me the patient s name/hospital number, is safer than using closed questions. We circulated this good practice and asked for reflection from other teams; Do members of your theatre team feel confident and empowered to lead the Time Out (and other safety checks)? Are open-ended questions used when checking patient identity? This year there were unfortunately three surgical Never Events (of a total of five,- see section ) where the wrong tooth was extracted. These incidents should never occur so we strive to learn as much as we can about what went wrong, and take all available steps to prevent them happening again. Following the first incident we immediately brought in an external patient safety consultant to provide intensive support to the dental department, including assistance in investigating the root causes and contributory factors, coaching teams, helping them to redesign their local WHO checklist and providing training and information to staff. This support was well received and we feel this model of focused support from an external expert can work well. The second two incidents occurred in March 2017 and at the point of writing, investigations are taking place to understand what processes failed and what human factors contributed to these events. Reducing harm from surgery remains a safety priority for 2017/18. We will continue to carry out regular surgical safety walkarounds and collect regular qualitative data for improvement. For more information see Section 3.4, Priority PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

100 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Reduce harm from unrecognised deterioration Unrecognised deterioration is where a patient s health becomes worse and this is not picked up and acted on quickly. This year we continued to work on improving the recognition, escalation and management of deteriorating patients. Sepsis, as the most common cause of deterioration, and acute kidney injury (AKI) were both brought into the wider deteriorating patients programme. As a result, the programme s focus moved from working closely with one or two wards to taking a hospital-wide approach to improvement using specific initiatives. We have also looked to learn from serious incidents relating to unrecognised deterioration. Our aim for the deteriorating patient project was originally to improve safety huddles, National Early Warning Scores, (NEWS) escalation, the use of Situation, Background, Assessment, Recommendation (SBAR) and handovers. Over the last year we have focused on: Improving NEWS scoring and vital signs recording, as the most effective tool for identifying at-risk and deteriorating patients Improving the measurement and use of SBAR as a tool to improve timely and effective escalation and response Improving the prompt and effective treatment of sepsis as the primary cause of deterioration We learnt that we were not supporting staff to use the communication tool SBAR effectively in escalations, so a working group was set up at the end of the year to design an approach to improve this across our hospitals. An electronic data dashboard was created for measures relating to deterioration, including timeliness of escalation to the Patient Emergency Response and Resuscitation Team (PERRT) and whether SBAR was used in communicating the referral. The data can be presented by ward or hospital-wide, is discussed at every deteriorating patients steering group meeting and is published on Insight, the UCLH website for staff, so teams can use it locally for improvement. Work continues with testing an electronic approach for patient monitoring. Vital signs: There has been significant progress here. Chart Q5 shows the percentage of vital signs completed based on a locally collected sample of 10 patients per ward per month. Our target was 96 per cent based on what we achieved in 2014/ /16, but this year it increased to an average of 98 per cent. This was a statistically significant change, and has been maintained throughout the year. Chart Q5: Per cent vital signs completed for patient trust-wide (sample of 10 patients per ward per month) last 12 months Percentage of completed vital signs 102% 100% 98% 96% 94% 92% 90% 88% 86% Mean Upper control limit Lower control limit 100 University College London Hospitals NHS Foundation Trust

101 SBAR: Our target was for 90 per cent of referrals to PERRT to be made using SBAR, where SBAR was required to be used. There were 2672 referrals made to PERRT in where SBAR was required, however use of SBAR was only recorded in 49 per cent (1315) of these referrals and within that only 63 per cent recorded this as yes. This was the same as last year i.e. we have seen no improvement in use of SBAR. We have improved our recording of this measure from 31 per cent in 2015/16 to 49 per cent in 2016/17. Improving the use of SBAR in referrals and recording whether it was used are priorities for 2017/18. Chart Q6: per cent of referrals to PERRT where SBAR was used (where this metric was recorded) 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% There is no single category for patient deterioration on our incident reporting system so a range of categories are used to capture all relevant incidents (see glossary for more information). We were aiming for a 20 per cent reduction in the number of incidents of deterioration leading to harm (using the categories we defined); however we have seen no statistically significant change in our numbers. As the number of incidents leading to harm has not gone down we could conclude that the initiative is not yet working, but this may also be due to an increase in reporting. The duty of candour requirement has increased awareness about reporting unexpected outcomes, which accounts for 40 per cent of the data. As we cannot be sure of what this data is telling us, we will look at this in more detail next year and in particular at learning from serious incidents, which are extensively investigated and result in detailed action plans. Reducing harm from unrecognised deterioration remains a safety priority for For more information see section 4, priority 2. Mean Upper control limit Lower control limit 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

102 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Reducing harm from sepsis Sepsis is a life-threatening illness caused by the body s response to an infection. It is one of the most common reasons for deterioration in hospital, and as with any deterioration it requires speedy recognition, escalation and treatment. Last year sepsis was a separate disease-specific priority under the Sign Up to Safety Campaign, but since November 2016 the work to reduce harm from sepsis has come under the wider work to reduce harm from all unrecognised deterioration. Over the last year, we have progressed with our work on implementation, education and measurement of sepsis; not just in the ED as originally planned but across all our hospitals, for both adults and children. Sepsis continues to be a patient safety priority at UCLH under the deteriorating patients programme. Progress against the three elements of our sepsis improvement project is as follows: Implementation: Clinical guidelines for sepsis in adults were revised, based on the Third International Consensus Definitions published in February For children and young adults, new sepsis guidelines were created and launched across our hospitals in February NEWS Paediatric Early Warning Score (PEWS) provide the basis for screening of sepsis under these guidelines, in line with our process for recognition of all deteriorating patients. The guidelines for patients under 16 are accompanied by management tools for different age groups. In the paediatric emergency department, a sepsis screening tool was added to the assessment booklet to help early recognition. Maternity-specific guidelines for sepsis were also created this year. A new patient information leaflet to explain sepsis to patients and families is in draft for publication in 2017/18. We decided that stickers to promote best practice were not needed for clinical records on the wards because sepsis guidelines are on the inpatient vital signs charts. However, in the ED where different documents are used, stickers are being used to help staff follow our guidelines, improve record-keeping, and review. Education: A sepsis nurse was recruited to collect and report on all our sepsis data and to provide training and awareness activities across our hospitals. For the moment, we believe that face to face training and awareness activities are more effective than e-learning so a sepsis module has not been created. Nonetheless, one of our sepsis leads is linking with both Health Education England and a commercial e-learning provider as advisor so that their education is informed by our thinking. We are also exploring combined training for topics relating to deteriorating 102 University College London Hospitals NHS Foundation Trust

103 patients. Trust wide communications, ward walk rounds, poster campaigns ( Sepsis: Spot it. Stop it ) and a stand in the atrium of University College Hospital all helped to raise awareness of sepsis and the new adult and paediatric guidelines. Targeted training has been designed, and is being rolled out on the wards and in the emergency department via clinical practice facilitators with support from our sepsis nurse. At the end of 2016/17 UCLH hosted an all-day sepsis master class aiming to share and learn from each other and hear about recent updates in sepsis care. There were 110 attendees (39 from UCLH and 71 from external organisations). Measurement: In 2016/17 we participated in the national sepsis CQUIN (Commissioning for Quality and Innovation) to measure whether screening for sepsis is happening and antibiotics are being given within one hour, and reviewed within 72 hours. The target for screening for sepsis in ED was 90 per cent of patients and we achieved this in 83 per cent. The target for screening for sepsis in inpatients was 90 per cent and we achieved this. The target for giving antibiotics within an hour in ED was 54 per cent of patients with confirmed sepsis and we achieved 43 per cent. The target for giving antibiotics within an hour for inpatients with confirmed sepsis was 86 per cent and we achieved 66 per cent. The target for review of antibiotics within 72 hours was 90 per cent and we achieved this. These results are averages for the year. We also collected monthly measures of quality using a measurement strategy agreed by the UCLPartners Sepsis Patient Safety Collaborative, of which UCLH are part. This helps us measure adherence to our clinical guidelines. Our measures now focus on specific aspects of best practice rather than measuring compliance with a bundle of care. Our clinical guidelines also support this approach to measuring how well we are doing. Incidents with harm from sepsis are not regularly counted as the numbers are so small and because we are unable to extract data from our incident database by diagnosis. When Serious Incidents (SIs) relating to sepsis occur these are investigated using the SI framework and the reports are reviewed by members of the project team, with learning incorporated into the project Continue trust-wide learning from serious incidents Monthly quality and safety bulletins to encourage learning from near misses The quality and safety bulletin contains details of learning and changes to practice from a variety of sources. These include near misses, SI investigations and complaints. We aim to feature a good catch (near miss) every month and to include more learning and changes in practice from investigating near misses. Evidence of good practice is highlighted within the bulletin. We include experiences with respect to the duty of candour and sharing the findings of investigations with patients and families. This continues to be an area of development for individuals and teams and support is offered regularly. Publication of learning from serious incidents on our trust website We have started to share learning from SIs internally via Look and Learn. SI reports tend to be complex and highly detailed and front-line staff members are not likely to have the time to read them. Look and Learn summarises serious incidents into an easy to read format including root causes, key learning and actions from the incidents. A new format was launched in January 2017 and allows ease of printing for display on local governance noticeboards. We have received very positive feedback and continue to share Look and Learn on a monthly basis, as part of our ongoing strategy for sharing learning from serious incidents. At least two quality forums per year focusing on safety This year there has been an emphasis on learning from University College Hospital s CQC inspection and preparing for any possible specialist hospitals inspection. To this end one quality forum took place in July at the NHNN with the theme improving care and services in line with the CQC fundamental standards of care. A session on leadership and the CQC took place at the UCLH leadership forum. Education services will support teams in sharing their learning from After Action Reviews (AARs) more widely. At least two stories based on one or more AARs to be published in the quality and safety bulletin The Institute improvement team introduces the concept of AAR to all new starters in the trust, delivering a one hour session on learning and improvement as part of every trust induction. AAR Foundation training courses are delivered monthly, open to all, and more advanced AAR conductor 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

104 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) training, quarterly, for those who wish to extend their capabilities in leading complex AARs. The Institute improvement team are in the process of reestablishing the AAR conductor network to provide peer to peer coaching to support individuals routinely using AAR. The AAR programme is clear in setting out expectations around learning. Capturing learning or actions from an AAR is principally the responsibility of the team or group involved in the AAR, not the AAR facilitator as it is for the team concerned to determine what can and should be shared from their experience, and how it is best communicated to the appropriate audience. When possible the team will contribute to quality and safety newsletters or similar. Occasionally, where appropriate, the Institute will report on AARs and key learning in the UCLH Institute Newsletter. The Institute improvement team is in the process of designing a prototype area on the Institute Insight pages that will allow teams to share learning from AARs. Learning from an AAR was shared in the August 2016 bulletin. This was about the processes and communication around a patient with a disability who travelled to UCLH for treatment/surgery and for whom it turned out that the surgery was not appropriate and therefore did not go ahead. Learning from an AAR about rapid deterioration in a frail, elderly patient and when to discuss do not attempt resuscitation was shared in the February 2017 bulletin. Achieve the national guidelines for investigation reports being completed following a serious incident (60 working days) We reported 56 serious incidents in 2016/17 of which two were subsequently not considered serious after investigation at the time of writing this report. Of the 35 that were due to be completed this year, 24 were completed within the 60 day target set in national guidelines (Serious Incident Framework supporting learning to prevent recurrence April 2015) or after agreeing an extension to the deadline with the commissioners. This means we achieved 69 per cent of reports being submitted within the agreed timeframe. Of those that did not meet the deadline, three were one day late and one was three days late and if these were included the compliance would be 80 per cent. Have no further Never Events reported Never Events are a particular type of serious incident that are wholly preventable, where guidance or safety recommendations that provide strong systemic 104 University College London Hospitals NHS Foundation Trust protective barriers (such as physical barriers or systems of double-checking) are available at a national level, and should have been implemented by all healthcare providers. The national requirement and our target is to have zero never events. Five Never Events occurred in 2016/17 (There was a never event reported in April 2016, However, this incident actually occurred in November 2015 and was included in last year s quality report). Learning from Never Events Misplaced nasogastric (NG) tube April 2016 A 60-year-old patient had a nasogastric tube placed and the position checked using the methods described in the UCLH guidelines, and feeding was commenced. The patient clinically deteriorated five to six hours later and the feed was stopped. Chest radiograph (plain x-ray and CT scan) revealed the tube to be misplaced in the lungs. The patient was subsequently transferred to critical care for respiratory support from which he recovered. There were no care or service delivery problems identified during this investigation as the check undertaken, the ph check, was correctly undertaken in line with UCLH policy. However, the policy for insertion of NG tubes was subsequently changed see later incident. Wrong site surgery dental (March 2016 identified in July 2016) The patient was referred for treatment at the Eastman Dental Hospital (EDH) for removal of the Lower Right 8 wisdom tooth roots. After administering the intravenous sedation, the doctor administered local anaesthesia (numbing medication) to the Lower Left 8 area and raised a muco-periosteal flap. The patient alerted the dentist that it was the wrong side and the flap was sutured (stitched) and the procedure completed on the correct tooth. The root causes included practices leading to pressure, excessive multi-tasking demands, and distractions and interruptions for the oral dental surgery team who were treating the patient. There was also no white board in place to remind staff of the correct side and there was a disconnect between expected practice, as described in policies and procedures, versus the real clinical world, for example, not taking into account that there may be staff shortages on the day. Recommendations include that the oral surgery team must ensure additional staff are available to step in and assist with planned lists when

105 team members call in sick. White boards must be implemented in all rooms in the oral dental surgery clinic to provide teams with a shared visual reminder of the patient s name and the type and site of the procedure. In addition, the EDH must improve the current WHO Surgical Safety checking practice and provide education to support oral dental surgery teams to carry out these checks effectively. Misplaced NG tube January 2016 (identified in July 2016 as part of an inquest) The patient presented to the emergency department on 12th January with complex pleural disease and multiple comorbidities. She required enteral feeding via a nasogastric tube (NG tube), which was placed on 13th January 2016 and she was fed. On the 23rd January the ITU consultant observed the tube to be in an unusual position. Radiology review of her chest X-ray showed the tip of the NG tube was lying above the level of the diaphragm (most likely in the pleural cavity (lung). Subsequent chest X-ray and CT scan with the use of contrast confirmed it was in the wrong position. The patient died four days after removal of the NG tube. The case was referred to the coroner, who after hearing the evidence concluded that that the X-ray (for checking that the placement of the tube was correct) was unclear and in hindsight should have been repeated. The coroner s report noted that the misplaced NG tube did not contribute to the death of the patient. Immediate actions included an instruction to all radiology staff of the need for the X-ray criteria for correct identification of placement of NG tubes to be included in all radiology reports. UCLH guidelines for the correct placement of NG tubes have been amended to be policy. A number of changes have been introduced including the need for double checking of ph and competency training for all doctors in interpreting X-rays and the need for documentation. The policy also includes specific information related to early identification of possible tube misplacement and deterioration. Wrong site surgery (dental) February 2017 The patient attended for removal of the retained root of the lower right wisdom tooth. However the lower right second molar tooth was removed instead. This event is being investigated and learning will be identified and actioned on completion of the investigation Wrong site surgery (dental) March 2017 The patient attended for multiple dental extractions under general anaesthetic including a tooth for which the patient had not been consented. This event is also under investigation. Consider using rate of recurrence of similar serious incidents (or root causes and contributory factors) as an indication of learning The quality and safety department has applied a number of processes for reviewing the rate of recurrence of serious incidents in identifying learning, as well as trends in near misses that have been highlighted and escalated, to prevent serious incidents occurring. These have included: An external review of information governance incidents related to the sending of confidential data, where the data was not fully anonymised (made confidential) prior to sending. Each of the serious incidents cited human error as the root cause Recruitment of an external investigator to investigate the second of two Never Events within the space of five months in the same location (EDH) with the same type of surgery (wrong site dental surgery) and similar contributory factors. Actions were implemented with the support of the divisional clinical director. A thematic analysis of all SIs relating to deteriorating patients in the last two years We have also undertaken a thematic analysis of near misses relating to in-hospital cardiac arrests which happened on the same ward in a short period of time. This identified a number of recurring themes including lack of escalation and no Do not attempt cardio-pulmonary resuscitation (DNACPR) orders in place. The themes were discussed and incorporated into an action plan to be implemented within the division. Continue with improving care walk rounds (ICRs) and the focus on learning, building on the experience of the CQC inspection in March 2016 Improving care walk rounds (ICRs) continue to take place twice a month, however, in January 2017 they were temporarily suspended due to outbreaks of flu and norovirus at UCLH. ICRs resumed in February. 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

106 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Priority 3: Clinical outcomes To set up a mortality surveillance group and a mortality governance structure The mortality surveillance group (MSG) has multidisciplinary membership, and is chaired by the corporate medical director. It met six times in 2016/17. NHS Improvement( NHSI) requires all trusts to have a policy in place for learning from deaths by September A policy is being drawn up by the group based on the guidance issued by NHSI Improvement in March The policy will include the use of the Structured Judgement Review method of reviewing deaths. We continue to measure the Summary Hospital-level Mortality Indicator (SHMI )as one of our measures of success and aim to maintain our position in the top 10 per cent of hospitals nationally for mortality rates as measured by this indicator. The MSG has reviewed data on patient deaths using SHMI. The latest SHMI data available (October 2015 to September 2016) shows that we have the second lowest mortality in England at We have designed a prioritisation tool to help us identify deaths for review. For example, we will review all deaths where the patient has undergone elective (planned) surgery or where concerns have been expressed by families about the care of their loved one. We already have strong systems in place for when a child, or a mother during pregnancy, dies. We are also taking part in the Mortality Review (LeDeR) programme commissioned by NHS England for when a patient with a learning disability dies. 3.4 Priorities for improvement 2017/18 How we consulted on our priorities for 2017/18 In choosing our quality priorities for the coming year, we consulted widely - with our staff, with commissioners, with representatives of local GPs, Healthwatch Camden and UCLH governors on behalf of our patients and the public. The priorities take account of progress against the 2016/17 priorities, described in section three, with some of last year s priorities identified as needing ongoing focus in 2017/18. The priorities agreed are summarised here: Table Q8: quality priorities summary Domains Patient experience Patient safety Priorities Improve overall patient satisfaction as measured by local and national surveys. We will continue to focus on the same three Friend and Family Test areas inpatients/day cases, outpatients and transport - as well as specific areas identified by our patients that require work such as our patients experience of waiting and of discharge. Continue to focus on the priorities of 2016/17 aiming to: Reduce surgery-related harm, focusing on surgery and invasive procedures. Reduce harm from unrecognised deterioration, focusing on failure to recognise, escalate and manage deterioration including sepsis and acute kidney injury Reduce the harm from failure to follow up on radiology results Continue trust-wide learning/continue to focus on learning from serious incidents and also include learning from mortality reviews and learning from things that could have gone wrong but were prevented near misses. 106 University College London Hospitals NHS Foundation Trust

107 Domains Clinical effectiveness Priorities Priority 1: Patient experience Responding and learning when patients die Even though our mortality rate is low, we have chosen this, because there is always more to be learnt when patients die. There is also a national priority to learn from deaths. We have completed our aim from last year, to set up a Mortality Surveillance Group Improving overall patient experience as measured by the Friends and Family Test (FFT) question. We know that good patient experience has a positive effect on recovery and clinical outcomes. To continue to improve that experience we have asked patients what is important to them. We have listened to patients and are responding to their feedback. This is central to caring for our patients. The Friends and Family Test (FFT) asks patients whether they would be happy to recommend us to friends and family if they needed similar treatment. We have chosen to focus on FFT because its use is a national requirement. What we are trying to improve We will continue to focus on the same four FFT areas inpatient/day case, outpatients, transport and A&E because we made less progress than we hoped for in 2016/17 for some, and as in previous years have chosen the four areas giving us the widest reported experiences across our hospitals. 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

108 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) What success will look like We will aim to maintain our scores for A&E and inpatients and day-case patients as these are comparable with our peers. We have set our targets at 95 per cent rather than edging them up slightly because marginal improvements on such a high score would not be very meaningful. However there is more room for improvement on our 2016/17 scores for outpatients and transport and that is reflected in the targets below. Table Q9. FFT priorities Friends and Family Test area Patients recommending UCLH to family & friends in 2016/17 Target for 2017/18 Inpatients and day-case patients 95% 95% Outpatients 91% 93% Transport 85% 90% A&E 95% 95% Improving patient experience in priority areas as measured by local and national surveys As well as the measures of overall experience, each year we target specific areas where patients have told us that experience could be improved. These are chosen based on performance in the national survey or as measured in real-time feedback from our patients. Our aim is to improve the experience of patients in those areas where patients continue to experience poorer standards than we would like, or where a particular decline in experience is noted. Some of these priorities have continued from last year so we can ensure the improvements are embedded. For our inpatients, the initial results of the 2016 Picker survey have shown that the general experience of care is good, but they have a poorer experience at the point of admission and discharge. This feedback is common across the range of patient feedback, including the three main surveys and we have identified a number of themes across them all Improving our patients experience of waiting We have over 1,000,000 outpatient attendances per year and we know that waiting times continue to be one of the biggest issues affecting patients experience. Waiting was also an issue for some of our inpatients, with waiting to get a bed and cancelled appointments specifically identified in the national survey results. Table Q10. Specific outpatient waiting priority Local real time survey question higher scores are better How long after the stated appointment time did the appointment start? (Percentage of patients who waited 30 minutes or less for appointment to start) 2016 Real time survey result 2017 Real time survey target 73% 78% Whilst we did not meet the target for the time patients reported waiting last year, we did improve slightly on the previous year. This remains a priority for us and as we still want to do better we have set a five per cent improvement target. There is no national survey planned again this year so local real-time feedback surveys will be used to measure how we are doing. Work will continue to improve waiting times through more efficient use of resources e.g. reducing the number of patients who do not attend without telling us. In addition, we will aim to improve the experience of patients while they wait. We will develop standards for the waiting experience across UCLH and take action to ensure these are met. This might include improvements such as the availability of refreshments and 108 University College London Hospitals NHS Foundation Trust

109 entertainment and making sure patients are kept informed. The national inpatient survey results from the CQC have yet to be published so we have selected questions based on the Picker survey. These are: Table Q11. Specific inpatient waiting priorities National Inpatient Survey questions 2015 result 2016 result* (Picker) Planned admission date changed by hospital Had to wait a long time to get a bed on a ward 2017 target* (Picker) 21% 24% 20% 24% 31% 28% * Problem scores - lower scores are better. See glossary for more information on how these are calculated. The targets chosen are based on scores achieved by similar trusts (in the same survey). In 2017/18, we are implementing a coordination centre which will provide real-time data on bed capacity and patient demand so we will better manage the flow of patients through University College Hospital, NHNN and EGA. This means we can reduce delays in patient care and prevent cancellations of procedures at short notice as a result of not being assured that there will be a bed for the patient to move in to. Also, by working with TeleTracking, our implementation partner, we will: Design and introduce new leading practice and standardised operational processes Be able to speed up the most efficient pick up and movement of patients around the hospital, reducing patient delays and times where beds are not being used Immediately know where important pieces of medical equipment are on the wards meaning we can find them as soon as we need them Staff will be able to spend more time caring for patients, with better, more real-time information. Staff will spend less time looking for equipment or trying to find available beds How will this work? Auto-discharge of patients and the triggering of bed cleans: When a patient leaves the hospital the patient badge (worn around the wrist) will be removed and dropped in a drop-box. This will automatically discharge the patient from the system and trigger a cleaning request of their bed. Automating and streamlining the movement of patients: Porters will be assigned jobs directly by the system based on their proximity to the patient, and the location of any equipment they will need to collect en route. As soon as they have dropped a patient off, they will immediately be able to see their next job on hand-held devices. Discharge planning and pathway progression: The coordination centre team will have a real-time view of all wards, and the status of each patient. Ward staff will set discharge milestones per patient which will be tracked and monitored on their ward electronic patient status board. The Coordination Centre will have a UCLHwide view of all the delayed patients, and those that are pending an action. This information will enable the coordination centre team to discuss with ward staff and corresponding teams what action could be taken to reduce the delays, offering help and support. They can help with prioritising supporting services, to ensure those patients who are currently being delayed, are seen first. Infection control: The Coordination Centre will have a real-time view of all wards and the status of each patient. As relevant infection related positive or negative results flow through from the laboratory system to the status boards, a patient will easily be identified as needing isolation or de-isolation respectively. The coordination centre team can then work with the wards to move patients to the correct bed in real time. The coordination centre with its real-time view of all beds will easily see where side rooms are empty or waiting to be cleaned, so can support rapid movement of patients to and from side rooms. Planning inpatient elective admissions: The operations team currently has only a view of the next week s Annual Report and Accounts 2016/ PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE)

110 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) elective programme, which is created from the To Come In (TCI) list, and pulled into a bed list. TeleTracking will provide the ability to view the TCI list as the data is received from the Patient Administration System (PAS) so will provide the coordination centre team with far greater real-time visibility of future demand. Together with improved data on capacity in the future (delivered by the TeleTracking analytics platform) and within 24 hours, planning for elective patients will be vastly improved. We will report progress against our performance in the national survey next year Improving our patients experience of care We remain focused on two priorities where have failed to improve as intended, but which remain important to our patients, and where we believe we can improve further. Inpatients not getting the right help with meals continues to be a priority. To further understand what s important to patients, we carried out a listen at lunchtime exercise across our hospitals in February 2017 to gather more detailed feedback about what we needed to do differently at mealtimes to ensure we better understand what help is required. Action plans are being developed based on the feedback received working with clinical teams across UCLH. Table Q12. Specific inpatient care priorities National Inpatient Survey questions 2015 result 2016 result* (Picker) Not always getting enough help from staff to eat meals 2017 target* (Picker) 35% 38% 33% * Problem scores - lower scores are better. See glossary for more information on how these are calculated. We recognise that patients who find it easy to contact their named CNS report a better experience overall. While there has been work carried out with CNSs this year and we exceeded our target, it is clear that much more improvement is needed. The targets chosen are based on scores achieved by similar trusts (in the same survey). We will report progress against our performance in the national survey next year. Table Q13. Specific cancer patient care priorities National Cancer Patient Survey questions How easy is it for you to contact your clinical nurse specialist (CNS)? 2015 result *Percentage of patients who said they found it easy to contact their CNS Improving our patients experience of discharge National 2016 result (no local result) National 2017 Target 63% 80% 85% The national inpatient survey results have yet to be published so we have selected two questions based on the Picker survey. These priorities are: Table Q14. Specific discharge priorities National Inpatient Survey questions 2015 result 2016 result* (Picker) Didn t know what was happening after leaving 2017 target* (Picker) Not asked 47% 43% 110 University College London Hospitals NHS Foundation Trust

111 National Inpatient Survey questions 2015 result 2016 result* (Picker) Staff did not discuss need for additional equipment/home adaptation 2017 target* (Picker) 20% 25% 21% *Problem scores - lower scores are better. See glossary for more information on how these are calculated. Our work for safe discharge planning has been ongoing for the last few years led by the Integrated Discharge Service (IDS). This year we designed and led six safe discharge workshops which were open to both our hospital and community staff (with excellent feedback from attendees). We are standardising our discharge processes. We have designed and published the UCLH Safe Discharge Guide for staff to use as a resource and guide to safe discharge policy and procedures. We are encouraging teams to use every opportunity to plan proactively for patients discharge, involving patients and other partners in the process. We have set standards for daily ward huddles, with the aim of discharging patients by midday. There has been a five per cent increase in pre-12pm discharges this year. To improve discharge planning and pathway progression we are introducing a Coordination Centre where the team will have a real-time view of all wards, and the status of each patient. This will include a clinical utilisation review to ensure patients are still needing to be in acute level of care, if not we can signpost patients to appropriate level of care e.g. Community services. This is a CQUIN too for 2017/18. Some of these changes were introduced after patients responded to the national survey so we would hope to see an improvement in next year s survey. The IDS nurse educator has also been working proactively on the wards supporting both individual and small group training with the ward multidisciplinary teams. We are piloting a tracker nurse who is supporting our patients being transferred to rehabilitation units across North Central London commissioning groups. The work continues next year, with further safe discharge workshops planned. We are discussing with the commissioners and the Community Education Providers Network (CEPN) both for safe discharge to be promoted and accessible for all staff across Camden and Islington (and other North Central London boroughs plus Westminster) and also for assistance with the funds. We are also designing e-learning modules for all staff to support safe discharge practice. The work on Discharge to Assess (D2A) has commenced and it is planned to pilot the first pathways with Camden and Islington in October The targets chosen are based on scores achieved by similar trusts (in the same survey). We will report progress against our performance in the national survey next year. Responsible director for Priority 1: Patient experience Flo Panel-Coates, Chief Nurse 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

112 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Priority 2: Patient safety The Sign Up to Safety campaign has been successful in driving forward a number of safety improvements. We are confident that the pledges on honesty, collaboration, and support to staff are embedded and would like to continue to focus on reducing avoidable harm (in surgery and from deterioration, which includes sepsis and learning Reduce surgery-related harm Why we have chosen this priority Since starting this initiative in April 2015 we have improved our incident reporting rates in theatres whilst seeing a reduction in the numbers of incidents of harm. Despite this, our observations during surgical safety walkarounds show that there is still progress to be made in ensuring best practice is followed for the 5SSS in every area, with every team, for every list and every patient. What we are trying to improve We are pleased that we have achieved our 2016/17 planned objectives and sustained these improvements. However as the numbers of incidents are low they provide us with a limited picture of safety in 2017/18 we will be looking at different measures of success based on providing and sustaining safety improvement interventions, in particular our Surgical safety walkarounds. We have started working with other areas performing invasive procedures outside of theatres to improve their use of the 5SSS through review or creation of new surgical safety checklists, providing training and practical support. Next year we will start to include more of these areas in Surgical safety walkarounds, whilst continuing over time to visit as many teams in theatres as possible to provide assurance of good practice. Importantly, we will also continue to revisit teams that require more support to achieve standards, in order to work with teams and monitor improvement efforts. We also intend to continue to share our approach with other NHS trusts to help spread improvements in surgical safety across the sector. This year we will: Continue to undertake regular surgical safety walkarounds to improve safety in all surgery and invasive procedures, increasing the frequency in areas requiring more support Repeat the safety culture survey in theatres and procedures and compare results over time Complete an interactive e-learning module to provide training for all relevant staff on what good looks like Continue to share learning throughout UCLH through publication of At the Sharp End surgical safety bulletins Continue to share our approach and learning with other NHS trusts by offering training and resources What success will look like: As we achieved significant increases in reporting surgical incidents in theatres (59.5 per cent) and near misses (169 per cent) and we reduced the number of incidents leading to harm by 80 per cent ( see section 3.2.1) we will sustain this level of incident reporting Undertake at least 18 Surgical safety workarounds across all hospital sites as relevant to support safer surgery, which will use observational measures to record how the checklist is used in practice, including relevant safety behaviours To improve sustainability, we aim to see surgical safety workarounds start to be led by a wider group of staff, both managers and clinicians rather than just the project team. Publication of at least two surgical safety bulletins in the trust How we will monitor progress Our performance will be measured by the reducing surgical harm project team, and reported to the QSC. 112 University College London Hospitals NHS Foundation Trust

113 Reduce harm from unrecognised deterioration Why we have chosen this priority Reducing harm from unrecognised deterioration remains a safety priority for 2017/18. We have created an overarching steering group for deteriorating patients that now includes sepsis and acute kidney injury (AKI), which are key reasons for patient deterioration. Reducing harm from unrecognised deterioration remains a safety priority for 2016/17. We have created an overarching steering group for deteriorating patients that now includes sepsis and AKI, which are key reasons for patient deterioration. What we are trying to improve We want to improve early recognition of patients at risk of deterioration and so reduce patient harm. We will continue with this project to improve timely recognition, escalation and management of deteriorating patients. We will make sure that vital signs are being reliably recorded, that escalation to medical, senior nursing staff and PERRT is quick and effective so that urgent action can be taken when needed, and that patients with sepsis and AKI are treated quickly according to clinical guidelines. To summarise, our work this year will focus on: Recognition of deterioration Improving vital signs and NEWS compliance Escalation of a deteriorating patient Improving the use of SBAR (Situation, Background, Assessment, Recommendation) in escalations Management of a deteriorating patient Improving recognition and treatment of sepsis Improving recognition and treatment of AKI SBAR is a standard, recognised communication tool used in healthcare. We learnt that for it to be used effectively at UCLH we needed to provide more support. We designed and distributed a survey to find out staff views and their understanding of SBAR, and provide us with a baseline from which to improve. 95 per cent of staff who responded knew what SBAR was, 90 per cent knew what it stood for, but only 58 per cent said they had received training. From this feedback we identified the need to provide more training to staff and provide materials such as stickers and posters to support staff to use SBAR and to document when patients have been escalated. Staff also said that during escalations staff did not always introduce themselves, and that there was sometimes no conclusion when using SBAR. As a result, we will add I (Identify) and D (Decision) to the beginning and end of SBAR, so it will now be ISBARD. What success will look like Maintain our average hospital-wide vital signs compliance of 96 per cent, based on a sample of one in five patients on every ward, every month. We have changed the sampling from last year to take account of different ward sizes* A 10 per cent relative increase inpatients escalated to PERRT using the communication tool (SBAR/ISBARD) from the 2015/16 baseline of 63 per cent to 69 per cent; and a 10 per cent relative increase in recording of this metric by PERRT] from the 2016/17 baseline of 49 per cent to 54 per cent of referrals. (The review of this year highlighted that our target of 80 per cent was too challenging to achieve in one year so we have set ourselves an improvement plan with a 10 per cent relative increase this year) Improve average compliance with provision of antibiotics within one hour of diagnosis for all sepsis patients from our 2016/17 baseline average of 56 per cent to the CQUIN target of 72.5 per cent, unless deviation is clinically appropriate and documented in the medical notes Undertake a clinical review of antibiotics within 72 hours of giving the first dose in 90per cent of patients with sepsis to determine if it is still needed, and if so, if the appropriate antibiotic is being used *We said we would continue to measure vital signs in 2016/17 based on a sample of 10 patients per 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

114 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) ward per month. This measure is part of an audit of all elements of the fundamentals of our nursing care. Our Exemplar Ward Accreditation programme is a scheme that enables us to understand all elements of performance in inpatient wards and target support where it is most needed. As part of this launch we reviewed the audits undertaken and decided to measure more metrics in each patient and for the number of audits to be proportionate to the ward size were selected. It was agreed by the Exemplar Programme Board and Nursing and Midwifery Board that a ratio of one in five patients would be appropriate. This was implemented in February Where results fall below the expected standards local improvement plans are developed and as part of this wards can increase either the sample size or the frequency of audits. Work last year showed 100 per cent of acute admissions with AKI were being recognised within the target of four hours of arrival, and an average of 75 per cent treated within the STOP targets defined by the London Acute Kidney Injury Network (Treatment for sepsis within one hour, for toxicity within 12 hours, for obstruction within 36 hours, and for primary renal disease within 72 hours). Next year we will start work to better understand how well we are recognising and treating AKI in patients who develop AKI while inpatients, and see where any improvement work may be needed both in inpatients and acute admissions. As we cannot be sure of what the incident data is telling us, we will look at this in more detail next year and in particular at learning from serious incidents, which are extensively investigated and result in detailed action plans. We will use these action plans to identify measures of improvement. How we will monitor progress Our performance will be measured and monitored by the Deteriorating Patient Steering Group, and reported to the Quality and Safety Committee (QSC) Reduce the harm from failure to follow up on radiology results Why we have chosen this priority A Safer Practice Notice in 2007 in relation to radiological imaging recommended that systems were put in place to ensure that all results are reported and that there is a policy for reporting on abnormal and unexpected findings. It also recommended that there should be safety net procedures within specialities to ensure results are read and acted upon. In 2015 UCLH introduced a new system where unexpected results could be clearly identified on the radiology system by a flag indicating that the result should be looked at urgently to help with this. However, recent serious incidents and results from a review undertaken by the Clinical Audit and Quality Improvement Committee (CAQIC) looking at which specialities have processes in place to follow up on imaging results have shown that there is still work to be done. (The audit checked that divisions have safety nets in place for checking results). What we are trying to improve We want to ensure that the flagging of unexpected results in radiology is happening effectively. Audits in radiology have shown that not all significant and unexpected findings are being identified with the urgent result alert. We also want to be assured that specialties have a local system in place for checking that all results have been received and read and that this has been shown to be effective. Specialities will be expected to report on this and how they are assured, for example via audits. This is a continuation of the work we undertook this year where we asked specialities what systems they had in place, to establish a baseline. What success will look like Every specialty will have a formal written process in place to follow up on results. Assurance will be provided that these systems are working effectively via evidence supplied by the specialities such as audits. Although harm is usually measured using incidents, in practice measuring harm from results not followed up is a poor measure as this is not a specific category on the Datix incident reporting system, at the moment. Various categories could be used instead but these are not easy to recognise or find. We will look into rationalising some of our categories to make this clearer. In addition we will be looking at actions from SIs to monitor their implementation as an additional initiative. How we will monitor progress Our progress will be monitored through the CAQIC reporting to the QSC Continue trust-wide learning Why we have chosen this priority Last year we focused on learning from SIs and we would like to continue this but also to include learning from mortality reviews (see the priority for clinical effectiveness) and learning from things that could have gone wrong but were prevented - near 114 University College London Hospitals NHS Foundation Trust

115 misses. Many of the initiatives for learning are well embedded but we think there is more that we could do. What we are trying to improve We are trying to improve the learning and subsequent changes in practice from SI investigations and other sources of learning, such as mortality reviews. We want to ensure that all actions arising from SIs are completed and fully implemented. In order to do this we will review and where necessary strengthen existing approaches for the monitoring of these actions. Last year we started to look at whether we could use the rate of recurrence of similar serious incidents or analysis of root causes and contributory factors as an indication of learning and we will continue that work this year. What success will look like We will set up a Patient Safety Committee (PSC) to develop further our learning across the divisions and UCLH as a whole. The membership will consist of a variety of staff including divisional matrons and managers and the deputy chief nurses. It replaces the Patient Safety and Risk Steering Group and will report to the QSC We will continue to publish monthly quality and safety bulletins with a regular focus on learning from near misses to encourage reporting and action from near misses. We will continue (ICRs) and the focus on learning. We will review the ICR methodology in view of learning from the March 2016 CQC inspection, the findings of our internal auditors and changes to the CQC inspection methodology. We will continue to aim to achieve the national guidelines for investigation reports being completed following a serious incident (60 working days) Have no further occurrence of Never Events Use the analysis of root cause and contributory factors to help with learning How we will monitor progress This will be undertaken by the PSC reporting to the QSC quarterly. Responsible director for Priority 2: Patient safety Professor Tony Mundy, Corporate Medical Director Priority 3: Effectiveness - clinical outcomes Responding and learning when patients die Why we have chosen this priority Even though our mortality rate is the second lowest in England, we have chosen this because there is more to be learned about when patients die. It also fits with the national priority. NHS England is promoting a common, systematic approach to potentially avoidable deaths. A review of our systems identified that meetings where deaths are discussed were not happening systematically across our hospitals. We are setting up systems to ensure that we are learning as much as possible from deaths is order to improve safety and care. We have completed our aim from last year, which was to set up a Mortality Surveillance Group (MSG). We will continue with this in order to implement new NHSI guidance on identifying, reviewing and learning from deaths. What we are trying to improve Learning from deaths to improve safety and patient care What success will look like We will publish and implement a UCLH policy on learning from deaths, including patients with learning disabilities, which will describe how we will identify deaths for review, how the reviews will be undertaken and how we will learn from them We will identify the skills required and deliver training We will identify a formal process for engaging with bereaved families and carers if they have any concerns about the care of their loved one We will publish information on deaths quarterly We will publish this information in our 2017/18 quality report How we will monitor progress The MSG will monitor progress against this priority and report to the QSC. Responsible director for Priority 3: Clinical outcomes Professor Tony Mundy, Corporate Medical Director Annual Report and Accounts 2016/ PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE)

116 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) 3.5 Overview of quality performance Table Q15: Progress against locally chosen priorities The following table provides information against a number of national priorities and measures that in conjunction with our stakeholders we have chosen to focus on and which forms part of our continuous review and reporting. These measures cover patient safety, experience and clinical effectiveness. Where possible we have included historical performance and where available we have included national benchmarks or targets so that progress over time can be seen as well as performance compared to other providers. In the following table the benchmark used is the comparison with the national average or comparable UCLH or local target and relates to 2016/17 unless otherwise stated. We have chosen to measure our performance against the following metrics: Safety measures reported 2014/ / /17 Benchmark Falls per 1000 bed days Inpatient falls with moderate harm, severe harm and death per 1000 bed days Cardiac arrests We don t have a local target but we want to see a continuing fall in numbers Surgical site infections % 5.5% 5.6% (data up until Dec 2016) Clinical outcome measures reported Summary Hospital-level Mortality Indicator (SHMI) Rolling one year period, six months in arrears+ Stroke mortality rates (Based on diagnoses 161x, 164x, P101, P524) Percentage of elective operations cancelled at the last minute (on the day) for non-clinical reasons + Clinical outcome measures reported Percentage of last minute cancellations operations readmitted within 28 days Oct 14- Sep Oct 15- Sep % 7.87% 6.82% 7.30% We don t have a local target but we want to see a continuing fall in numbers This is a target, not a benchmark. No benchmark is available This is a target, not a benchmark. No benchmark is available 1 28 day emergency readmission rate + (readmissions to UCLH) 3.0% 3.2% 3.5% 7.8% (CHKS national peer group average) 116 University College London Hospitals NHS Foundation Trust

117 What this means Benchmark is from the Royal College of Physicians (RCP) reporting on falls rates across most hospitals in England in the calendar year Lower scores are better As above Lower numbers are better Number of surgical site infections/number of operations. Ideally there should be no infections. Lower scores are better. Lower scores are better. See glossary for explanation of indicator Lower scores are better. Lower scores are better. Higher scores are better. Notes The methodology for counting falls changed in , with unwitnessed falls now being included. Inpatient falls with harm has become per 1000 bed days. The RCP audit did not run in but will run in 2017/18 with a different methodology. As above Only includes cardiac arrests as per the criteria for a deteriorating patient by UCLP and excludes those in critical care areas, theatres, ED and catheter labs. This indicator looks at the number of patients with these codes who died in the trust in that time period compared with the total number of patients discharged with the same codes. The numbers of deaths for this indicator are relatively few and confidence limits for this indicator can be provided on request This is the percentage of patients cancelled on the day of surgery for non-clinical reasons, who then have their operation within 28 days. 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Lower numbers are better. Annual Report and Accounts 2016/

118 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) We have chosen to measure our performance against the following metrics: Safety measures reported Studies approved (NHS permission) UCLH by calendar year and Study type 2014/ / /17 Benchmark 272 (94 clinical trials other studies) 326 (131 clinical trials other studies) 320 No local target Number of trial participants 21,363 12,704 19,986 No local target Academic papers, which acknowledge NIHR (National Institute for Health Research). Percentage of patients on diagnostic waiting list seen within six weeks+ The percentage of inpatient discharge summaries e-messaged to GPs within 24 hours of discharge for those patients with NHS numbers No local target for Camden and Islington patients No benchmark but the standard NHS contract states that hospitals are required to send discharge summaries by direct electronic or transmission for all inpatient, day case or A&E care within 24 hours. Patient Experience national inpatient survey 2016/17 data or a current benchmark is not available until 31 May 2017 Overall satisfaction rating How many minutes after you used the call button did it usually take before you got the help you needed? + Beforehand, did a member of staff explain the risks and benefits of the operation or procedure in a way you could understand? University College London Hospitals NHS Foundation Trust

119 What this means Higher numbers are better. Higher numbers are better. Higher numbers are better. Higher numbers are better. The benchmark is the national target. Prompt discharge summaries enable GPs to follow up hospital care efficiently and safely. Higher numbers are better More points for answering in less time. Higher scores are better. Higher numbers are better Notes The number of new clinical research studies approved to take place at UCLH categorised by the type of study The number of subjects (usually patients) consented to take part in clinical trials at UCLH - it is important for UCLH to have many studies and good recruitment of patients to studies because they are indicators of the level of engagement with research across UCLH, for how research active UCLH is and for how integral research is within UCLH s clinical departments The number of research papers published in journals and the number of times that the papers have been cited in other journal articles (citations are a measure of the importance of the paper amongst the academic community - this is important as a measure of the quality of our research and therefore affects our reputation and the likelihood of further research opportunities). Currently, this data is only collected for patients with GPs in Camden and Islington. Work is underway to extend the service to other CCGs 98 per cent of UCLH patients have an NHS member at discharge. This is a new indicator so there is no previous data. Weighted aggregated score based on a rating scale of 0-10 where is 0 is the lowest score. Score based on an aggregate of the following responses: 0 minutes/straight away 1-2 minutes 3-5 minutes More than 5 minutes I never got help when I used the call button I never used the call button Score based on an aggregate of the following responses: Yes, completely Yes, to some extent No I did not want an explanation Not applicable 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

120 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) We have chosen to measure our performance against the following metrics: Safety measures reported After the operation or procedure, did a member of staff explain how the operation or procedure has gone, in a way you could understand?+ 2014/ / /17 Benchmark Staff Experience Measures national staff surveys Appraisal + 93% 89% 93% 87% Staff would recommend the trust as a place to work + If a friend or relative needed treatment, I would be happy with the standard of care provided by this trust % 82% 84% 70% Staff engagement Table notes + These indicators use nationally agreed definitions in their construction. Otherwise, indicators are necessarily locally defined. 120 University College London Hospitals NHS Foundation Trust

121 What this means Higher numbers are better Higher numbers are better. Benchmark is the national average Higher numbers are better. The score is the average out of five. Benchmark is the national average Higher numbers are better. Benchmark is the national average Higher numbers are better. The score is the average out of five. Benchmark is the national average Notes Score based on an aggregate of the following responses: Yes, completely Yes, to some extent No Per cent of staff reporting that an appraisal has taken place in the last 12 months. This question allows respondents to strongly disagree, disagree, neither agree nor disagree, agree or strongly agree Per cent of staff who strongly agree with the statement. The overall score is calculated by using the scores for the following key findings: Staff members perceived ability to contribute to improvements at work (key finding 7), their willingness to recommend UCLHs as a place to work or receive treatment (key finding 1), and the extent to which they feel motivated and engaged with their work (key finding 4). 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

122 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Table Q16: Progress against the risk assessment framework and the single oversight framework This section provides details of performance against indicators based on the risk assessment framework and the single oversight framework Indicator Access Maximum time of 18 weeks from point of referral to treatment (RTT) in aggregate patients on an incomplete pathway A&E: Maximum waiting time of four hours from arrival to admission/ transfer/discharge Cancer 62 Day Waits for first treatment (from urgent GP referral for suspected cancer) Cancer 62 Day Waits for first treatment (from NHS Cancer Screening Service referral) C.difficile meeting the C.difficile objective Threshold Actual Threshold Actual % 94.2% 92% 93.4% 95% 92.4% 95% 88.3% 85% 67.2% 85% 70.1% 90% 79.6% 90% 85.6% C.difficile due to lapses in care (YTD) Total C.difficile ytd (including: cases deemed not to be due to lapse in care and cases under review) C.difficile cases under review (YTD) We undertake extensive validation work on the data underpinning our performance reporting for RTT, 6 week diagnostics and A&E access standards. Along with the rest of the NHS, we need to carry out this validation to ensure that data collected by a wide range of clinical and non-clinical staff is put on to our systems accurately, and then processed in line with rules that are sometimes complex to follow. As a result of this validation work and the quality account external audit review we are aware that our reported RTT performance figures in particular will not include all pathways that fall within the remit of the policy, and that the figures also include patient pathways where the patient was no longer waiting for treatment. We have,however, made good progress in the last year in reducing the number of these inaccuracies in our reported numbers, as demonstrated in particular by this year s external audit review. There do, however continue to be clinical and administrative data entry errors in the management of these pathways. To address these we continue to use and develop a set of operational reports which help clinical teams closely manage waiting lists. We have operational meetings at all levels of the organisation to ensure that waiting lists are scrutinised at least weekly. Teams have a suite of data quality reports, including identification of where errors occurred, to help pinpoint issues. In 2016/17 we introduced regular checks of electronic records against paper records to identify any common sources of error. These sample audits have been particularly useful in developing training for staff to avoid the data quality issues that we find. We have also introduced support for clinicians so that they can provide the information needed to manage patients along their RTT, diagnostic and emergency pathways. We need to do more work to improve how we document and provide assurance on waiting times in the ED. We have improved validation processes and introduced monthly audits of how staff are documenting waiting times. While these have demonstrated no systematic inaccuracies in the waiting times that we report 122 University College London Hospitals NHS Foundation Trust

123 for individual patients, this year s external audit has again shown that we do not consistently have documented evidence for the waiting times that we have reported. We will need to make further improvements to our record keeping and validation mechanisms so that we can provide full assurance on the accuracy of our recorded waiting times Core indicators for 2016/17 Amended regulations from the Department of Health require trusts to report performance against a core set of indicators using data made available to UCLH by NHS Digital. These mandated indicators are set out below, and are as at the time of this report and may not reflect the current position. Where the required data is made available by NHS Digital, a comparison has been made with the national average results and the highest and lowest trusts results. Table Q17: Summary hospital level mortality indicator and patient deaths with palliative care UCLH considers that this data is as described for the following reasons: UCLH has a robust process for clinical coding and review of mortality data so is confident that the data is accurate. Access The value and banding of the summary hospital level mortality indicator ( SHMI ) for UCLH for the reporting period The percentage of patient deaths with palliative care coded at either diagnostic or speciality level for UCLH for the reporting period. UCLH Performance Oct-13 to Oct (Band 3) UCLH Performance Oct-14 to Sep (Band 3) UCLH Performance Oct-15 to Sep (Band 3) National Av Oct-15 to Sep-16 Highest Performing trust Oct-15 to Sep (Band 3) Lowest Performing trust Oct-15 to Sep (Band 1) UCLH has taken the following action to improve this percentage and so the quality of its services by: Monthly review of specialty level mortality at local and trust level Patient level clinical and coding review of any specialty or conditions, which show as mortality outliers when compared with national data Presenting a monthly report to the QSC detailing the percentage of patient deaths with palliative care coding. UCLH has also set a local target to monitor its rate of palliative care coding and any large variances 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

124 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) are investigated by the clinical coding team Table Q18: Patient Reported Outcome Measures (PROMs) UCLH considers that this data is as described for the following reasons: UCLH has processes in place to ensure that relevant patients are given questionnaires to complete. However, it has no control over their completion and return. Adjusted average health gain (EQ-5D) Access UCLH performance 2013/14 (final) UCLH performance 2014/15 UCLH performance 2015/16 National average 15/16 Lowest performing trust 2015/16 Highest performing trust 2015/16 Groin Hernia 0.06 n/a Hip-Primary Hip-Revision * n/a * Knee - Primary Knee - Revision * n/a * Varicose Vein UCLH has taken the following actions to improve this score and so the quality of its services by: Monitoring performance and agreeing actions with appropriate specialties through the PROMs Steering Group, chaired by a consultant lead and with consultant representatives from all relevant specialties Undertaking a more detailed review of the updated PROMs total knee arthroplasty (TKA) data due to UCLH having a lower than average score, to understand the reasons for the low scores. The more detailed review revealed that UCLH is no longer an outlier. UCLH is slightly lower than average (the majority of patients with poor scores at six months have two or more significant co-morbidities and comorbidities at UCLH are under reported). UCLH is reassured by the data review findings. Table Q19: 28-day emergency readmission rate The percentage of patients aged: Access UCLH performance 2009/2010 UCLH performance 2010/11 UCLH performance 2011/12 National average amongst our peers 2011/12 Lowest performing trust 2011/12 (i) 0 to (ii) 16 or over Update from NHS Digital Highest performing trust 2011/12 Work to investigate methodological issues relating to the emergency readmissions indicators has been completed. However, a review of the indicator sets in which these indicators are published is currently underway. Pending the completion of this review, the development of these indicators has been paused and we have no update as to when the indicators will next be released. The latest available data for 2002/ /12 for emergency readmissions to hospital within 28 days/30 days of discharge are available via the NHS 124 University College London Hospitals NHS Foundation Trust

125 Digital Indicator Portal Despite the fact that recent national data is not available, we monitor locally each month and this monitoring has informed our actions to reduce 28 day emergency readmissions. UCLH has taken the following actions to improve this percentage and so the quality of its services by: Undertaking an audit of re-admissions in 2016/17 to gain a richer understanding of the drivers for this Collaborative working with primary care and other secondary care providers across patient pathways Admissions avoidance providing a team in the ED and Acute Medical Unit for the avoidance of preventable or inappropriate admission of patients to hospital Specialist nurse discharge support UCLH will continue to enhance the skills of its established discharge and admission avoidance team to optimise patient care across organisational boundaries. Table Q20: Responsiveness to personal needs of patients* UCLH considers that this data is as described for the following reasons: undertaken independently as part of the annual national inpatient survey. National inpatient survey* The trust's responsiveness to the personal needs of its patients during the reporting period UCLH performance 2014/15 UCLH performance 2015/16 National average 15/16 Lowest performing trust 15/16 Highest performing trust 15/ *Responsiveness to personal needs of patients is a composite score from five CQC National Inpatient Survey questions. The five questions are: Were you as involved as you wanted to be in decisions about your care and treatment? Did you find someone on the hospital staff to talk to about worries and fears? Were you given enough privacy when discussing your condition or treatment? Did a member of staff tell you about medication side effects to watch for when you went home? Did hospital staff tell you who to contact if you were worried about your condition or treatment after you left hospital? UCLH has taken the following actions to improve this score and so the quality of its services by: Monitoring performance using Envoy, our real-time survey tool through regular discussion at quality huddles and agreeing local action plans Ensuring all patients lockers have a call for concern sticker to give 24 hours a day, seven days a week, contact details for patients and families who, after speaking to ward staff and PALS, feel that their concerns are not being addressed. Improving our discharge processes through the introduction of daily ward based discharge huddles around the Patient Status At A Glance (PSAAG) board, which focuses on 10 key elements that are essential to discharging patients at the right time. 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

126 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Table Q21: Staff recommendation of the Trust as a provider of care to their family or friends UCLH considers that this data is as described for the following reasons: survey undertaken independently as part of the annual national staff survey. National staff survey The percentage of staff employed by, or under contract to the trust during the reporting period who would recommend the trust as a provider of care to their family or friends. UCLH performance 2015/16 UCLH performance 2016/17 National average of acute trusts 16/17 Lowest performing acute trust 16/17 Highest performing acute trust 16/ UCLH has taken the following actions to improve this percentage and so the quality of its services. Please refer to 3.1 on how we are working to improve patient care. Table Q22: Friends and Family Test for Accident and Emergency UCLH considers that this data is as described for the following reasons. Data collection is undertaken independently. Friends & Family Test UCLH performance Apr 15 - Mar 16 UCLH performance Apr 16 - Dec16 National average Dec 16 Lowest performing trust Feb 16 Highest performing trust Feb 16 A&E survey 94.6% 94.8% 86.0% 47.4% 99.0% The above data are the percentages of patients asked who said they would recommend the service 126 University College London Hospitals NHS Foundation Trust

127 UCLH has taken the following actions to improve this rate and so the quality of its services by: Continuing to develop our ambulatory care pathways, with direct streaming from the point of triage Mobilising a primary care service at the front door, with access to the patients primary care record, to see them, treat them and redirect patients back to their GP or appropriate community services Refurbishment of the Emergency Day Unit: increased cubicle space and additional washroom facilities, two en-suite side rooms, plus increasing clinic capacity from two to five rooms Commencing Phase six of the ED Redevelopment programme, to create increased cubicle and clinic room capacity and a co-located CT scanner Implementing a clinical navigator at the front door to stream patients directly to the most appropriate area, ensuring patients are seen by the right clinician at the start of their pathway Implementing a Rapid Assessment and Treatment model for ambulance conveyance, to ensure handover and assessment of patients arriving by ambulance is undertaken by senior staff promptly on arrival, reducing delays Table Q23: Rate of admissions assessed for Venous Thromboembolism (VTE) UCLH considers that this data is as described for the following reasons: UCLH has a robust electronic process for measuring VTE risk assessment of patients Risk Assessment for VTE Percentage of admitted patients risk-assessed for VTE UCLH performance Oct 2015 to Dec 2015 UCLH performance Oct 2016 to Dec 2016 National average Oct 2016 to Dec 2016 Lowest performing trust Oct 2016 to Dec 2016 Highest performing trust Oct 2016 to Dec UCLH has taken the following actions to improve this percentage and so the quality of its services by: Monitoring as part of the key performance indicators from ward up to board level Identifying and taking action in low performing areas Table Q24: Clostridium difficile rate UCLH considers that this data is as described for the following reasons: the data has been sourced from NHS Digital and compared to internal UCLH data and data hosted by Public health England. C. difficile Infection rate per 100,000 bed days amongst patients aged two or over UCLH performance 2014/15 UCLH performance 2015/16 National average 2015/16 Lowest performing trust 2015/16 Highest performing trust 2015/ This refers to all UCLH attributable Clostridium difficile (C. difficile )infections including those subsequently appealed and under review. Our threshold, set by Public Health England, is to have less than 97 patients suffering from C difficile whilst in our hospitals in , and we had 90 cases. The threshold is based on patient characteristics and previous performance of UCLH and our threshold is higher because we have a high number of cancer/haematology patients and other high risk groups. The transfer into the hospital of haematology/oncology services last year was predicted to increase our numbers by 40 cases but our threshold was not changed to reflect this. However, we still had fewer cases than the threshold set. This year fewer than 10 per cent of the C difficile cases were related to lapses in care. 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

128 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) UCLH has taken the following actions to improve this rate and so the quality of its services by: Ensuring a multidisciplinary review of all cases of toxin positive C difficile is undertaken (root cause analysis - RCA). The RCA is then reviewed with the commissioners and any lapses in care identified. Lapses include delays in isolation, sampling and treatment Ensuring a detailed action plan is in place and monitored regularly which is based on learning from the RCAs Ensuring there is a constant focus on ensuring the basics of infection prevention are communicated and understood Continuing focus on antibiotic stewardship to optimise practice and patient outcome Table Q25: Incident reporting UCLH considers that this data is as described for the following reasons: data have been submitted to the National Reporting and Learning System (NRLS) in accordance with national reporting requirements. Patient safety incidents Number of patient safety incidents reported within the trust during the reporting period The rate of patient safety incidents reported within the trust during the reporting period The number of such patient safety incidents that resulted in severe harm or death The percentage of such patient safety incidents that resulted in severe harm or death UCLH performance October March 2015 UCLH performance October March 2016 National average October March 2016 Lowest performing trust October March 2016 Highest performing trust October March UCLH has taken the following actions to improve this rate and so the quality of its services by: Continuing to encourage incident reporting through the monthly quality and safety bulletin, which shares learning on reporting from incidents, information related to duty of candour (including positive feedback or experiences) and encourages the reporting of near misses Promoting learning from serious incidents by introducing a monthly report in the form of Look and learn which includes learning and actions and distributing this via directly to front-line staff members and governance leads Continuing to share the quarterly report on incident trends and learning and commending high reporters Amending Datix reporting to make it easier to report as well as improving the duty of candour fields to make them easier to understand by providing prompts and information as pop-ups Creating and developing dashboards for wards to allow review of their incidents at local level. 128 University College London Hospitals NHS Foundation Trust

129 3.6 Board assurance statements Introduction All providers of NHS services are required to produce an annual quality report and certain elements within it are mandatory. This section contains the mandatory information along with an explanation of our quality governance arrangements. The quality governance arrangements within UCLH ensure that key quality indicators and reports are regularly reviewed by clinical teams and by committees up to and including the board of directors. There are a number of committees and executive groups with specific responsibilities for aspects of the quality agenda, which report to the UCLH Quality and Safety Committee (QSC). This is the key committee for monitoring and assuring on quality and safety. The committee seeks assurance that issues of quality and safety are addressed. For example, the committee requested assurance following a small number of potential high value claims and serious incidents in the spinal service. As a result, the neurosurgery team presented a report on quality and safety within the spinal surgery service, from which QSC took assurance. This included changes to the spinal injury pathway where arrangements were made to improve access to MRI scanning. The committee also identified some concerns as a result of a small number of SIs in the maternity service and the division attended to provide assurance. The committee has also requested regular updates on the vein to vein project, which aims to improve the safety of blood transfusion. The audit committee is responsible on behalf of the board for independently reviewing the systems of governance, control, risk management and assurance. The board of directors receives a regular corporate performance report (available on the UCLH website as part of the published board papers) that includes a range of quality indicators across the three domains of patient safety, experience and clinical effectiveness (outcomes). In addition, the Board receives quarterly reports in areas such as serious incidents, and quarterly and annual reports in areas such as child safeguarding and complaints. The board is further assured by reviews undertaken by internal audit which this year has included risk management looking at the timeliness of risk reviews; complaints looking at the processes including developing action plans; duty of candour looking at divisions with good and less good compliance to learn about best practice; dissemination of guidance including that related to clinical effectiveness how this done; and serious incidents looking at the processes for reporting serious incidents and key factors in time delays in submitting reports. In addition, board members including the chairman and chief executive, medical directors, chief nurse, and non-executive directors, regularly undertake walkabouts around UCLH talking to staff and patients. We are fortunate to have seven board members who are practising clinicians including six doctors. They focus on the CQC key questions of safe, effective, caring, responsive and well-led care. These visits, and what is learned provides additional assurances on services. There are other visits, matrons undertake quality rounds and the governors visit clinical areas A review of our services During 2016/17 UCLH provided and/or subcontracted 69 relevant health services. UCLH has reviewed all the data available to them on the quality of care in all of these relevant health services. The income generated by the relevant health services reviewed in 2016/17 represents 100 per cent of the total income generated from the provision of relevant health services by UCLH for 2016/ Responding to our stakeholders comments When our quality report was published last year we invited our commissioners, Healthwatch Camden and the Adult Social Care Scrutiny Committee to comment on it. These are our responses to those comments: NHS Camden Clinical Commissioning Group (CCCG) The CQRG suggested that we looked how to strengthen our learning from Never Events to reduce recurrence. Please refer to section on Never Events The CCCG suggested that we report on improvements to patient experience in relation to waiting times. We have made progress in some areas to improve waiting times in outpatients and work will continue in the year ahead. This is one of our priorities in the coming year see the section on patient experience priorities for more information The CCCG suggested that we commit to improvements to the patient experience for those with cancer and in our maternity services. Annual Report and Accounts 2016/ PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE)

130 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Both these areas are discussed extensively with our commissioners at the CQRG meetings with a focus every quarter on both cancer and maternity. The content of the reports from UCLH are continually under review to reflect the concerns and queries of the commissioners The CCCG suggested that wemake improvement to resilience planning to ensure sustainable patient access and experience. We have strengthened our service resilience across a range of areas in order to sustain or improve access to our services. We have sustained delivery of referral to treatment times performance through the year, making sure that our patients do not wait too long for their planned treatments. We have now also delivered the standard that patients do not wait more than six weeks for a diagnostic test. We have improved access to cancer services, and we are now achieving the standards that patients should wait no longer than 14 days for their first appointment following a referral for suspected cancer, and that once a patient receives a confirmed diagnosis of cancer, they should receive treatment within 31 days. We have made significant improvement against the standard that cancer patients should wait no longer than 62 days from referral to treatment, although we are not yet fully there yet. The CCCG suggested that we demonstrate positive results in 2016/17 that reflect an improvement in the quality of services provided to patients with a focusing on ensuring services are well led, caring, responsive, safe and effective. Please see section for our update on the CQC inspection. Healthwatch Camden and Adult Social Care Scrutiny Committee Healthwatch Camden and the Adult Social Care Scrutiny Committee (ASCSC) asked us to show that the local community is a priority for the hospital and that the financial reports demonstrate that local income as a percentage of the overall budget is not reducing each year. The hospital board has recently discussed and reaffirmed the importance of the services that we provide to our local community. It is essential to our strategy that we continue to provide excellent local services, just as much as providing more specialist services, teaching, training and research and development. We are currently implementing a new musculo-skeletal service for patients in Camden that sees us, for the first time, taking responsibility for the management of a patient population. This gives us an excellent opportunity to deliver joined-up care for local patients. Whilst financial information is not the best measure of commitment to our local community (as it is affected, for example, by technical issues such as tariff changes), we provided reports to Healthwatch Camden and the ASCSC showing that for the last two years income from Camden commissioners has been stable at 69m per year. Healthwatch Camden and the ASCSC asked us to demonstrate how we are working to make sure that patients do not have wait more than 30 minutes after their booked appointment. We have invested in a new patient feedback system, Envoy that will soon allow us to text every patient following an outpatient appointment to find out how long they waited in the department before being seen. This will allow us to pinpoint more accurately the clinics that have problems with their waiting times and to learn from the clinics that see their patients on time. The University College Hospital Macmillan Cancer Centre has seen a 20 per cent increase in outpatient activity in 2016/17 compared to 2015/16. Whilst this growth is a welcome it puts constraints on our capacity and in some cases, for example when clinics are overbooked, leads to longer waiting times. We have set up an outpatient s improvement group with representatives from the five divisions that run clinics. This group will focus initially on freeing up capacity to meet the growth in demand and thus improve patient waiting times. This will be done by identifying and reallocating rooms that are given up for planned reasons such as annual and study leave. We will then work with patient representatives to look at how we can best improve patient waiting times in the cancer centre. We have identified 10 outpatients improvement measures to work through over the next 24 months and many of these will improve patient waiting times. We will use our Check and Track system to identify at doctor and clinic code level the number of patients who actually wait more than 30 mins. The intention is to share this data with clinical teams and to be able to measure improvements. Outpatient waiting times is one of our patient experience priorities in the year. See section Healthwatch Camden and the ASCSC asked us to demonstrate how we are capturing feedback relating to frustration with the outpatient booking and communications processes, which is not captured in the current reporting. See section Healthwatch Camden and the ASCSC commented that there is still room for improvement in the quality report in terms of tailoring the content and style 130 University College London Hospitals NHS Foundation Trust

131 of the report for a public readership and saying more about how it has engaged with the public, patients and governors in setting its priorities as a manifestation that serving the local community and being reportable to the local community is a strong priority for the organisation. This year we have engaged much earlier in the year with Healthwatch Camden in discussing the quality priorities and have maintained our working relationship with the governors. We have tried to improve the readability of the quality report for all, but this is a challenge. We have used the Flesch Reading Ease score throughout the document to improve its clarity but words such as quality, priorities, safety, outcomes, governors and reporting are regarded as hard words and push the score down considerably. A score of is regarded as standard or average, but with hard words, it is difficult to bring the score above 45. In addition, there are sections where the content is mandated and technical and this limits our ability to make it easily readable throughout Participation in national audits Clinical audit evaluates care against agreed standards, providing assurance and identifying improvement opportunities. UCLH has a yearly programme of clinical audits in three categories national, corporate and local. For national audits, we aim to participate in all that are applicable to us. Corporate audits are based on UCLH priorities and all specialties are expected to undertake them. Local audits are set up by clinical teams and specialties to reflect their own priorities and interests. Audit findings are reviewed by clinical teams in quality and safety (governance) meetings, as a basis for peer review and for targeting or tracking improvements. The CAQIC oversees the corporate clinical audit programme and activity, and reports directly to the board s QSC. During 2016/17, 37 national clinical audits and nine national confidential enquiries covered relevant health services that UCLH provides. During that period, UCLH participated in 97 per cent of national clinical audits and 100 per cent of national confidential enquiries of the national clinical audits and national confidential enquiries, in which it was eligible to participate. The one audit, National Core (part of National Diabetes Audit - Adults), where data was not submitted was related to internal IT systems and work is ongoing to resolve this. The national clinical audits and national confidential enquiries that UCLH was eligible to participate in during 2016/17 and the national clinical audits and national confidential enquiries that UCLH participated in, and for which data collection was completed during 2016/17 are listed below, alongside the number of cases submitted to each audit and enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry. Table Q26 lists the national audits and shows UCLH participation. Table Q27 does the same for national confidential enquiries. 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

132 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Table Q26:National Clinical Audits Audit UCLH eligible UCLH participation 1 Acute coronary syndrome or acute myocardial infarction (MINAP) Yes Yes 100% 2 Adult asthma Yes Yes 100% Adult cardiac surgery No N/A 3 Asthma (paediatric and adult) care in emergency departments Yes Yes 58% Percentage of cases submitted 4 Bowel cancer (NBOCAP) Yes Yes Data collection in progress Cardiac Rhythm Management (CRM) No 5 Case Mix Programme (CMP) Yes Yes 100% (1 April December 2016) Chronic kidney disease in primary care No N/A N/A Congenital Heart Disease (CHD) No N/A Coronary angioplasty/national audit of percutaneous coronary interventions (pci) 6 Diabetes (Paediatric) (NPDA) Yes Yes 100% 7 Elective surgery (National PROMs Programme) Endocrine and thyroid national audit 8 Fracture Liaison Service Database (part of Falls and Fragility Fractures Audit programme (FFFAP) No N/A Yes Yes Groin Hernia: 88.9% Hip Replacement: 86.4% Knee Replacement: 100%. Varicose Vein: 72.1% (April Jan 2017) No Eligible for the facilities audit component only N/A Yes, participating in the facilities audit component New. Data collection in progress. 9 Inpatient falls (part of FFFAP) ) Yes No data collection requested by the national team between 1 April 2016 and 31 March Data collection in May National hip fracture database(part of FFFAP) Yes Yes 100% 11 Head and neck cancer audit Yes Yes Data collection in progress. 12 Inflammatory Bowel Disease (IBD) programme Yes Yes 100% 132 University College London Hospitals NHS Foundation Trust

133 Audit UCLH eligible UCLH participation 13 Major trauma audit Yes Yes 100% Mental health clinical outcome review programme No Percentage of cases submitted 14 National audit of dementia Yes Yes Case notes: 100% Carers Paper Questionnaire: 50% Carers online: 0% Staff paper questionnaire: 66% Staff online questionnaire: 100% National audit of pulmonary hypertension 15 National Cardiac Arrest Audit (NCAA) National Chronic Obstructive Pulmonary Disease (COPD) audit programme No 16 National comparative audit of blood transfusion - audit of patient blood management in scheduled surgery 17 National foot care audit (part of national diabetes audit adults) 18 National diabetes inpatient audit (part of national diabetes audit - adults ) 19 National pregnancy in diabetes audit (part of national diabetes audit - adults ) 20 National diabetes transition (part of national diabetes audit - adults) 21 National core (part of national diabetes audit - adults) No N/A N/A Yes Yes 100% N/A N/A Yes Yes 80% Yes Yes 100% Yes Yes 100% Yes Yes Data collection in progress Yes No data collection 2016/17: Central Linkage Project Yes No Not participating as current diabetes database not suitable for data collection. Ongoing work with Infoflex team to aid participation 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) 22 National Emergency Laparotomy Audit (NELA) Yes Yes 100% 23 National heart failure audit Yes Yes 100% Annual Report and Accounts 2016/

134 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Audit UCLH eligible UCLH participation 24 National Joint Registry (NJR) Yes Yes 100% 25 National Lung Cancer Audit (NLCA) 26 National neurosurgery audit programme Yes Yes 100% Yes Yes 91% National ophthalmology audit No N/A 27 National prostate cancer audit Yes Yes 100% 28 National vascular registry Yes Yes 100% 29 Neonatal Intensive and Special Care (NNAP) Nephrectomy audit 30 Oesophago-gastric Cancer (NAOGC) Paediatric Intensive Care (PICANet) Yes Yes 100% No Percentage of cases submitted Yes Yes Data collection in progress. No 31 Paediatric pneumonia Yes Yes Data collection in progress. Percutaneous Nephrolithotomy (PCNL) Prescribing Observatory for Mental Health (POMH-UK) 32 Radical prostatectomy audit Yes Yes 100% Renal replacement therapy (renal registry) 33 Rheumatoid and early inflammatory arthritis 34 Sentinel Stroke National Audit programme (SSNAP) 35 Severe sepsis and septic shock care in emergency departments 36 Specialist rehabilitation for patients with complex needs No No No Yes N/A N/A N/A N/A The national team is not collecting data in 2016/17 Yes Yes 100% (up to Nov 2016) Yes Yes 100% Yes The national team is not collecting data in 2016/17 37 Stress urinary incontinence audit Yes Yes 100% UK cystic fibrosis registry No N/A 134 University College London Hospitals NHS Foundation Trust

135 Table: Q27 National Confidential Enquiries National Confidential Enquiry UCLH eligible UCLH participation 1 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Mental health in general hospitals 2 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Acute Pancreatitis 3 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Non-invasive ventilation 4 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Chronic Neurodisability 5 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Cancer in Children, Teens and Young Adults 6 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Young People s Mental Health 7 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Acute Heart Failure 8 Learning Disability Mortality Review Programme (LeDeR Programme) 9 Maternal, Newborn and Infant Clinical Outcome Review Programme MBRRACE programme Yes Yes 100% Yes Yes 100% Yes Yes 100% Percentage of cases submitted Yes Yes 91% (study still open - data collection in progress) Yes Yes 12% (study still open - data collection in progress) Yes Yes Study in progress cases required to be confirmed by NCEPOD Yes Yes Study in progress cases required to be confirmed by NCEPOD Yes Yes 100% Yes Yes 100% Separate leads for neonatal / newborn and maternal MBRRACE programmes Ongoing reporting and completion of audit process as required (as cases arise) 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

136 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) The reports of seven national clinical audits and 12 local clinical audits were reviewed by UCLH in 2016/17 and UCLH intends to take the following actions to improve the quality of healthcare provided: Table Q28: Examples of actions from National Clinical Audits Royal College of Emergency Medicine - VTE risk in lower limb immobilisation in plaster cast clinical audit The audit looked at current performance in emergency departments against two standards a requirement that there should be written evidence of referral for thromboprophylaxis (clot busting) in patients unable to walk and that a patient information leaflet should tell such patients to seek medical advice if they develop symptoms of a clot. We will be addressing these recommendations. Women s Health - National Neonatal Audit Programme (NNAP) The overall aims of this audit are to assess whether babies requiring specialist neonatal care receive consistent, high quality care across England and Wales in relation to the audit questions and to identify areas for improvement in relation to service delivery and the outcomes of care. Overall results showed that UCLH was above the national average for most of the indicators. We also scored well on data completeness and quality issues. We will continue with monthly reporting on the Neo Natal Unit scorecard and use of the BadgerNet dashboard to monitor performance and ensure early identification of issues. Gastrointestinal Services - audit on sedation for endobiliary procedures and its effect on patient satisfaction and endoscopy outcomes The audit highlighted that whilst endobiliary (within the bile duct) procedures under conscious sedation used dosages of fentanyl (painkiller) which were higher than the recommended dosages these did not result in adverse outcomes. It also found that 50 per cent of patients having procedures under conscious sedation would also like to be offered the sedative and relaxant Propofol. Recommendations have been made for sedation options to be considered as part of discussions with patients during clinic appointments and for local guidelines to be developed to support best practice. This will be informed by further clinical analysis, which is already underway Participation in Corporate Audits Our corporate clinical audit programme aims to help UCLH meet its top 10 objectives, provide assurance to commissioners, demonstrate compliance with recommendations from the National Institute for Health and Care Excellence (NICE) and help manage risk. A summary of the programme is below. Although they are not clinical audits per se, patient surveys are included because they are an important part of quality improvement and the best indicator of patient experience. 136 University College London Hospitals NHS Foundation Trust

137 Table Q29: Objective Quality priorities Supporting Corporate Audit activity Improve Patient Safety Deliver Excellent Clinical Outcomes Deliver high quality patient experience and customer service excellence *Some of these audits will be reported in 2017/18 Deliver Sign up to Safety campaign pledges so that we further reduce harm to patients Achieve hospital acquired infection targets Ensure that we check and action all patient test results Maintain upper decile Standard Hospital Mortality Indicator results Agree an integration strategy with CCGs Avoid increase in levels of emergency admissions Maintain patient survey satisfaction ratings Reduce the number of outpatient cancellations Avoid increase in the number of inpatient cancellations Local systems for radiology Imaging results NG tubes correct documentation and placement Non-delegated consent Harm free care Hospital Acquired pressure ulcers & falls feature at UCLH Blood transfusion Safeguarding Tracheostomy care Resuscitation IV catheter care Nutrition screening Medication safety and medicines management Prescribing documentation Secure storage Dose omissions Discharge prescriptions Antimicrobial prescribing Outcome and safety of new interventional procedures Readmissions reported monthly via the performance pack Patient Surveys: Inpatients Outpatients Cancer Maternity Pre and post-operative patient reported outcomes End of life care Audit of care given to patients with learning disabilities duty of candour* 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

138 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Local clinical audit and quality improvement (QI) The importance of clinical audit in stimulating quality improvement stems from a willingness to use the information obtained to make improvements. This year we want to highlight the work undertaken by the Clinical Audit and Quality Improvement Committee (CAQIC) to educate and support clinical audit leads to use QI methodologies in their audit activity. From January 2017 UCLH has partnered with the British Medical Journal (BMJ) in a pilot study which hopes to demonstrate better QI methodology, better reporting (in line with international standards), opportunities for training and opportunities for publication and showcasing what we do to a wider audience. BMJ Quality is an online workspace that supports individuals and teams through healthcare improvement projects and on to publication. The necessary interactive workbooks, learning modules, tools and resources are provided to help make healthcare improvement simple. The CAQIC has been given 17 licenses (one for each division), each allowing one quality improvement project to be developed within the BMJ Quality Reports portal. This online tool guides users through the process of quality improvement by allowing authors to complete a structured template which develops as the project evolves, finally becoming a completed paper which will go through a publication process and is most likely to result in publication in the journal. The aim is to engage all UCLH divisions, allowing each to nominate a quality improvement project for online development and hopefully publication. By the end of 2017, we aim to have up to 17 publications in the journal. Local clinical audits are developed by teams and specialties in response to issues identified at a local level. They may be related to a specific procedure or equipment, patient pathway, or service. Some examples are given below. Examples of improvement resulting from local clinical audit Throat, nose and ear surgery for children A report published in 2016/17 looked at the outcomes and patient experience of 87 children having minor, ear or nose surgery or having their tonsils and/or adenoids (T&As) removed at the RNTNEH during September and October We also followed up 72 of the children after their operation. We looked at current anaesthetic and surgical techniques and at the need for medication such as pain relief or anti-sickness treatment in the recovery room or on the ward. We asked about the adequacy of pain relief after discharge and we looked at any late complications such as bleeding after surgery. We assessed the level of support required after discharge and what the experience was like for children and their parents and what we could improve. We found that overall pain was controlled in the majority of children and, on average it took just under five days for them to return to normal activities. However, a third of children who had their T&As removed felt their pain was not well controlled. A number of parents sought medical advice for their children after discharge from their general practitioner, from the staff on the ward or by attending Accident and Emergency. Of the 41 children who underwent a T&As, 19 required further advice. Almost all families felt well supported after discharge and all would recommend the Royal National Throat, Nose and Ear hospital to other families. 138 University College London Hospitals NHS Foundation Trust

139 Table Q30: What did we learn We must work to improve the admission procedure for children. We must explore how to make having an anaesthetic less distressing. We should take into consideration that parents would like to be with their child in the recovery room. Families would like us to find solutions for children crying on the ward which other children find distressing. A routine follow-up phone call to the family following throat, nose and ear surgery may be supported by this audit. Routine follow-up of children who have undergone a tonsillectomy might reduce the care burden on GP and district general hospital services. Paediatric & Adolescent Services What are we doing to improve We are doing this by explaining the process at pre-assessment and again on the day of admission. We are doing this by ensuring 1:1 time with the nurses and the play specialist, and by using an ipad and other distraction therapy. We are providing an honest explanation of what to expect for older children. At RNTNEH, the ethos is that as soon as a child is awake and their airway is safe after surgery they are brought to their parent, on the ward. The rest of the child s recovery happens on the ward. On any occasion where a child needs further supervision in the recovery room then their parent is taken to recovery. We aim to explain the reasons for crying to all families to alleviate distress. We are working to set up a telephone follow-up clinic by summer Our nursing staff provide focused 1:1 advice after surgery which is followed up with written information. This includes pain relief medication, when pain relief should be given and what to do in an emergency with emergency contacts telephone numbers. The Royal College of Paediatrics and Child Health (RCPCH) has led the Situation Awareness For Everyone (SAFE) two year programme in partnership with paediatric units from 28 hospitals across England to develop and trial a suite of quality improvement techniques. These aim to improve the safety of children in hospital, reduce mistakes and avoidable death in paediatric departments throughout the UK. Examples of improvement techniques include the huddle which is a 10 minute, free and frank exchange of information between clinical and non-clinical professionals involved in a child or young person s care. The huddle encourages information sharing and equips professionals with the skills to spot when a child s condition is deteriorating and escalate appropriate treatment. UCLH chose to focus on a number of priorities to reduce deterioration and avoidable harm. These were: Identify deterioration by recording vital signs and calculating an early warning score for treatment escalation Staff safety huddles and review of the early warning score Responding to deterioration review of our response to raised early warning scores. Improve through learning using staff safety attitudes, patient/parent feedback and review of 2222 calls using RECALL tool (Rapid Evaluation of Cardio-respiratory Arrests with Lessons for Learning) 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

140 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) What did we learn? We introduced a daily staff huddle using a script to follow the daily ward round at 11.45am. A review of these huddles undertaken in February 2016 showed that: Huddles were more efficient when led by the nurse Pharmacists attended if the huddles were held on time The paediatric early warning scores (PEWS) were discussed every day All staff think huddles have helped in the recognition of the deteriorating child Our baseline audit of practice showed that we are 96 per cent compliant with recording vital signs and accurate calculation of early warning scores. Documentation that we responded appropriately to raised early warning scores was only evident 70 per cent of the time. Review of our 2222 calls showed very good outcomes. We also looked at handover and a review of patient handovers in January 2016 showed that: Consultants were always present Nurses were not present All aspects were discussed except the bed status and nursing staffing levels The communication tool Situation, Background, Assessment and Recommendation (SBAR) was used in almost 70 percent of handovers and the average length of time for handover is 42 minutes. An Experience of Care survey of patient and parents was carried out in January 2016 for children aged nine to 18 years. Over 80 per cent of parents either strongly agreed or agreed that the ward has a healthy patient safety culture. The majority of patients and parents felt they were listened to by staff, their views/worries were taken seriously, staff knew how to help, information about help available was given and staff worked together to help. What are we doing to improve? Our plans for Situation Awareness For Everyone (SAFE) going forward include: Exploring the potential for night time huddles Introducing SAFE huddles on other paediatric wards Sharing learning across UCLH Using an electronic joint handover sheet and meeting at the huddle as nursing and doctors handovers do not occur at the same time Introducing SBAR training for staff ( this is a quality priority for ) Training for staff, using simulation Monitoring and reviewing all emergency calls (for urgent deterioration), in real time, to learn lessons Improving the documentation of escalation from 70 per cent by completing the PEWS chart at the huddle Ongoing surveys from patients, parents and staff Emergency services A lumbar puncture is a procedure where a needle is inserted into the lower part of the spine to test for conditions affecting the brain, spinal cord or other parts of the nervous system. Lumbar punctures are often used to exclude sub-arachnoid haemorrhage (SAH) in patients presenting with thunderclap headache. Normally computed tomography (a CT scan) of the patients head is the first examination carried out; if this is negative a lumbar puncture is then carried out. However, there is lack of consistency and consensus amongst experts about when to perform a lumbar puncture. In order to develop local guidance we carried out a clinical audit of such procedures to find out: If there is any national guidance What the current practice is on the UCLH Acute Medical Unit (AMU) How many patients underwent lumbar puncture Usefulness of the lumbar punctures in making the diagnosis The audit of current practice on the AMU included patients admitted between 27th August 2015 and 11th November 2015 with a sudden onset headache suggesting the patient had suffered an SAH. What did we learn? The findings were that there is no national guidance in England. We also found that local practice is not consistent, that we may be doing more lumbar punctures than are required. What are we doing to improve? An action plan was put into place to: Develop a local protocol for assessment of thunderclap headache with normal neurology, 140 University College London Hospitals NHS Foundation Trust

141 including seven red flags Include the assessment when taking the patient s history on admission Refrain from changing clinical practice, until fully validated Re-audit to assess if the clinical picture in patients bears correlation with investigations undertaken Our participation in clinical research A key focus for the National Institute for Health Research is the development and delivery of high quality, relevant, and patient focused research within the NHS. UCLH continues to embrace this aim, remaining at the forefront of research activity, creating and supporting research infrastructures, providing expert and prompt support in research and regulatory approvals, and promoting key academic and commercial collaborations. UCLH continues to develop the active involvement of patients and the public in research design and process through training and other resources, ensuring studies, which take place at UCLH, are relevant to, and inclusive of patients. UCLH will also be focusing its efforts on improving patient and public access to information about research to improve patient choice and experience. In the period April March 2017 a total of 320 new research studies were approved to begin recruitment at UCLH. These range from clinical trials of medicinal products and device studies, through to service and patient satisfaction studies. There are currently 1482 studies involving UCLH patients that are open to recruitment or follow-up. Of these, approximately 64 per cent of studies are adopted onto the National Institute of Health Research Clinical Research Network (NIHR CRN) portfolio of research. The number of patients receiving relevant health services provided or sub-contracted by UCLH in 2016/17 that were recruited during the period to participate in research approved by a research ethics committee was 19,986. UCLH is recognised as one of 11 leading centres for experimental medicine in England. In partnership with University College London, UCLH has National Institute of Health Research Biomedical Research Centre (BRC) status. During 2016/17 further funding was awarded to renew this status for the next five years and to support new research in hearing and deafness, oral health, mental health, obesity and dementia (replacing the Dementia Biomedical Research Unit), and to introduce crosscutting platforms to support and enable research across disease areas. This is in addition to the BRC s traditional focus on four broad areas of world-class strength for innovative, early phase research in cancer, neuroscience, cardiometabolic diseases and infection, immunity and inflammation. UCLH s commitment to research is further evidenced by the fact it is part of UCLPartners, one of five Academic Health Science Partnerships. UCLPartners itself has a director of quality committed to sharing best practice across the partnership CQUIN payment framework Commissioning for Quality and Innovation (CQUIN) is a payment framework that allows commissioners to agree payments to hospitals based on agreed quality improvement and innovation work. A proportion of UCLH s income in 2016/17 was conditional on achieving quality improvement and innovation goals agreed between UCLH and its commissioners through the Commissioning for Quality and Innovation payment framework. Through discussions with our commissioners, we agreed a number of improvement goals for 2016/17 that reflect areas of improvement interest nationally, within London and locally. The total of income conditional upon achieving quality improvement and innovation goals for 2016/17 is 10,894,497*. A high-level summary of the CQUIN measures for 2016/17 is shown in the following table together with the forecast income taking into account performance against each CQUIN target. * This figure is still provisional. A final figure will not be available until all activity has been billed through at the beginning of June. 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

142 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Table Q31: CQUIN measures 2016/17 CCG CQUINs Forecast full year income Introduction of health and wellbeing initiatives 657,000 Healthy food for NHS staff, visitors and patients 657,000 Improving the uptake of flu vaccinations 328,500 Timely identification and treatment for sepsis in the Emergency Department 176,569 Timely identification and treatment for sepsis in inpatients 209,419 Reduction in antibiotic consumption 105,120 Empiric review of antibiotic prescriptions 131,400 Obesity prevention and management in hospital settings 142,350 Nutrition and hydration 142,350 Nutrition and hydration - discharge on oral nutritional supplements (ONS) 186,150 Reasons for delayed discharges 394,200 Discharge medication for the frail elderly. 394,200 Discharge information for GPs 246,375 GP e-messaging 394,200 Discharge pre-mid-day 320,288 Provision of accessible discharge plan 219,000 Communication and access 219,000 Improve elective LD pathway 219,000 NHSE CQUINs Forecast full year income Enhanced supportive care for advanced cancer 432,500 Cancer dose banding 324,262 Clinical utilisation review tool 176,000 Adult critical care timely discharge 0 Patient activation management 324,262 Telemedicine 378,306 Discharge CQUIN: Discharge by mid-day 175, University College London Hospitals NHS Foundation Trust

143 NHSE CQUINs Forecast full year income Discharge CQUIN: Reasons for delays to discharges 243,197 Nutrition & hydration management 175,642 Nutrition and hydration on ONS 183,749 Local critical care CQUIN 162,131 Reduction in unnecessary appointments 172,940 Reduction in Did Not Attends (DNAs) 194,557 Further details of the agreed goals for 2016/17 and for the following 12-month period are available on request from: Performance Department 2nd Floor Central, 250 Euston Road London, NW1 2PG Phone: PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

144 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Care Quality Commission (CQC) registration and compliance UCLH is required to register with the Care Quality Commission (CQC) and its current registration status that all UCLH locations are fully registered with the CQC, without conditions. The CQC has not taken enforcement action against UCLH during 2016/17. UCLH has contributed to a number of inspections of linked providers by the CQC during the reporting period. These included the inspection of the Gamma Knife Centre at NHNN in November 2016, the City of London Children Looked After and Safeguarding Review in October 2016 and the inspection of Independent Ambulance Services in December We underwent the first inspection of our core services that provided a rating for UCLH in March The services inspected were: Medical care Urgent and emergency services Surgery Critical care OPD and diagnostic imaging Children and young people Maternity and gynaecology The inspection rated UCLH overall as good. No services were rated as inadequate but there were five areas that require improvement for which action plans are in place. Further detail is available in section University College London Hospitals NHS Foundation Trust

145 Data quality Clinicians and managers need ready access to accurate and comprehensive data to support the delivery of high quality care. Improving the quality and reliability of information is therefore a fundamental component of quality improvement. At UCLH, we monitor the accuracy of data in a number of ways including a monthly data quality review group, coding improvement and medical records improvement groups NHS number and general medical practice code validity UCLH submitted records during 2016/17 (December) to the Secondary Uses service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data: Which included the patient s valid NHS number was: 96.3 per cent for admitted patient care 96.1 per cent for outpatient care 80.4 per cent for accident and emergency care Which included the patient s valid General Medical Practice Code was: 95.4 per cent for admitted patient care 96.1 per cent for outpatient care 80.7 per cent for accident and emergency care Information Governance Toolkit attainment levels The Information Governance Toolkit (IGT) provides an overall measure of the quality of data systems, standards and processes. The score a trust achieves is therefore indicative of how well they have followed guidance and good practice. The UCLH Information Governance Assessment Report overall score for 2016/17 was 80 per cent and was graded green Clinical coding error rate UCLH was not subject to the Payment by Results clinical coding audit during 2016/17 by the Audit Commission. Clinical coding is the process by which patient diagnosis and treatment is translated into standard, recognised codes that reflect the activity that happens to patients. The accuracy of this coding is a fundamental indicator of the accuracy of patient records. UCLH will be taking the following actions to improve data quality: The continuation of a systematic training and audit cycle that underpins high quality coding within the coding department Ongoing engagement with clinicians and clinical divisions in the validation of coded activity ensuring accuracy between coding classifications and clinical care provided Clinical coding engagement programmes and roadshows to maintain coding awareness and support activity recording standards Peer comparative benchmarking to ensure coding quality continues to fall within the upper performance decile 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

146 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annex 1: Statement from Commissioners and Healthwatch Statement from NHS Camden Clinical Commissioning Group Camden Clinical Commissioning Group (CCG) is responsible for the commissioning of health services from University College London Hospitals (UCLH) NHS Foundation Trust on behalf of the population of Camden and surrounding boroughs. Camden CCG has worked closely with UCLH to ensure we have the right level of assurance in relation to these commissioned services. During 2016/17 we have undertaken quality assurance visits in UCLH and seek assurance regarding the quality of services at the Clinical Quality Review Group (CQRG) meetings. CCG welcomes the opportunity to provide this statement on UCLH Trust s Quality Accounts. We have taken particular account of the identified priorities for improvement for UCLH and how this work will enable real focus on improving the quality and safety of health services for the population they serve. We confirm that we have reviewed the information contained within the draft Quality Account (provided to the CCG in April 2017). We confirm that the document received complies with the required content as set out by the Department of Health or where the information is not yet available a place holder was inserted. We have discussed the development of this Quality Account with UCLH over the year and have been able to contribute our views on consultation and content. This account has been shared with NHS Islington, NHS North West London CCGs, NHS Haringey, NHS Enfield and NHS Barnet Clinical Commissioning Groups, NHS England and by colleagues in NHS North and East London Commissioning Support Unit for their review and input. It is assuring to see the significant work the Trust has undertaken in the early identification, treatment and ongoing management of patients where sepsis has been identified. UCLH has worked in collaboration with UCLPartners, to review the current evidence base to inform their clinical guidelines in the treatment of adult and paediatric patients diagnosed with sepsis. The Trust held a Sepsis Masterclass in March 2017 to showcase this work, with internal and external clinical colleagues. We are pleased to see that this remains a Trust priority for 2017/18. As part UCLH s ongoing priority to reduce harm by early recognition of the deteriorating patient, we expect the Trust to at least maintain their 2016/17 performance in relation to the monitoring and recording of patient vital signs. Whilst we recognise the work undertaken by UCLH to reduce avoidable harm during 2016/17, it is disappointing to note that the Trust has reported five Never Events. We expect to see significant improvements throughout the coming year and in reducing avoidable harm to patients. UCLH have committed to establishing a patient safety committee which will facilitate organisational wide learning from all incidents and near misses. This work will be further enhanced by the Trusts commitment to undertake a minimum of 18 surgical safety walkarounds across all hospital sites during 2017/18, using observational measures to provide assurance that 5 Steps to Safer Surgery methodology (5SSS) is being applied consistently. UCLH has enhanced the method for collecting real time patient feedback through the procurement of a new system. We envisage this will help support patient experience as the system allows for surveys to be completed in any language, has a read aloud function in different languages, a test resizer and colour contract options which are compliant with the NHS Accessible Information Standard. We acknowledge the work undertaken to support patients at meal times through the provision of dining companions within some areas of the hospital. UCLH accept that this work needs to be strengthened across the organisation to ensure that all patients are getting the help they need at meal times. It is recognised by the Trust that failure to share relevant information with other health care professionals or patients may lead to delays in safe discharge and may impact on patient safety. UCLH has sought to address this through the introduction of the Exemplar Discharge Programme. Camden CCG expect to see improvements in discharge planning and a provision of appropriate information provided to patients, their carers/families, and other health care professionals as part of this programme. UCLH has acknowledged that they need to improve the time taken to respond to complaints to allow for timely learning and service changes to be implemented. Camden CCG continue to monitor against the Trust trajectory at CQRG. UCLH have noted that they need to continue with improving patient experience in relation to waiting times. It is expected that UCLH has robust business continuity plans which are regularly reviewed and reflect the changing service requirements to support patient flows. There are still areas for improvements to be made, such as information technology, data quality, discharge communication and e-referral systems, and as commissioners, we will continue to work with UCLH. At the time of writing this statement, Camden CCG cannot authenticate the achievement of 2016/17 CQUINs. Overall, this is a positive Quality Account and 146 University College London Hospitals NHS Foundation Trust

147 we welcome the vision described and agree on the priority areas. Statement from Healthwatch Camden, incorporating comments from North Central London Joint Health Overview and Scrutiny Committee We congratulate all at UCLH for another strong year, including a patient safety award and a CQC outstanding rating for well-led in surgery. The Quality Account provides a recognition that UCLH has many areas of good or excellent clinical practice and has clearly identified throughout this report areas where improvement needs to be made. One area where it is less clear is on how improvements within the A&E service would be made and tracked over the next year, in response to the CQC rating of UCLH in 2016 which identified the A&E as requires improvement in 3 out of the 5 areas. We note that patient satisfaction issues will remain a priority for the coming year. We are pleased to see a focus on patient experience. We were disappointed that improvements in the specific measures set for the current year have not been achieved. Under the heading of Patient Experience, the Trust is actually doing reasonably well with the area of concern with the Transport service problems having already been identified as issues relating to a new provider and actions put in place. The Friends and Family test is a useful starting point but the Trust could look at further ways of exploring patient issues in more depth. We think that all the work on patient experience could be supplemented by a stronger sense of working in partnership with patients the remedial measures described all sound like staff working to come up with solutions for patients, rather than staff and patients working together to design solutions. We have highlighted issues around equal treatment in the past, and we note that this issue was also highlighted by CQC. We are pleased to see further efforts to ensure that patients who are flagged as having dementia or learning disabilities get the tailored treatment that they need. We have highlighted issues with outpatient appointments in the past, and we are pleased to note a programme of work to address the problems identified, including the use of a Check and Track system to monitor the time people spend in Outpatients. We know that referral to treatment times continue to be a challenge in some specialisms. We hope that the system improvements you are introducing will help to get these back on target. We note the initiative to increase staff awareness of complaints. We also note that a high percentage of people whose complaint is not upheld then approach the Ombudsman for help. At Healthwatch Camden we are contacted by some of these patients, who often say that their poor experience is compounded by a slow or unfeeling response. We cannot emphasise strongly enough the value of swift and sympathetic complaints responses, even where the decision is not to uphold a complaint. The NCL JHOSC made some specific comments on Patient Safety: This had clear areas of concern within it however the graphs and explanation on near misses didn t fully explain the assumption that the increased rate of reporting was down to better reporting or whether this indicated an actually rise in near misses. The fact that actual rate of harm was down by 50 per cent was given as proof that this is the case however, near misses are different to actual harm being done. Further analysis of the near misses would be helpful within this report to make this clear. Under Patient Safety, sepsis is identified as a clear issue and a proactive approach to identifying the risk of sepsis early on is clear but, as the Trust identifies, there seems to be problems in measuring this outcome as the patient numbers are too small. One easily identifiable measurement is Improve average compliance with provision of antibiotics within 1 hour of diagnosis for all sepsis patients from our 2016/17 baseline average of 56 per cent to 61per cent (a 10per cent increase) This appears to be a low target as administration of antibiotics within the hour of diagnosis would seem to be a must. UCLH note: Please note this statement is in response to an early draft allowing 30 days to respond (as required by the legislation). Therefore some of these comments have already been addressed. Annual Report and Accounts 2016/ PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE)

148 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annex 2: Statement of Directors Responsibilities The directors are required under the Health Act 2009 and the National Health Service (quality reports) Regulations to prepare quality reports for each financial year. NHS Improvement has issued guidance to NHS foundation trust boards on the form and content of annual quality reports (which incorporate the above legal requirements) and on the arrangements that NHS foundation trust boards should put in place to support the data quality for the preparation of the quality report. In preparing the quality report, directors are required to take steps to satisfy themselves that: the content of the quality report meets the requirements set out in the NHS Foundation Trust Annual Reporting Manual 2016/17 and supporting guidance the content of the quality report is not inconsistent with internal and external sources of information including: Board minutes and papers for the period 1 April 2016 to 24 May 2017 Papers relating to quality reported to the Board over the period 1 April 2016 to 24 May 2017 Feedback from the commissioners dated 16 May 2017 Feedback from the governors between 25 November 2016 and 17 May 2017 Feedback from Healthwatch Camden and Camden Health and Adult Social Care Scrutiny Committee dated 11 May 2017 The trust s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated 23 September 2016 National patient survey dated January 2017 National staff survey dated 7 March 2017 The head of internal audit s opinion over the trust s control environment dated 23 May 2017 CQC inspection report dated 15 August 2016 the quality report presents a balanced picture of the NHS foundation trust s performance over the period covered; the performance information reported in the quality report is reliable and accurate; here are proper internal controls over the collection and reporting of the measures of performance included in the quality report, and these controls are subject to review to confirm that they are working effectively in practice; the data underpinning the measures of performance reported in the quality report is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review; and the quality report has been prepared in accordance with NHS Improvement s annual reporting manual and supporting guidance (which incorporates the Quality Accounts regulations) as well as the standards to support data quality for the preparation of the quality report The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the quality report. By order of the Board Chairman 23 May 2017 Chief Executive 23 May University College London Hospitals NHS Foundation Trust

149 Annex 3: External audit limited assurance report Independent auditor s report to the council of governors of University College London Hospital NHS Foundation Trust on the quality report We have been engaged by the council of governors of University College London Hospitals NHS Foundation Trust to perform an independent assurance engagement in respect of University College London Hospitals NHS Foundation Trust s quality report for the year ended 31 March 2017 (the Quality Report ) and certain performance indicators contained therein. This report, including the conclusion, has been prepared solely for the council of governors of University College London Hospitals NHS Foundation Trust as a body, to assist the council of governors in reporting University College London Hospitals NHS Foundation Trust s quality agenda, performance and activities. We permit the disclosure of this report within the Annual Report for the year ended 31 March 2017, to enable the Council of Governors to demonstrate they have discharged their governance responsibilities by commissioning an independent assurance report in connection with the indicators. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Council of Governors as a body and University College London Hospitals NHS Foundation Trust for our work or this report, except where terms are expressly agreed and with our prior consent in writing. Scope and subject matter The indicators for the year ended 31 March 2017 subject to limited assurance consist of the national priority indicators as mandated by NHS Improvement ( NHSI ): Percentage of patients with a total time in A&E of four hours or less from arrival to admission, transfer or discharge; and Percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the end of the reporting period. We refer to these national priority indicators collectively as the indicators. Respective responsibilities of the directors and auditors The directors are responsible for the content and the preparation of the quality report in accordance with the criteria set out in the NHS Foundation Trust Annual Reporting Manual and supporting guidance issued by NHSI. Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything has come to our attention that causes us to believe that: the quality report is not prepared in all material respects in line with the criteria set out in the NHS Foundation Trust Annual Reporting Manual and supporting guidance; the quality report is not consistent in all material respects with the sources specified in section 2.1 of the NHS Improvement 2016/17 Detailed guidance for external assurance on quality reports; and the indicators in the quality report identified as having been the subject of limited assurance in the quality report are not reasonably stated in all material respects in accordance with the NHS Foundation Trust Annual Reporting Manual and supporting guidance and the six dimensions of data quality set out in the Detailed guidance for external assurance on quality reports. We read the quality report and consider whether it addresses the content requirements of the NHS foundation trust annual reporting manual and supporting guidance, and consider the implications for our report if we become aware of any material omissions. We read the other information contained in the quality report and consider whether it is materially inconsistent with: Board minutes and papers for the period 1 April 2016 to 24 May 2017 Papers relating to quality reported to the Board over the period 1 April 2016 to 24 May 2017 Feedback from the commissioners dated 16 May 2017 Feedback from the governors between 25 November 2016 and 17 May 2017 Feedback from Healthwatch Camden and Camden Health and Adult Social Care Scrutiny Committee dated 11 May 2017 The trust s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated 23 September 2016 National patient survey dated January 2017 National staff survey dated 7 March 2017 The head of internal audit s opinion over the trust s control environment dated 23 May 2017 CQC inspection report dated 15 August 2016 Annual Report and Accounts 2016/ PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE)

150 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) We consider the implications for our report if we become aware of any apparent misstatements or material inconsistencies with those documents (collectively, the documents ). Our responsibilities do not extend to any other information. We are in compliance with the applicable independence and competency requirements of the Institute of Chartered Accountants in England and Wales (ICAEW) Code of Ethics. Our team comprised assurance practitioners and relevant subject matter experts. Assurance work performed We conducted this limited assurance engagement in accordance with International Standard on Assurance Engagements 3000 (Revised) Assurance Engagements other than Audits or Reviews of Historical Financial Information issued by the International Auditing and Assurance Standards Board ( ISAE 3000 ). Our limited assurance procedures included: evaluating the design and implementation of the key processes and controls for managing and reporting the indicators; making enquiries of management; testing key management controls; reviewing the process flow of the indicator with management; limited testing, on a selective basis, of the data used to calculate the indicator back to supporting documentation; comparing the content requirements of the NHS Foundation Trust Annual Reporting Manual and supporting guidance to the categories reported in the quality report; and reading the documents. A limited assurance engagement is smaller in scope than a reasonable assurance engagement. The nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited relative to a reasonable assurance engagement. Limitations Non-financial performance information is subject to more inherent limitations than financial information, given the characteristics of the subject matter and the methods used for determining such information. The absence of a significant body of established practice on which to draw allows for the selection of different, but acceptable measurement techniques which can result in materially different measurements and can affect comparability. The precision of different measurement techniques may also vary. Furthermore, the nature and methods used to determine such information, as well as the measurement criteria and the precision of these criteria, may change over time. It is important to read the quality report in the context of the criteria set out in the NHS foundation trust annual reporting manual and supporting guidance. The scope of our assurance work has not included testing of indicators other than the two selected mandated indicators, or consideration of quality governance. Basis for qualified conclusion As set out in the Review of Quality Performance section of the Trust s Quality Report, the Trust identified a number of issues in the referral to treatment within 18 weeks for patients on incomplete pathways indicator and percentage of patients with a total time in A&E of four hours or less from arrival to admission, transfer or discharge indicator reporting during the year that was supported by our testing. Issues identified for 18 week referral to treatment included: the clock having started on the wrong date due to an input error in one case the duplication of a pathway in one case in the reporting metric a systemic issue being identified, which impacts a large portion of the population, with 2 cases identified where pathway clock starts being sent from local referral management centres were incorrect by a few days, leading to pathway times and breaches being understated. The Trust has been aware of this issue from its own internal audit work and is working with the referral management centres and NHS Digital to understand the cause of the issue and then consider the best way of resolving. As a result of the issues identified, we have concluded that there are errors in the calculation of the 18 week Referral-to-Treatment incomplete pathway indicator. We are unable to quantify the effect of these errors on the reported indicator for the year ended 31 March Issues identified for A&E four hour wait included: Our testing identified that the trust does not retain an audit trail for adjustments made following validation of apparent breaches; Instances where supporting documentation was 150 University College London Hospitals NHS Foundation Trust

151 not available to substantiate the discharge date and time; Patient files indicating journey times after the discharge time noted on CareCast Seven files not being available for testing. As a result there is a limitation upon the scope of our procedures which means we are unable to determine whether the indicator has been prepared in accordance with the criteria for reporting A&E four hour waiting times for the year ended 31 March Furthermore, we are unable to quantify the effect of the errors identified on the reported indicator for the year ended 31 March The Trust s Quality Report summarises the actions the Trust is taking post year end to address the issues identified in relation to the documentation of its validation processes. Qualified Conclusion Based on the results of our procedures, except for the matters set out in the basis for qualified conclusion paragraph above, nothing has come to our attention that causes us to believe that, for the year ended 31 March 2017: the quality report is not prepared in all material respects in line with the criteria set out in the NHS Foundation Trust Annual Reporting Manual and supporting guidance; the quality report is not consistent in all material respects with the sources specified in 2.1 of the NHS Improvement Detailed requirements for quality reports for Foundation Trusts 2016/17; and the indicators in the quality report subject to limited assurance have not been reasonably stated in all material respects in accordance with the NHS Foundation Trust Annual Reporting Manual and supporting guidance. Deloitte LLP Chartered Accountants St Albans 23 May PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

152 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annex 4: Glossary of terms and abbreviations Acute Kidney Injury (AKI): A sudden episode of kidney failure or kidney damage that happens within a few hours or a few days. After action review (AAR): A structured review or de-brief process for analysing what happened, why it happened, and how it could be done better BadgerNet: A live patient database used by most of the neonatal units in the UK. Care Quality Commission (CQC): The independent regulator of all health and social care services in England Cardiac Arrest: A collapse when the heart stops beating Carter productivity programme: Operational productivity and performance in English NHS acute hospitals: Unwarranted variations An independent report for the Department of Health by Lord Carter of Coles CDR- Clinical Data Repository: Where we store all patients details electronically CHKS: A provider of healthcare intelligence and quality improvement services, using data from the NHS Secondary Uses Service to enable trusts to review performance and benchmark CNS: Clinical nurse specialist Commissioners: The local and national bodies contracting to buy care for UCLH patients Complaints: A complaint is upheld (fully agreed) by UCLH when it is agreed that action(s) need to be taken to prevent the subject of the complaint occurring again. It is partially upheld (partly agreed when some aspects of the complaint require action and not upheld (not agreed) when no action is required. Patients are always offered an apology. CQUIN: Commissioning for Quality and Innovation a framework that allows commissioners to make payments to hospitals for agreed improvement work Deteriorating patient: An evolving, predictable and symptomatic process of worsening physiology towards critical illness (worsening of the patients condition) Discharge to Assess (D2A): A service run by NHS England Where people who are clinically optimised and do not require an acute hospital bed, but may still require care services are provided with short term, funded support to be discharged to their own home (where appropriate) or another community setting. Assessment for longer-term care and support needs is then undertaken in the most appropriate setting and at the right time for the person. Duty of candour: The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 sets out the legal obligation for health service bodies to act in an open and transparent way in relation to care and treatment provided. The aim of the legislation is to ensure that patients/their families/ representatives are told about patient safety incidents that affect them, receive appropriate apologies, are kept informed of investigations and are supported to deal with the consequences. DNACPR: Do not attempt cardio-pulmonary resuscitation Essence of care audits: DOH guidance on standards of care which should be delivered to patients Exemplar Ward: A ward accreditation scheme that seeks to measure and celebrate excellence in ward standards. 5 Steps to Safer Surgery (5SSS): The 5SSS should be performed for every patient undergoing an invasive procedure, and are designed to improve performance at safety critical time points within the patient s intraoperative care pathway. The five checks are: Team brief the team to identify themselves and their role, discuss what procedures are planned, what is required and what problems may be anticipated to ensure that any issues may be dealt with early Sign in includes confirmation of correct patient identity and procedure prior to anaesthesia or sedation Time out the theatre team make final checks prior to the procedure commencing Sign out to check that all information has been recorded, equipment, swabs and specimens are accounted for and to ensure there is an ongoing plan for patient care Team debrief to discuss what went well, what needs attention and any learning Friends and Family Test (FFT): Is an important feedback tool that supports the fundamental principle that people who use NHS services should have the opportunity to provide feedback on their experience. It asks people if they would recommend the services they have used and offers a range of responses. When combined with supplementary follow-up questions, the FFT provides a mechanism to highlight both good and poor patient experience. This kind of feedback is vital in transforming NHS services and supporting patient choice. 152 University College London Hospitals NHS Foundation Trust

153 Harm definitions No Harm: Incident reported but no harm was experienced by the person involved/affected Low harm: Person affected required extra observation or minor treatment as a result of the incident Moderate harm: Person affected required a moderate increase in treatment; the incident caused significant but not permanent harm to the person. Moderate increase in treatment includes an unplanned return to surgery, an unplanned re-admission, a prolonged episode of care, extra time in hospital or as an outpatient, cancelling of treatment, or transfer to another treatment area (such as intensive care) Prolonged psychological harm: Incident that appears to have resulted in psychological harm which a service user has experienced, or is likely to experience, for a continuous period of at least 28 days Severe harm: Incident that appears to have resulted in permanent harm to the person affected. This means a permanent lessening of bodily, sensory, motor, physiologic or intellectual functions, including removal of the wrong limb or organ or brain damage that is related directly to the incident and not related to the natural course of the person s illness or underlying condition Death: Incident that directly resulted in the death of the person affected rather than as a result of their underlying medical condition Hot debriefs: Carried out immediately after an incident or event to obtain immediate feedback from staff or partner agencies participating in the incident/event Incident classification: For incidents counted under surgical incidents for University College Hospital s theatres (see reduction of surgical harm priority) List order changed Consent form not signed by patient Anaesthetics difficult/failed intubation Intra/post operatively foreign body left in situ post procedure Intra/post operatively incorrect surgical procedure Intra/post operatively incorrect surgical site Intra/post operatively swab/needle/ instrument count issue Operation performed on incorrect patient Incorrect implant prosthesis Observations not acted upon Verbal communication general poor communication Verbal communication interpreter not available Verbal communication within the MDT Written communication incorrect information Written communication procedure or process issue Equipment checks not completed Incident classification: For incidents with harm caused by unrecognised patient deterioration Observations not acted upon Failure to rescue In-hospital cardiac arrest Delay due to abnormal observations not acted upon Delay in resuscitation Unexpected outcome/deterioration/death Improving care rounds: At UCLH, multidisciplinary and multi-level teams visit a clinic, ward, or facility to observe with fresh eyes and give feedback, using the same questions as the Care Quality Commission (Is care safe, effective, caring, responsive and well led?) Matron quality rounds: Quality, environmental and patient/staff experience reviews by groups of UCLH Matrons, outside of their own clinical areas, with instant feedback via a huddle. NHSI: NHS Improvement is responsible for overseeing foundation trusts and NHS trusts, as well as independent providers that provide NHSfunded care. Never Event -: Patient safety incidents which have the potential for, or cause severe harm, and which should not occur if relevant preventative measures are put in place. Ombudsman: The Parliamentary and Health Services Ombudsman can consider complaints against NHS trusts which local processes have failed to resolve Patient pathway: The route that a patient will take from first contact with the NHS, through referral, to the completion of treatment. PERRT: Patient Emergency Response and Resuscitation Team Problem scores (Picker survey): Shows the percentage of patients for each question who, by their response, indicated that a particular aspect Annual Report and Accounts 2016/ PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE)

154 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) of their care could have been improved. Problem scores are calculated by combining response categories. Lower scores are better. Root Cause Analysis (RCA): An investigation into why specific patient safety incidents happen and identify areas for change to make care safer Safety huddles: Daily meetings on the ward to highlight safety and quality issues and promote discussion among team members. SBAR: A communication tool process to improve providing information and decision-making when urgent referrals are made - Situation, Background, Assessment and Recommendation. Shelford: The Shelford Group is made up of 10 leading NHS multi-specialty academic healthcare organisations. They are dedicated to excellence in clinical research, education and patient care. Summary hospital-level mortality indicator (SHMI): The ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated here. It includes deaths, which occur in hospital, and deaths, which occur outside of hospital within 30 days (inclusive) of discharge. NHS Digital release the external SHMI every quarter but there is a sixmonth time lag. SSI: Surgical site infections Text resizer, text simplifier and a screen ruler- Envoy Browsealoud lists their features as follows: Text-to-speech with choice of reading speeds and highlighters to enhance reading comprehension Translate web pages into 99 languages; speak translated text aloud in 40 languages On-screen text magnifier helps users with visual impairments MP3 generator converts text to audio files for offline listening Screen mask blocks on-screen clutter, letting readers focus on text being read Web page simplifier removes ads and other distracting content for easier reading Custom settings that are built in to suit individual user needs and preferences UCLH future: UCLH programme that aims to improve patient and staff experience by embedding a culture of continuous improvement and innovation. The programme delivers this through introducing new ways of working, supported by significant investment in technology and staff development. UCLH trust values: Safety, kindness, teamwork, improving Vital Signs: describes six physiological parameters:(measurements) 1. Respiratory rate 2. Oxygen saturation 3. Pulse rate, 4. Blood pressure 5. Level of consciousness 6. Core body temperature 7. The requirement for supplemental oxygen (by mask or nasal cannulae) VTE: Venous thromboembolism (blood clot) WHO Surgical Safety Checklist: Safety checks before anaesthesia ( sign in ), before the incision of the skin ( time out ) and before the patient leaves the operating room ( sign out ). 154 University College London Hospitals NHS Foundation Trust

155 Annual Report and Accounts 2016/ PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE)

156 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) 4 Annual Accounts University College London Hospitals NHS Foundation Trust Foreword to the accounts These accounts, for the 12 months ended 31 March 2017, have been prepared by the University College London Hospitals NHS Foundation Trust in accordance with paragraphs 24 and 25 of Schedule 7 to the National Health Service Act Presented to Parliament pursuant to Schedule 7, paragraph 25(4) of the National Health Service Act Marcel Levi Chief Executive 23 May University College London Hospitals NHS Foundation Trust

157 INDEPENDENT AUDITOR S REPORT TO THE BOARD OF GOVERNORS AND BOARD OF DIRECTORS OF UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST Opinion on financial statements of University College London Hospitals NHS Foundation Trust In our opinion the financial statements: give a true and fair view of the state of the Trust s affairs as at 31 March 2017 and of the Trust s income and expenditure for the year then ended; have been properly prepared in accordance with the accounting policies directed by NHS Improvement Independent Regulator of NHS Foundation Trusts; and have been prepared in accordance with the requirements of the National Health Service Act The financial statements that we have audited comprise: the Statement of Comprehensive Income; the Statement of Financial Position; the Statement of Changes in Taxpayers Equity; the Statement of Cash Flows; and the related notes 1 to 33. The financial reporting framework that has been applied in their preparation is applicable law and the accounting policies directed by NHS Improvement Independent Regulator of NHS Foundation Trusts. Certificate We certify that we have completed the audit of the accounts in accordance with the requirements of Chapter 5 of Part 2 of the National Health Service Act 2006 and the Code of Audit Practice. Summary of our audit approach Key risks Materiality Scoping Significant changes in our approach The key risks that we identified in the current year were: NHS revenue and provisions Property valuations; and Management override of controls. Within this report, the risks which are the same as the prior year are identified with a. The materiality that we used in the current year was 10.1m which was determined on the basis of 1% of revenue. Audit work was performed at the Trust s head offices in Euston Road directly by the audit engagement team, led by the audit partner. In 2015/16 we used 0.8% of operating income as the basis for materiality. We reassessed the percentage used to 1% of operating income in the context of our cumulative knowledge and understanding of the audit risks faced by the Trust for this year. 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

158 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Going concern We have reviewed the Accounting Officer s statement contained within the annual report that the Trust is a going concern. Independence We are required to comply with the Code of Audit Practice and Financial Reporting Council s Ethical Standards for Auditors, and confirm that we are independent of the t Trust and we have fulfilled our other ethical responsibilities in accordance with those standards. Our assessment of risks of material misstatement We confirm that: we have concluded that the Accounting Officer s use of the going concern basis of accounting in the preparation of the financial statements is appropriate; and we have not identified any material uncertainties that may cast significant doubt on the Trust s ability to continue as a going concern. However, because not all future events or conditions can be predicted, this statement is not a guarantee as to the Trust s ability to continue as a going concern. We confirm that we are independent of the Trust and we have fulfilled our other ethical responsibilities in accordance with those standards. We also confirm we have not provided any of the prohibited non-audit services referred to in those standards. The assessed risks of material misstatement described below are those that had the greatest effect on our audit strategy, the allocation of resources in the audit and directing the efforts of the engagement team. NHS revenue and provisions Risk description As described in notes 1.3 and 1.22 there are significant judgements in recognition of revenue from care of NHS patients and in provisioning for disputes with commissioners due to: the complexity of the Payment by Results regime, in particular in determining the level of over-performance and Commissioning for Quality and Innovation revenue to recognise; the judgemental nature of provisions for disputes, including in respect of outstanding over-performance income for quarters 3 and 4; and the risk of revenue not being recognised at fair value due to adjustments agreed in settling current year disputes and agreement of future year contracts. Details of the Trust s income, including 759.6m of Commissioner Requested Services, are shown in note 3 to the financial statements. NHS debtors of 95.5m (excluding STF accrual) are included in the financial statements. The Trust earns revenue from a wide range of commissioners, increasing the complexity of agreeing a final year-end position. The settlement of income with Clinical Commissioning Groups continues to present challenges, leading to disputes and delays in the agreement of year end positions. 158 University College London Hospitals NHS Foundation Trust

159 NHS revenue and provisions How the scope of our audit responded to the risk Key observations Property valuations Risk description How the scope of our audit responded to the risk We evaluated the design and implementation of key controls for recording and reporting revenue and any significant judgements and estimates involved in respect of recognition of unsettled revenue. We performed detailed substantive testing on a sample basis of the recoverability of over-performance income and adequacy of provision for underperformance through the year, and evaluated the results of the agreement of balances exercise. We challenged key judgements around specific areas of dispute and actual or potential challenge from commissioners and the rationale for the accounting treatments adopted. In doing so, we considered the historical accuracy of provisions for disputes and reviewed correspondence with commissioners. We consider revenue recognised from care of NHS patients to be appropriate based. We also consider the receivables balance recognised and the associated bad debt provision recorded to be appropriate although we consider that the Trust continues to be prudent with the level of debt it provides for. The Trust holds property assets within Property, Plant and Equipment at a gross modern equivalent use valuation of 492.2m. The valuations are by nature significant estimates which are based on specialist and management assumptions (including the floor areas for a Modern Equivalent Asset, the basis for calculating build costs, the level of allowances for professional fees and contingency, and the remaining life of the assets) and which can be subject to material changes in value and which have been described in notes 1.6, 1.22 and 11. The net valuation movement on the Trust s estate shown in note 14 is an impairment of 9.9m. We evaluated the design and implementation of controls over property valuations, and tested the accuracy and completeness of data provided by the Trust to the valuer. We used Deloitte internal valuation specialists to review and challenge the appropriateness of the key assumptions used in the valuation of the Trust s properties, including through benchmarking against revaluations performed by other Trusts at 31 March We have reviewed the disclosures in notes 1.6, 1.22 and 11 and evaluated whether these provide sufficient explanation of the basis of the valuation and the judgements made in preparing the valuation. We assessed whether the valuation and the accounting treatment of the impairment were compliant with the relevant accounting standards, and in particular whether impairments should be recognised in the Income Statement or in Other Comprehensive Income. 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

160 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Property valuations Key observations Management override of controls Risk description We consider the valuation of the property assets held by the Trust to be reasonable and the assumptions used in its calculation to be appropriate. We consider that in the current year there is a heightened risk across the NHS that management may override controls to fraudulently manipulate the financial statements or accounting judgements or estimates. This is due to the increasingly tight financial circumstances of the NHS and close scrutiny of the reported financial performance of individual organisations. The Trust has been allocated 43.3m of the Sustainability and Transformation Fund, contingent on achieving financial and operational targets each year, equivalent to a control total for the year of a surplus (adjusted for certain items) of 34.7m. NHS Improvement has allocated funding for a bonus to organisations that exceed their control total, including offering trusts 1 of additional funding for each 1 above the control total. This creates an incentive for reporting financial results that exceed the control total of ( 11.1m). Control total Surplus on control total basis Core STF funding Finance incentive ( 11.1m) 45.6m 14.4m 25.4m Bonus incentive 3.7m Operating surplus 34.7m All NHS Trusts and Foundation Trusts were requested by NHS Improvement in 2016 to consider a series of technical accounting areas and assess both whether their current accounting approach meets the requirements of International Financial Reporting Standards, and to remove excess prudence to support the overall NHS reported financial position. The areas of accounting estimate highlighted included accruals, deferred income, partially completed patient spells, bad debt provisions, property valuations, and useful economic lives of assets. Details of critical accounting judgements and key sources of estimation uncertainty are included in note University College London Hospitals NHS Foundation Trust

161 Management override of controls How the scope of our audit responded to the risk Key observations Manipulation of accounting estimates Our work on accounting estimates included considering each of the areas of judgement identified by NHS Improvement. We have considered both the individual judgements and their impact individually and in aggregate upon the financial statements. In testing each of the relevant accounting estimates, engagement team members were directed to consider their findings in the context of the identified fraud risk. Where relevant, the recognition and valuation criteria used were compared to the specific requirements of IFRS. We evaluated the design and implementation of controls over property valuations. We tested accounting estimates (including in respect of NHS revenue and provisions and property valuations discussed above), focusing on the areas of greatest judgement and value. Our procedures included comparing amounts recorded or inputs to estimates to relevant supporting information from third party sources. We evaluated the rationale for recognising or not recognising balances in the financial statements and the estimation techniques used in calculations, and considered whether these were in accordance with accounting requirements and were appropriate in the circumstances of the Trust. Manipulation of journal entries We used data analytic techniques to select journals for testing with characteristics indicative of potential manipulation of reporting focusing in particular upon manual journals. We traced the journals to supporting documentation, considered whether they had been appropriately approved, and evaluated the accounting rationale for the posting. We evaluated individually and in aggregate whether the journals tested were indicative of fraud or bias. We tested the year-end adjustments made outside of the accounting system between the general ledger and the financial statements. Accounting for significant or unusual transactions We considered whether any transactions identified in the year required specific consideration and did not identify any requiring additional procedures to address this risk. We did not identify concerns involving management override of control nor have we have found evidence of management bias in the estimates adopted by management. We consider the accounting estimates made to be reasonable. These matters were addressed in the context of our audit of the financial statements as a whole, and in forming our opinion thereon, and we do not provide a separate opinion on these matters. 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Annual Report and Accounts 2016/

162 1. PERFORMANCE REPORT 2. ACCOUNTABILITY REPORT 3. QUALITY REPORT 4. ANNUAL ACCOUNTS (INCLUDING AUDITOR S REPORT AND CERTIFICATE) Our application of materiality We define materiality as the magnitude of misstatement in the financial statements that makes it probable that the economic decisions of a reasonably knowledgeable person would be changed or influenced. We use materiality both in planning the scope of our audit work and in evaluating the results of our work. Based on our professional judgement, we determined materiality for the financial statements as a whole as follows: Materiality Basis for determining materiality Rationale for the benchmark applied 10.1m (2016: 7.3m) 1% of revenue (2016: 0.8% of revenue) We assessed the percentage used in the context of our cumulative knowledge and understanding the audit risks at the Trust and our assessment of those risks for this year. Revenue was chosen as a benchmark as the Trust is a non-profit organisation, and revenue is a key measure of financial performance for users of the financial statements. We previously agreed with the Audit Committee that we would report to the Committee all audit differences in excess of 250k (2016: 146k), as well as differences below that threshold that, in our view, warranted reporting on qualitative grounds. We also report to the Audit Committee on disclosure matters that we identified when assessing the overall presentation of the financial statements. An overview of the scope of our audit Our audit was scoped by obtaining an understanding of the Trust and its environment, including internal controls, and assessing the risks of material misstatement. Audit work was performed at the Trust s head offices in Euston Road directly by the audit engagement team, led by the audit partner. The audit team included integrated Deloitte specialists bringing specific skills and experience in property valuations and information technology systems. Opinion on other matters prescribed by the National Health Service Act 2006 In our opinion: the parts of the Directors Remuneration Report and Staff Report to be audited have been properly prepared in accordance with the National Health Service Act 2006; and the information given in the Performance Report and the Accountability Report for the financial year for which the financial statements are prepared is consistent with the financial statements. 162 University College London Hospitals NHS Foundation Trust