Trust Board. Infection Prevention and Control Service Annual Report 2014/15

Transcription

1 Trust Board Infection Prevention and Control Service Annual Report 2014/ Meeting Date: 28 th January 2016 Author: Sponsoring Executive Director: Report Presented by: Committee/Group who have received or considered this paper: Jayne Elias Assistant Director of Nursing and Service Improvement Professor Susan Morgan, Executive Director of Nursing and Service Improvement Professor Susan Morgan, Executive Director of Nursing and Service Improvement Infection Prevention and Control Committee Trust Resolution to: (please tick) Approve: Endorse: Discuss: Note: Recommendation: The Board are asked to NOTE the Infection prevention and Control of Infection Service Annual Report 2014/ This report supports the following Trust objectives as set out in the Integrated Medium Term Plan: (please tick) Equitable and timely services Providing evidence based care and research which is clinically effective Supporting our staff to excel Safe and reliable services First class patient /donor experience Spending every pound well

2 2 [Report Title] 1. Introduction / Background: The Infection Prevention and Control Team Annual Report provides an overview of the progress, activities and achievements of the Trust s Infection Prevention and Control Team (IPCT) between April 2014 and March 20. The Trust takes its responsibility for the prevention and control of infections very seriously. The Annual Report draws on key infection prevention and control matters, and is generated through consideration of activity and issues reported and scrutinised by the Infection Prevention and Control Committee, Health and Safety Management Group, Executive Management Board and the Quality and Safety Committee during the identified time period. 2. Timing The Infection Prevention and Control Team Annual Report is generated each year as part of the Board s usual business cycle. The Report presents a retrospective summary of activity and issues encountered reported and scrutinised during the reporting period. 3. Description: The Infection Prevention and Control Team Annual Report provides an overview of the progress, activities and achievements of the Trust s Infection Prevention and Control Team (IPCT) between April 2014 and March 20. The Report is structured to provide information in respect of: Performance in respect of national drivers including targets, standards and best practice guidance, The management of infection outbreaks and reported incidents within Velindre Cancer Centre, Surveillance data in respect of alert organisms, Antimicrobial prescribing, Decontamination, Water safety, Activities of the team including audit, policy development and training, and Priority actions for the coming year (20/16) 4. Financial Impact: Although the management of infection prevention and control generates expenditure there are no specific financial considerations to draw to the attention of the Board. 5. Quality, Equality, Safety and Patient Experience Impact. The Trust adopts a zero tolerance approach to hospital acquired infection. The IPCT routinely monitor and report the number of infections monthly, quarterly and annually. Instances where alert organisms are identified are subject to root cause analysis, and lessons learnt are shared to improve practice and patient/donor outcomes. Patients are asked directly about aspects of infection prevention and control within the Patient Experience survey. Page 2

3 3 [Report Title] 6. Considerations for Board / Committee Of note during 2014/, there were: Significant reductions achieved in the rate of some alert organisms and good performance maintained in others Challenges associated with the Vancomycin-resistant Enterococcus (VRE) outbreak and the number of influenza cases Concerns about water and Legionella management within the Velindre Cancer Centre site A number of initiatives put in place to maximise staff engagement with the annual influenza vaccination campaign Weekly infection prevention and control ward rounds initiated by the Trust s Infection Control Doctor and Pharmacist Continued utilisation of 1000 lives plus methodologies to support implementation of care bundles 7. Next Steps The Trust Board are asked to NOTE the contents of the Infection Prevention and Control Service Annual Report for 2014/. Page 3

4 Annual Report of The Infection, Prevention and Control of Infection Service April 2014 March 20 1

5 Contents 2 Abbreviations 4 1. Introduction Current Structure and Responsibilities 5 2. Performance Management Key Achievements 6 3. Outbreak & Incidents Outbreaks Incidents 6 4. Surveillance Mandatory Alert Organism 7 4.2a MRSA 7 4.2b Clostridium difficile 8 4.2c Bacteraemia 8 4.2d Central Venous Catheters (CVC) 9 4.2e Multi-resistant Organisms f Other Alerts Catheter Associated Urinary Tract Infection (CAUTI) Antimicrobial Prescribing Audit Policy External Campaigns Training & Development IPCT Professional Development Education and Training Welsh Blood Service Progress Against Annual Programme Water Safety Other issues Building and Estates Decontamination Genetically Modified Sub Committee Priorities for Action Conclusions 14 Appendices Appendix 1 - Organisational Chart Appendix 2 Prevention and Control of Infection Annual Strategy and 17 Related Programme April

6 Appendix 3 Numbers of Clostridium difficile in inpatients in Velindre NHS 28 Trust (compared with ) Appendix 4 VCC Infection Control Audit Programme Results 29 Appendix 5 IPCT Staff Training Record 34 3

7 Abbreviations AMP Antimicrobial Pharmacist AOS Acute Oncology Service AQF Annual Quality Framework ASU Active support unit CAUTI Catheter Associated Urinary Tract Infection CDT Clostridium difficile toxin CVC Central Venous Catheter FF First Floor HCAI Healthcare Associated Infection H&CS Health and Care Standards HCW Healthcare Worker HIW Health Inspectorate Wales HPV Hydrogen Peroxide Vapour HSW HCAI reduction Strategy for Hospitals in Wales 2012 ICD Infection Control Doctor ICN Infection Prevention Control Nurse IPCSC Infection Prevention Control and Standards Committee IPCT Infection Prevention Control Team LINAC Linear Accelerator MCCC Marie Curie Cancer Centre MHRA Medicine and Healthcare products Advisory Authority OCCH Occupational Health PCR Polymerase chain reaction PGD Patient Group Directive PHW Public Health Wales PICC Peripheral inserted central catheter PMW Princess Margaret Wing PPE Personal Protective Equipment PVC Peripheral Venous Cannula RCA Root cause analysis SAI Serious Adverse Incident SBAR Situation, Background, Assessment & Recommendations SCIF Significant Clinical Incident forum SHO Senior House Officers SICN Senior Infection Control Nurse SLA Service Level Agreement SS Screening Services SWOT Strengths, Weaknesses, Opportunities and Threats UTI Urinary Tract Infection VRE - Vancomycin Resistant Enteroccoci VCC Velindre Cancer Centre VIP Venous Infusion phlebitis VZV Varicella Zoster Virus WBS Welsh Blood Service WG Welsh Government WHAIP Welsh Healthcare Associated Infection Programme 4

8 1. Introduction This report outlines the progress, activities and achievements of the Infection Prevention and Control Team (IPCT) for Velindre NHS Trust in preventing and controlling patient and donor risks of acquiring infection through contact with the Health Care services provided at Welsh Blood Service (WBS) and Velindre Cancer centre (VCC). This a summary report based on the yearly activity already reported, scrutinised and managed during the year by the IPCS, Q&S and H&S committees Current Structure and Responsibilities: There have been some changes within the Infection Prevention and Control Team (IPCT): a) The Deputy Director of Nursing took over the line management of the team with effect from 1 st April 20 (Appendix 1). b) A band 7 nurse is currently on secondment from Public Health Wales for 1 year until 27 th October, 20. c) A change of Infection Control doctor occurred in August d) The Service Level Agreement (SLA) for support in managing infection prevention and control with Marie Curie Cancer Centre has continued but has not been widely utilised by the service due to management changes at the centre. 2. Performance Management Welsh Government (WG) targets continue to be monitored via reporting mechanisms: a) Standards for Healthcare Services in Wales (SHS) a continued self assessed score of 4 has been approved by Trust Board for the year 2014/ with agreed actions achieved. b) The Healthcare Associated Infection (HCAI) Reduction Strategy committment to purpose for hospitals in Wales (HSW) (2011) the majority of planned actions have been achieved and this is superseded by the following document. c) The HCAI code of practice (CoP)(2014) a gap analysis has been completed and areas to be addressed are included in the Health and Care Standards (H&CS) action plan 20/16. d) Healthcare Associated Infection (HCAI) published data this is updated and reviewed monthly on the Trust Internet site for the public to view. No negative public comments received by the team to date. e) Performance dashboard Trust performance measures are reported monthly. f) Inpatient performance - performance data per ward are reported monthly to ward managers. 5

9 The majority of key objectives in the IPCT annual work programme for 2014/ have been achieved. The annual work programme for the IPCT has been agreed (Appendix 2) Key Achievements: Clostridium difficile (C.diff) A reduction of 43% this year: 08 cases in 2014/ 14 cases in 2013/14 13 cases in 2012/13 21 cases in 2011/12 3. Outbreaks and Incidents Meticillin Resistant Staphylococcus aureus (MRSA) Blood stream infection remains low: 0 cases in 2014/ 2 cases in 2013/14. 0 cases in 2012/13 1 case in 2011/12 In all cases the MRSA had been acquired before admission to Velindre Cancer Centre. Meticillin Sensitive Staphylococcus aureus (MSSA) Blood stream infection reduced by 71% this year: 2 cases in 2014/ 7 cases in 2013/14 7 cases in 2012/13 4 cases in 2011/12 Only 3 cases possibly acquired at VCC since 2011 Flu vaccine uptake in HCW s An increase achieved: 69% in 2014/ 55% in 2013/14, 58% in 2012/13 59% in 2011/12 (VCC only) During the year the following outbreaks and incidents were reported and managed by the IPCT: 3.1 Outbreaks a) January 20 Outbreak of Vancomycin Resistant Enterococci (VRE) on FF female ward involving 4 patients. A sudden Untoward Incident (SUI) form was submitted to Welsh Government (WG). 3.2 Incidents a) April 2014 Chicken pox exposure in the main Outpatient Department (OPD) involving 64 patients and 5 staff. A sudden Untoward Incident (SUI) form was submitted to Welsh Government (WG). b) September 2014 Chicken pox exposure in LA1 involving 8 patients and 5 staff. c) October 2014 to February 20 three flu exposure incidents on CIU (2) and ASU (1) wards involving 28 patients and 38 staff. The required investigations, SBAR reports and SUI closures have been completed on all incidents and the outbreak. These have been discussed and noted by relevant management and monitoring committees. Action has been taken to complete all 6

10 recommendations as a result of investigations and lessons learnt identified. No patients or staff were seriously harmed as a result of these events. 4.Surveillance 4.1 Mandatory The department continued to be 100% compliant with each mandatory surveillance scheme as required by WG. 4.2 Alert Organism The only significant increase in alert organisms reflects unprecedented increases in flu and other respiratory viruses (as seen on an all Wales basis) this winter. 4.2a MRSA The revised MRSA policy was approved during the year. Consistent levels of admission screening have been maintained. As a result NONE of the 38 new cases identified are attributed to Velindre NHS Trust acquisition. Screening has been extended to pre operative brachytherapy patients and screening compliance is reported weekly and monthly to ward managers. MRSA Cases: April March Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan- Feb- Mar- New Isolates Positive Screen Isolates Head and Neck Cases Number of New MRSA Cases 7

11 4.2b Clostridium difficile toxin (CDT) A reduction in cases of 43% (6 cases) was achieved this year (Appendix 3) although 7 of the 8 were in the 66yr+ age group (same trend as previous as year). Only 2 were deemed as Velindre NHS Trust acquired. Improvement may be attributed to improved training, environmental management, use of sporicidal disinfectant, and antimicrobial stewardship. This culminated in the FF female ward achieving the 1000 lives+ target of 500 days between cases on the 29 th March, 20. This was celebrated to thank the teams involved for their combined efforts. 4.2c Bacteraemia Work has been ongoing to improve Peripheral Vascular Cannula (PVC) and Central Venous Catheter (CVC) care with the aim of reducing Velindre acquired bacteraemia. This work included the introduction of care bundles, insertion packs, and Aseptic Non Touch Technique (ANTT) training in collaboration with the IV nurse specialist. While bacteraemia rates are comparable with the previous year (48 versus 47 in 2013/14), fewer cases were deemed as Velindre NHS Trust acquired (3 versus 7). Patients with a CVC remain at higher risk of bacteraemia but this year only 31% (44% in 2013/14) had a CVC with only 1(6 in 2013/14) case deemed Velindre NHS Trust acquired. There were no MRSA bacteraemia 8

12 12 Bacteraemia Cases: April March Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan- Feb- Mar- As seen across Wales and the rest of the UK, E.coli and S. aureus continue to be the predominant organisms in the Top ten for VCC bacteraemia. During this year only 2 cases of Meticillin sensitive S. aureus (MSSA) bacteraemia were reported which is 5 less than 2013/14. Both patients had a CVC line but neither bacteraemia was Velindre NHS Trust acquired. 4.2d Central Venous Catheters (CVC) Low rates of CVC infection have been maintained. Between July and September 2014 a prevalence survey of the lines placed during these months was undertaken. Results showed that 133 CVC s were placed (all PICC lines) with 2 infections that matched the HELICS definition of CVC infection. This gives an infection rate of 0.31 per 1000 catheter days which compares favourably to 0.39 per 1000 catheter days in the last prevalence survey January March Continuous Surveillance Point Prevalence 9

13 4.2e Multi-resistant Organisms There were increased numbers of multi- resistant organisms identified this year (32 compared to 10) but not necessarily Velindre NHS Trust acquired. These were mainly identified in urines and sputum, with the increase also reflecting the 4 outbreak cases of VRE. 4.2f Other Alerts The only significant increase in alert organisms reflects unprecedented increases in flu and other respiratory viruses as seen on an all Wales basis this winter (23 of 38). Two of the 23 were deemed Velindre NHS Trust acquired. 4.3 Catheter Associated Urinary Tract Infection (CAUTI) Data since 2012 indicates that compliance with the bundle has been maintained but has been variable at points in the year due to staff change, need for additional awareness training, or failure to submit the audit reports. Training in the prevention of CAUTI is taught alongside catheterisation competency updates. The STOP campaign continues to be promoted. 5. Antimicrobial Prescribing During the year the Antimicrobial Pharmacist has worked closely with the Microbiology Consultant to secure weekly microbiology ward rounds at Velindre Cancer Centre (VCC). These ward rounds have been well received by all staff and have had a positive impact on the management of infections at VCC. 10

14 The weekly antimicrobial prescribing audit has continued to be reported monthly on the performance dashboard and via quarterly IPCS committee. The documentation of indication has remained excellent; duration has been variable but has improved since the introduction of the microbiology ward rounds, especially during the last 3 months of the year. The updated antimicrobial guidelines will be released imminently to shape change in 20/16, including changes to support further reduction of Clostridium difficile rates, antimicrobial resistance and improve antimicrobial stewardship. Use of the antimicrobial MicroGuide App and an antimicrobial prescribing sticker will be introduced to encourage appropriate use of antimicrobials within the Trust. 6. Audit Audits planned for have been mostly achieved with scores for the environmental audits maintained (Appendix 3). Some audits were deferred due to refurbishment of clinical areas. Clinical audits identified areas needing improved PVC care. Actions have been taken to change practice in line with current guidance and work streams. In the WBS regular audit of cleanliness following contractors cleaning regimes remain very favourable. 7. Policy Development A significant number of polices have been revised and reviewed during 2014/ in line with the Trust policy programme. Six will be presented for approval at the Quality and Safety Committee in June 20 (i.e. Needlestick Injury, Hand Hygiene, The Built Environment, Single Use Devices, Transport of Specimens, and Legionella Management). Several other policies are under development or review.. 8. External Campaigns The IPC programme continues to focus on the 1000 lives improvement methodologies and EPIC3 guidelines in the prevention of HCAI. Performance data and outcome measures were reported monthly via the performance dashboard, to Ward Managers, and reflected in the narrative published on the Trust s website. Hand hygiene compliance rates have varied, consistency of reporting has improved on inpatient areas. 11

15 Participation in 1000 lives plus mini-collaborative work on implementing care bundles continues. The STOP campaign is still being promoted. Provision and use of a Peripheral Venous Cannula (PVC) insertion pack containing Chloraprep and Catheter insertion packs continues. Velindre has participated in the Public Health Wales weekly reporting of Norovirus and viral respiratory infection activity introduced during the winter of Training and Development Course Infection Control Level 1 Infection Control Level 2 Target Staff Group Frequency # Staff Completed During Repetition Period # Staff who Require Combined % Compliance Corporate % Compliance VCC % Compliance WBS % Compliance All staff 3 Years % 23% 57% 90% Staff working in high risk environments Annual % 100% 32% TBC 9.1. IPCT Professional Development IPC staff have participated in annual appraisal and personal development reviews during the year Education and Training Provision of Healthcare Worker (HCW) education The team continue to provide monthly training at induction, level 1, level 2 and targeted training at VCC as well as update training for Welsh Blood Service (WBS) staff (Appendix 7). Changes to frequency, method and type of training in line with the Core Skills Training Framework have been agreed at Board level. Compliance for level 2 at VCC remains low. 10. Welsh Blood Service Progress Against Annual Program WBS has achieved their stated objectives for 2014/ including maintaining the successful WBS nurse vaccinator programme. The IPCT continue to provide training and guidance on all aspects of infection prevention and control when requested. Cleanliness reports have been good for all areas and positive verbal feedback on the Legionella assessment has been received. Objectives for The WBS continues 100% surveillance for bacterial contamination of platelet products, 12

16 with cumulative confirmed positive results compliant with regulatory requirements. Annual results for environmental monitoring of blood and components are also compliant with regulatory requirements. The WBS Change Control process now includes an impact assessment opportunity for the infection control programme so that change and innovation can be evaluated. 11. Water Safety Improvements were made to water flow in the isotope rooms in 2014 but, maintaining flushing to these rooms has been the main challenge in water management at VCC during the year. Delays in admitting patient to the rooms did occur to allow bacterial counts to be brought back within a normal range. Ownership and responsibility for the flushing in this area is yet to be fully resolved. An advisory statement from the Water Safety Group (WSG) was sent to the Executive team outlining the risks to patients in relation to management of the isotope cubicle flushing regimen. Otherwise, sporadic rises of bacterial counts at other outlets have been successfully managed, usually by flushing and/or disinfection. Response to water closures and opening due to refurbishment are ongoing. Risk assessments and the Water Safety Action Plan have been updated, and water management issues remain on the Trust Risk Register. 12. Other Issues Building and Estates The infection control team have been strategically involved in a number of projects and refurbishments at VCC during the year but refurbishment of FF ward has been a main focus. IPC input has directly led to the creation of 2 new cubicles during this project which is due to complete in July 20. This partly compensates for single rooms lost in the previous redesign and refurbishment work Decontamination A WG audit of endoscopes and probes took place on 28 th July, A positive audit outcome was received and no further actions have been recommended. The IPCT have contributed to the development of a business case and introduction of a new contract for bed and mattress management. This will ensure mattresses are sent for decontamination after use with infected cases, and routinely twice per year. 13

17 12.3. Genetically Modified Sub-Committee (GMSC) The Senior Infection Control Nurse (SICN)is a member of the Genetically Modified Sub- Committee (GMSC). This year the IPC team have enabled trials staff to be fit tested for FFP3 masks and have advised on the commissioning and use of the autoclave machine for existing trial protocols Priorities for Action In addition to the annual programme of work (Appendix 2) the priorities for the coming year include: Maintaining a low case rate of CDT cases with an emphasis on those aged 66yrs+ Using data from observational audits to identify service improvement requirements for direct patient care. Investigating new technologies /practices and procedures that will further reduce risks from IV devices. Achieving the SHS action points in the agreed timescale. Updating policies in line with the agreed schedule Maintaining consistency in care bundle compliance and mandatory schemes in partnership with departmental managers Continued improvement in prudent antimicrobial prescribing through ward rounds and RCA Exploring ways to improve levels of training across the organisation within and in collaboration with national projects. Effectively contributing to refurbishment projects and water management and safety across VCC site. 13 Conclusion The data within this report shows that there have been some significant reductions in target organisms with good performance maintained in others. The areas of most concern during the year were the VRE outbreak, the significant burden of flu cases and issues arising in water and Legionella management across the Velindre Cancer Centre site but particularly in isotope rooms. The input of the ICD over the last 6 months in doing ward rounds has been invaluable in moving forward the agenda for prudent prescribing. Good progress has also been achieved in intravenous line management and flu vaccination uptake. Good progress has been made in the updating and revision of polices in line with the Trust policy review programme. 14

18 A matrix score of 4 in the self-assessment for Standard 13 in the Standard for Health Services has been validated by the Trust s scrutiny process and affords confidence that service provision is being maintained at a high standard.

19 APPENDIX 1 Organisational Chart April Organisational Chart shows the relationship of the Infection Prevention and Control Team within the Trust Quality Safety and Governance Group/Executive Management Board Current Organisational Structure Executive Director for Nursing and Service Improvement Dr Susan Morgan Infection Prevention, Control and Standards Committee IPC Team ICD Dr Rishi Dhillon (1 ICD session) Antimicrobial pharmacist - Jaimie Leighfield (10hrs) SICN Gail Lusardi (22.5hrs) SICN Beverley Gregory (37.5hrs seconded) ICN Edwina Price (25 hrs) Surveillance Nurse Hayley Harrison Jeffreys ( hrs) Admin - Charlotte Black (20hrs) Assistant Director of Nursing Jayne Elias NWIS Cancer Services Welsh Blood Service SLA Marie Curie Cancer Centre 16

20 APPENDIX 2 Prevention and Control of Infection Annual Strategy and Related Programme April This program/strategy identifies the general infection control requirements at corporate and service level to meet the requirements of the Standards for Health Services in Wales (H&CS), AQF and the National Strategy for prevention of HCAI (HSW). Additional requirements for Velindre Cancer Centre (VCC) have been identified in more detail in a SWOT analysis and action plan. Framework HSW H&CS HSW H&CS HSW H&CS HSW H&CS AQF HSW H&CS Corporate Level Advise the Trust and IPCSC on progress of the action plan against the national strategy commitment to purpose and code of practice for HCAI reduction. Produce an annual report that reflects a summary of the years activity and IPC progress. Assist the Divisions/Services to ensure that their infection control protocols and policy reflects national guidelines. Prioritise, review and update Trust Infection Control Policies to reflect new guidelines and Trust configuration. Produce quarterly reports for the Trust and Infection Control Lead : o IPCT team report to the IPCS Responsible person/s SICN/ICD Frequency Quarterly Time scale July, October 20 Jan., April 2016 SICN/ICD yearly July 2016 IPCT As required Continuous IPCT Various depending on review date As detailed in Trust review of policy document. SICN Quarterly July, October 17

21 committee o Quality Management Framework (QMF) report to Trust Quality and Safety Committee with any exception highlight report as needed. o Trust Health and Safety Committee highlight report o Updated Action plan derived from SWOT.Complete monthly performance dashboard report for SMT and WG meeting 1000 Lives Plus Provide appropriate monthly HCAI data for ward managers. Build on improvement work to maintain CAUTI and CVC bundle compliance 1000 Lives Plus and reduce PVC infection by reducing catheter days, embedding bundles and promoting STOP. Produce ad hoc reports as required by the Trust Infection Control Executive Lead/Committee H&CS MHRA H&CS Produce report for IPCSC on decontamination issues - develop key indicators that assist Services/Divisions to monitor standards in decontamination. Audit and assess compliance with decontamination of medical devices. Liaise with operational services, Medical Devices Working Group and Procurement to ensure medical SICN IPCT monthly Monthly Monthly prevalence, ongoing surveillance and training 20 Jan., April 2016 As per schedule By the 10 th of each Month In accordance to 1000 Lives plus campaign SICN As required As required Decontamination lead IPCT Quarterly As required Quarterly MDW Revised deadline to complete risk assessment and audit to be agreed as part of HCS. Day to day advise ongoing As required 18

22 HSW HTM ACOP Legionella Management HSW H&CS H&CS H&CS/HSW/ devices purchased are suitable for use (with regard to decontamination), and advise the medical devices group appropriately Participate in, and advise the Water Safety Group about microbiological quality. Report progress on the Water Safety Action Plan and any issues arising with water management to the IPCSC. Participate in projects and advise Estates department as required on new building and refurbishment plans. Review related policies. Collaborate with Catering department with regard to reducing the risk of food contamination to service users. Review related policies. Review microbiology testing results from sandwich provider. SICN/ICD will assist services to identify IPC needs as required. SICN/ICD group meeting Quarterly July, October 20 Jan., April 2016 IPCT As required As required SICN As required As required SICN/ICD As required As required HSW 1000 lives Refine audit programme and assist service divisions in prioritising work plan for audit. Report outcomes and actions to Executive Management Board and the Quality and Safety Committee. IPCT, WBS As per divisional program and as required. April 2016 HSW/H&CS Putting things right Assist service divisions to investigate incidents and outbreaks of infection. Report outcomes and lessons learnt. Comply with mandatory outbreak surveillance and serious adverse Within the quarterly report to committee and as July, October 20 Jan., April

23 H&CS HSW incident reporting procedures. Undertake and submit annual SWOT assessment to Trust Board against the H&CS documented in Doing well, Doing better and develop a corresponding action plan To work with the Antimicrobial Pharmacist to improve antibiotic prescribing practices. IPCSC receive quarterly report on progress and actions and receive monthly prevalence data for 1000 lives plus report IPCT Annual Work Programme 20/16 Infection Control Team carry out staff appraisals using Knowledge and Skills Framework (KSF) utilising ESR (when available) get all IPCT staff up to date with Trust mandatory training. Maintain professional skills and knowledge SICN/ IPCT Lead SICN ICN s SICN, ICD, Operational Services, WBS Antimicrobial pharmacist/icd required Annual (quarterly update) Quarterly (Monthly prevalence data) January 20 July, October 20 Jan., April 2016 Area Task Lead Key Indicators Timescale Appraisals and personal development plans completed and signed off Training compliance with mandatory topics Attendance at National forums, IPS conferences, study days and related meetings. Participate if IPS activities e.g. research and development, national study days, workshops. February 2016 March 2016 As they occur Working maintain effective SICN Effective infection control July 20 20

24 relationships Service development activity Policy development working with WBS and Hosted organisations continue to provide an SLA with Marie Curie Cancer for provision of infection control service. provide infection control input into new build and refurbishments. update Trust intranet/internet webpage for service users and Trust staff. review the policies identified in the Trust policy review action plan. develop new policies as and when new risks are identified or in accordance with SICN/ IPCT Lead IPCT SICN IPCT IPCSC SICN IPCT programme in place for both services Review service provision and actions taken during the year to ensure both parties satisfied with arrangements Evidence of attendance at project meetings or of advice given and Infection Control standards are met. Report within quarterly team report to IPCSC WebPages populated and accessible via intranet/internet with up to date information and events Policies reviewed, approved and disseminated. Staff have access to information to facilitate evidence based practice and risk reduction. Policies have been reviewed and ready for approval. Quarterly report on progress to IPCSC July 20 As required Ongoing with annual review March 2016 Various review dates until March March 2016 Ongoing 21

25 national guidelines. audit the implementation of policies, clinical care and the environment according to the annual audit programme and as need arises (Appendix 6) To report on compliance scores for all areas, to assist managers to develop action plans and review these to ensure actions completed. To achieve 80% or more for all departments. As audits are done. Programme completion by April 2016 Audit Surveillance and hospital reduction targets Facilitate twice monthly observational audits of hand hygiene on wards and monthly audits in outpatient areas at VCC. Annual audit of all HH facilities maintain surveillance schemes according to the SWOT analysis and action plan 2014/20 and IPN s IPCT ICD/SICN/WBS lead Quarterly report to IPCSC Compliance with Hand Hygiene audits for WHO and 1000 lives plus. Compliance score 95% or more for all staff groups. Monthly report to 1000 lives plus Board 100% Compliance with Mandatory Schemes Achievement of infection reduction targets Ongoing Yearly Monthly report to 1000 lives plus Board on HH compliance Ongoing April

26 local WBS plans Proactive approach to antimicrobial prescribing in collaboration with pharmacy and clinicians. Antimicrobial Pharmacist Evidence of data analysis and actions against surveillance data. Monthly data report to inpatient areas Quarterly and Monthly reports to Q&S divisional meeting Ongoing Training Provide data and feedback to clinical staff Provide: All staff induction training to VCC and WBS induction Level 1 training VCC all clinical staff Level 2 training and updates to all services Support staff undertaking the infection control champions e- SICN for WBS IPCT for all others Attendance records Good compliance with training (data supplied by training department) Quarterly report to committee Evidence of positive session evaluation Evidence of improved awareness of infection prevention when areas audited Ongoing 23

27 Decontamination learning programme Provide adhoc training for contractors Provide adhoc and target training for specifics staff groups or to deal with identified risks Advise and assist Services/Divisions to monitor standards in cleanliness and decontamination. Advise on decontamination issues in the procurement and use of medical devices SICN as Lead and WBS IPCT Acceptable cleanliness scores against the National Standards for cleanliness Attendance at operational and Cleanliness standards groups for VCC Completed PPQ s for all new devices introduced. Attend medical devices and theatre users working groups. Quarterly report to committee Ongoing monthly As required Ongoing As required Monitor and review SLA for Sterile Services with Llandough hospital ICN s SLA agreed and signed by both IPCT and Theatres. January

28 Incidents and Outbreaks report and/or investigate incidents as necessary and enter information in the Datix system Report patients with severe or untoward outcomes from HCAIv to the SCIF group Participate in RCAs where necessary when a HCAIv are identified Notify WG of any HCAI death SICN IPCT IPCT SICN/Executive Lead SICN/ICD Review of all infection related incidents forms. Evidence of investigations and actions taken documented e.g. SBAR reports Referral and submission of data on serious cases to SCIF Attendance at SCIF. Completed RCA Completion of SUI forms to WG for outbreaks as well as closure forms. Documented actions where are incident occurs. As required/ Ongoing monthly As required As they occur Identify and manage possible infectious incidents or outbreaks and report outcomes and lessons learnt. ICN s Completed risk assessments and action plans. Reporting risk and attendance at to Risk Management and Health and Safety committees. ICN s to attend Health and Safety mandatory training. Quarterly report to IPCSC Quarterly report 25

29 Complete risk assessments where significant risk identified Information Technology Antimicrobial prescribing Appropriate level of training in risk and health and safety management Comply with Trust policies on data protection and information governance. Facilitate the introduction of IC Net if approved by WG Continue to monitor /improve infection control aspects of CANISC Improve antimicrobial prescribing practices IPCT Antimicrobial pharmacist/icd Complete Trust risk assessment of data control. IPCT staff to complete mandatory training for information governance Auditing in-patient antimicrobial prescriptions to ensure 100% have the indication and a duration or review date documented by the prescriber on initiation and that 100% of antimicrobials have documented As per training requirements Ongoing monthly Dashboard/100 lives 26

30 review by a prescriber after 48 hours Teaching session offered to the SpR training rota for the year 20/2016. Before March 2016 Key: HCS Standards Health Care Standards HSW Healthcare Associated Infections -A Strategy for Hospitals in Wales 1000 Lives Lives plus Programme for Patient Safety MHRA Medicines and Healthcare products Regulatory Authority AQF Annual Quality Framework IPCSC Infection Prevention, Control and Standards Committee SICN Senior Infection Prevention and Control Nurse ICD Infection Control Doctor IPCT Infection Prevention and Control Team WG Welsh Government 27

31 APPENDIX 3 Numbers of Clostridium difficile in inpatients in Velindre NHS Trust for the period 01/04/2014 to 31/03/20 Progress against baseline year (April March 2014) 28

32 APPENDIX 4 Velindre Cancer Centre - Infection Control Audit programme Results up to and Including March 20 The Infection Prevention Society (IPS) Audit Tool audits all aspects of infection control. When a clinical area is audited the management of and the cleanliness of the clinical environment and patient equipment, the management and safe disposal of linen, waste and sharps, the provision and correct use of personal protective clothing, the provision of hand hygiene and isolation facilities and staff knowledge of and adherence to hand hygiene and isolation guidelines are audited. The ward kitchens and the clinical practices governing invasive techniques are also audited using the IPS tool. Please see attached complete list of audits using IPS tool. Some audit tools have been developed by the IPS team for example the bare below the elbows audit and MRSA screening. Hand hygiene compliance is monitored using the University College London Observational tool and the care bundles are based on the national templates which been developed in collaboration with nursing staff. The audit programme is flexible and responds to issues as they are identified, some audits are deferred due to refurbishment or re-location of wards and units. The aim once refurbishment and re-organisation is completed will be to audit the wards, the ward kitchens, the day case chemotherapy units and the theatre on an annual basis. The outpatient department, radiology, radiotherapy and nuclear medicine will be audited every two years. Audits that fall below 75% compliance will be re-audited within six weeks. Clinical area Active Support Unit (ASU) First floor ward (FF) ASU/FF Ward combined April 2011 March 2012 Mar 96% Mar? April 2012 March 2013 Marie Curie Holme Towers hosted on ASU (ASU patients moved to First Floor Ward) ASU patients combined with FF patients see below - Aug 92%(Brought forward due to merger of two wards) April 2013 March 2014 closed - - Under refurbishment April 2014 March 20 Area now occupied by PMW renamed Chemotherapy Inpatient Unit (CIU) June/July 29

33 Princess Margaret ward (PMW) Nov 92% March 93% Deferred - ward relocated to what was ASU and renamed CIU June/July FF Ward kitchen May 96% Mar 93% re-audit Apr 100% June/July PMW Ward kitchen May 96% Mar 73% re-audit Apr 100% June/July ASU Ward kitchen May 74% Closed closed June/July (Now CIU) Rhosyn Day Unit (RDU) Feb 98% Deferred due to reorganisation Aug 95% Oct/Nov Chemotherapy Day Unit (CDU) Feb 96% Deferred due to reorganisation Oct 95% Oct/Nov Chemotherapy Outpatients Dept (COPD) Feb 97% Deferred due to reorganisation Oct 95% Oct/Nov Chemotherapy Trials Unit (CTU) Dec 96% Dec Mattresses - - Jan - see report - Theatre Sept 86% - Aug 93% Sept Main Outpatients Radiology June 81% Sept 97% Nov 91% under July/Aug refurbishment - Jan/Feb. 30

34 Radiotherapy Nuclear Medicine Dec - - Jan/Feb. 97% - - April 99% Jan/Feb. Marie Curie Holme towers Jun 96% (hosted on ASU) - - All depts. - Bare Below the Elbows - Aug - 93% Aug The management and disposal of clinical waste. Staff kitchens Oct 54% - report available March - all March clinical areas, results currently outstanding - - Staff Toilets Feb - report available - - Sharps audit - Nov Frontier Ltd report available Macerators - - March Vernacare Ltd, report available - Clinical practices ASU - Non tunnelled venous catheters Sept 91% Sept 91% Mar 100% Monthly care bundles Audits FF - Non tunnelled venous catheters PMW - Non tunnelled Sept 91% Sept 91% Sept 90% Mar 100% Monthly care bundles Audits Sept 90% Mar 100% Monthly care bundles 31

35 venous catheters COPD - Non tunnelled venous catheters CDU - Non tunnelled venous catheters Radiotherapy Day Unit Non tunnelled venous catheters ASU - Peripheral Intravenous Lines FF - Peripheral Intravenous Lines PMW - Peripheral Intravenous Lines COPD - Peripheral Intravenous Lines CDU - Peripheral Intravenous Lines Radiotherapy Day Unit Peripheral Intravenous Lines Sept 100% Sept 100% Sept 82% Sept 91% Sept 91% Sept 100% Sept 100% Sept 100% Audits Sept 100% Mar 100% Monthly care bundles Audits Sept 100% Mar 100% Monthly care bundles Audits Sept 100% Mar 100% Monthly care bundles Audits Sept 91% Mar 100% Monthly care bundles Audits Sept 91% Mar 100% Monthly care bundles Audits Sept 91% Mar 100% Monthly care bundles Audits Sept 100% Mar 100% Monthly care bundles Audits Sept 100% Mar 100% Monthly care bundles Audits Sept 100% Mar 100% Monthly care bundles Audits ASU - Urethral Catheter Management Sept 100% Sept 100% Mar 100% Monthly care bundles Audits FF - Urethral Sept Sept 94% Mar 100% Monthly care 32

36 Catheter Management PMW - Urethral Catheter Management FF/ASU Management of enteral feeding lines PMW Management of enteral feeding lines FF/ASU Isolation PMW Isolation 100% bundles Audits Sept Sept 100% Mar 100% Monthly care 100% bundles Audits May/June May/June May/June May/June Weekly and monthly audits MRSA screening on admission compliance Observational hand hygiene audits Urethral catheter Care Bundles Peripheral vascular cannula Care Bundles Ward manager and Operational Services Combined Environmental audit Ongoing on a monthly basis see monthly reports Ongoing on a monthly basis see monthly reports Ongoing on a monthly basis see monthly reports Ongoing on a monthly basis see monthly reports Ongoing on a monthly basis see monthly reports IPCD/NP/VEL/April

37 APPENDIX 5 IPCT Staff Training Record Date Location No. of Attendees Course Name Start Duration Finish Trainer (Initials) 24 April 2014 VCC 34 Infection Control - L2 12:00 13:00 GL 28 April 2014 VCC 14 VCC Induction 10:30 11: HJ 08 May 2014 VCC 2 M&S Day 3 (Catheter Update) :30 17:00 GL 22 May 2014 VCC 30 Infection Control - L2 12:00 13:00 GL 09 June 2014 VCC 8 Infection Control - L1 10:30 11: NP 19 June 2014 VCC 17 Infection Control - L2 12:00 13:00 NP 24 July 2014 VCC 13 Infection Control - L2 12:00 13:00 GL 28 July 2014 VCC 5 Infection Control - L1 10:30 11: NP 21 August 2014 VCC 7 Infection Control - M&S 12:00 13:00 GL 25 September 2014 VCC 20 Infection Control - L2 12:00 13:00 GL 17 October 2014 VCC 10 Fit Testing HJ 23 October 2014 VCC 7 Infection Control - L2 12:00 13:00 GL 20 November 2014 VCC 16 Infection Control - L2 12:00 13:00 BG 21 November 2014 VCC 6 Fit Testing 11:30 13:00 External 24 November 2014 VCC Infection Control - L1 10:30 11: NP 11 December 2014 VCC 8 Infection Control - L2 12:00 13:00 GL January 20 VCC 9 Infection Control - L2 12:00 13:00 GL 28 January 20 VCC 5 Infection Control - L1 (Induction) 11:00 12:00 NP 19 February 20 VCC 12 Infection Control - L2 12:00 13:00 GL 10 March 20 VCC 4 Infection Control Updates 12:00 14:00 NP 19 March 20 VCC 9 Infection Control - L2 12:00 13:00 GL 25 March 20 VCC 5 Infection Control - L1 10:00 11:00 NP 26 March 20 VCC 7 M&S Day 3 (Catheter Update) :30 16:30 GL NUMBER OF STAFF TRAINED:

38 Trust Board Cancer Annual Report Meeting Date: 28 th January 2016 Author: Sponsoring Executive Director: Report Presented by: Committee/Group who have received or considered this paper: Ashleigh O Callaghan, Planning and Performance Manager Carl James, Director of Planning and Performance Andrea Hague, Director of Cancer Services Velindre Cancer Centre Senior Management Team Executive Management Board Planning and Performance Committee Trust Resolution to: (please tick) Approve: Endorse: Discuss: Note: Recommendation: The Trust Board are asked to APPROVE the Cancer Annual Report for submission to Welsh Government and publication on the Trust website. This report supports the following Trust objectives as set out in the Integrated Medium Term Plan: (please tick) Equitable and timely services Providing evidence based care and research which is clinically effective Supporting our staff to excel Safe and reliable services First class patient /donor experience Spending every pound well

39 2 [Report Title] 1. Introduction / Background: In 2012, the Minister for Health and Social Services launched Together Against Cancer- A Cancer Delivery Plan, which outlined what people can expect from cancer care by The link to this plan can be found below: The key message in the document is that Wales should aim to be amongst the best in Europe for cancer treatment and outcomes. It aims to achieve this through the following domains: Meeting people s needs (Person Centred Care) Focus on preventing cancer and early detection Delivering fast, effective treatment and care Improving information Caring at the end of life Targeting Research The Plan provides a framework for action by Health Boards and Trusts by setting out Welsh Government s expectation of NHS in Wales to tackle cancer: People of all ages to have a minimised risk of developing cancer and where it does occur, an excellent chance of surviving, wherever they live in Wales Wales to have cancer incidence, mortality and survival rates comparable with the best in Europe The following indicators are used to measure success: Cancer incidence rates (European Age Standardised Rates) Cancer mortality rates (European Age Standardised Rates) 1 and 5 year cancer survival rates Improvements have been seen nationally against all of these indicators- as a tertiary centre, VCC is not directly responsible for these population outcomes but does provide a big contribution, particularly in the domain of delivering fast and effective treatment and care. 2. Timing: This report is an annual report and is a retrospective look back of the year to date. 3. Description: Together for Health - A Cancer Delivery Plan was designed as a framework for the individual Health Boards to be held to account on the outcomes they deliver for their populations through the planning innovation and delivery of high quality, effective services in partnership. Page 2

40 3 [Report Title] Velindre NHS Trust, as a tertiary centre who is not responsible for a local population, has not been specifically asked to produce a cancer annual report, but the Division has decided to develop its own annual cancer report. The template of the report is prescribed by Welsh Government, and the Cancer Centre are asked to include specific information under each of the domains mentioned within the section above- thus, this report is not designed as a comprehensive report of the Cancer Centre itself, but a report outlining progress against the domains within the WG Together Against Cancer strategy. The Cancer Centre have made progress this year in all of the key domains, and the main achievements are summarised within the executive summary at the front of the document. 4. Financial Impact: There are no financial considerations in respect of this report. 5. Quality, Safety and Patient Experience Impact: This report highlights the excellent work undertaken in the areas of quality improvement and patient experience. 6. Considerations for Board / Committee: The Board are asked to consider the progress made against all the relevant Cancer Delivery Plan domains, particularly around the advances in radiotherapy technology and techniques, improvements in how we listen to and act upon the patient voice, the many initiatives listed under the meeting patients needs section including increased support for carers, initiatives around improving the experience for dementia patients and increased support in terms of accessing advice regarding benefits. Also notable is the continued excellent work undertaken by the palliative care team. 7. Next Steps The Trust Board are asked to APPROVE the Cancer Annual Report for submission to Welsh Government and publication on the Trust website Page 3

41 Velindre Cancer Centre: Cancer Annual Report 20 1 Draft v.2

42 Contents Contents Executive Summary Introduction Background Our challenges- an overview Cancer Incidence, Mortality and Survival Overview Our Approach to Tackling Cancer Detecting Dancer Quickly Delivering fast, effective treatment and care Access and cancer waiting times Mortality Rates following treatment National Standards Participation in Peer Review High quality clinical research Tissue donations to the Wales Cancer Bank Meeting People s Needs Patient experience The Framework in Action Living with the impact of cancer Metastatic Cancer Patients Caring at the end of life Improving Information Conclusion and Focus for the next 12 months and beyond

43 Executive Summary The Cancer Delivery Plan, published by Welsh Government in 2012, provides a framework for action by Local Health Boards and NHS Trusts. It sets out the Welsh Government s expectations of the NHS in Wales to tackle cancer in people of all ages, wherever they live in Wales and whatever their circumstances. The Plan is designed to enable the NHS to deliver on their responsibility to meet the needs of people at risk of cancer or affected by cancer. It sets out: The population outcomes expected The outcomes from NHS treatment expected How success will be measured and the level of performance expected Themes for action by the NHS, together with its partners. Velindre NHS Trust shares the Welsh Government vision that the following outcomes will be achieved for our population; People of all ages to have a minimised risk of developing cancer and, where it does occur, an excellent chance of surviving, wherever they live in Wales. Wales to have cancer incidence, mortality and survival rates comparable with the best in Europe. Recent data and trends indicate that the incidence of cancer is increasing; Wales, as with the rest of the UK, is tracking a steady increase in the number of all cancers registered per 100,000 population per year. However, it is encouraging to know that in Wales; Mortality from cancer is decreasing The number of people living with and after cancer treatment is increasing Survival following cancer is improving VCC, as a specialist tertiary treatment centre, contributes towards the achievement of the above outcomes. However, achievement of these outcomes is dependent upon primary, secondary and tertiary care working effectively together, alongside the third sector, in order to progress action against the key areas for improvement. 3

44 We have made progress this year in all of these key areas, and our main achievements are summarised below; Detecting cancer quickly We have engaged in the Macmillan Primary Care Oncology programme which will provide an excellent vehicle for strengthening the role of primary care and improving communication links; as part of this programme we have appointed to a GP lead facilitator post for VCC. We have continued to work in partnership with the health boards in the development of the hub and spoke Acute Oncology Service model. Delivering fast, effective treatment and care We have successfully reduced the current waiting times target for radical radiotherapy treatment from 28 days to 14 days, initially for those cancer sites in which this time reduction would be most clinically beneficial; head and neck cancer, lung cancer and neuro-oncological cancers. We have regularly achieved compliance with the radiotherapy and chemotherapy waiting times targets despite increasing demands and pressure upon the service. We have undertaken a number of service improvement initiatives to focus improvements to the chemotherapy treatment pathway and to ensure that services are efficient, effective and patient focussed. We have piloted a chemotherapy toxicity screening tool We have brought a number of services in to clinical use in line with agreed business cases and implementation plans including: o A further increase in the number of patients receiving IMRT o Implementation of SBRT with the introduction of a service to treat liver metastasises o Increased used of IGRT through clinical trials and local initiatives o A new service for patients receiving brachytherapy for gynaecological cancers which involves image guidance for the first time o An increase in patients having access to the most advanced image guided techniques and technologies. We have continued to recruit effectively to both drug based and radiotherapy based clinical trials. We have secured 3 million pounds of charitable funds for radiotherapy developments. We have launched a Trust Research and Development Strategy, focussing on Radiotherapy 4

45 Meeting peoples needs We continue to regularly undertake our own patient experience surveys on a monthly basis and are committed to putting action plans in place to address issues that are raised from both the national and our local surveys using the you said, we did approach. Our Patient Experience manager is developing a number of methods for patients to feedback their experience to suit their preferences, including the use of comment cards and social media. We are currently rolling out a stratified patient focussed pathway which will ensure patients are supported in living with the impact of their cancer. We have significantly increased the support that the centre provides for carers Our Welfare Rights Officer was responsible for patients and their families being able to access over 1.5 million in benefits. We have worked in collaboration with Cardiff and the Vale University Health Board to develop a pathway for patients with drug and alcohol dependencies. All patients and professionals in the health boards and primary care teams can access the cancer information support programme facilitating better care in the community and ensuring that patients are given the first opportunity to self manage and access support. We have worked on strengthening the handover of patients across organisational boundaries. Research is a priority for the Trust and Velindre continues to deliver high quality projects that provide cutting edge therapies and treatments to our population, and the knowledge gained will ultimately benefit future generations. We have launched a children s book Caring for my family with cancer Caring at the end of life 5 Seven day/week specialist palliative care nursing has shown significant benefits for patients, families and staff. Integrated Care Priorities documentation is being used to provide best supportive care for those patients in the final stages of life and VCC are participating in the annual audit to measure quality. The palliative care team have worked to increase the number of patients who can access their preferred place of death. The palliative care team have strengthened links with the clinical psychology team to jointly manage patients and relatives suffering extreme distress and grief, including bereavement follow up service. We have focussed on delivery of the End of Life Care Delivery Plans set out by Welsh Government We have implemented McKinley syringe-drivers in all clinical settings

46 We have improved our IT infrastructure We have developed the new Care Decisions at the End of Life guidance Improving information We have continued to make improvements to the information we provide our patients We have further increased our chemotherapy education sessions We have developed a programme of support for carers. Priorities We ve had an extremely busy and fruitful 12 months at the cancer centre, and staff have gone the extra mile to provide not only the very best care but also innovations, new technologies and advances in patient care. There is still much that must be done if the outcomes of our population are to be improved. It is recognised that early diagnosis and rapid access to treatment are essential if patient outcomes are to improve in Wales. This will require close working between us as a tertiary centre and the Local Health Boards to ensure that timely treatment within the required cancer standard timelines are delivered. We will work with colleagues to support the implementation of service improvement methodologies to improve patient journey through all pathways, both the 31/62 cancer waiting times standards and for subsequent treatments. We will continue to use the results of our patient feedback to focus improvements. One of the key findings of the National Patient Experience Survey was the need for improved access to support for cancer patients. We are currently working to address gaps in our Clinical Specialist Nurse provision across our tumour sites, working closely with partners in the third sector. One of our key challenges in VCC is the lack of physical space and capacity to develop services. The increasing demand for services, the ageing condition of the cancer centre, the lack of physical space to treat people, and the need to keep pace with advances in treatment and technology have made the development not only of a new facility, but a new service model, a high priority for the Trust. We want to work closely with partners to develop a set of services which are fit for the 21 st Century and support them with a world class cancer campus which brings together the best possible patient care and environment and to develop cutting edge research which would enable improved clinical outcomes. This is a very exciting time for VCC as our above vision is becoming closer to realisation. Velindre NHS Trust submitted the Transforming Cancer Services (TCS) Strategic Outline Programme (SOP) to the Welsh Government on 23 rd October The Trust received Ministerial approval of the SOP on 27 th January 20 and in doing so we were given approval to proceed in further developing the TCS 6

47 programme, with a requirement to focus on the proposed service model, up to the completion of a Key Stage Review of the Programme. The Key Stage Review was successfully completed from 29 th June 1 st July 20. The Trust received ministerial approval on the 24 th July to proceed within the development of an Outline Business Case (OBC) for a new VCC. In parallel the Trust agreed to update the Programme Business Case (PBC) relating to the overarching clinical service model. The programme aims to achieve the following Investment Objectives: To provide patients with high quality services that deliver optimal clinical outcomes. To continuously improve clinical outcomes by being a leader in research, development and innovation. To achieve all national cancer and clinical standards and practice which are considered to be best in class internationally. To deliver cancer services to the population in the most cost effective, efficient and productive manner. To deliver a high quality and sustainable service. Central to the achievement of the Investment Objectives is the development of an integrated service model which focuses on improving the quality for individual patients, families and carers by ensuring that services are designed around their needs and that their views and choices are the organising principle for the delivery of care i.e. placing the patient at the centre of everything we do. The proposed service model has been developed in accordance with the principles of co-production and Prudent Healthcare and Welsh Government policy on end of life care set out in Together for Health. The model will operate as an integrated network of services organised around a range of evidence based pathways. The provision of seamless services will require all organisations to work together to develop a set of services which provide patients with all the care, support and information they require at the earliest opportunity in their journey. The proposed service model operates on a hub and spoke principle. This exciting development, together with the development of the Velindre Radiotherapy Strategy is another step towards Velindre s aspiration to provide high quality care and outcomes for the people of Wales, comparable with the best in Europe. 7

48 1.0 Introduction Welcome to the Velindre Cancer Centre (VCC) Cancer Annual Report 20.This report is an opportunity to share with the public a number of good news stories and developments achieved within the last year under the domains of the Welsh Government cancer delivery plan. It is also a chance to outline areas for further development and also priorities for the future. Our vision is that VCC will be recognised locally, nationally and internationally as a renowned organisation of excellence for patient and care, education and research. We have a set of objectives to help us reach this vision; Equitable and timely services: providing patients and donors with access to services according to their clinical needs in a fair way Safe and reliable services: prevent all avoidable harm to patients and donors Providing evidence based care and research which is clinically effective: identifying and using the most effective treatment, drugs and technology to get the best outcome Supporting our staff to excel: providing our staff with the support, encouragement and environment to achieve their potential Spending every pound well: ensuring everything we do adds value for patients, donors and partners We share, and contribute to the Welsh Government vision set out within the Cancer Delivery Plan, that the following outcomes will be achieved for our population; People of all ages to have a minimised risk of developing cancer and, where it does occur, an excellent chance of surviving, wherever they live in Wales. Wales to have cancer incidence, mortality and survival rates comparable with the best in Europe. This report outlines the progress that we, in collaboration with our partners, have made in the last 12 months in our journey towards achieving this vision, as well as highlighting areas where more work is required. 8

49 This report aims to build on the Cancer Centre s progress since the previous Cancer Annual Report, which was published in December It has been the aim of this report to include the most up to date and appropriate data according to each measure. Where possible, data has been included up to end of October 20. However, there are some measures in which it is more appropriate and meaningful to track improvements over a number of years, and as such, for some measures, data is analysed by financial years. 9

50 2.0 Background 10

51 Velindre Cancer Centre (VCC), a division of Velindre NHS Trust, is the largest of the three cancer centres in Wales, and one of the ten largest regional clinical oncology centres in the United Kingdom. We are the only provider of non-surgical specialist cancer services to the catchment population of 1.5 million across South East Wales, from Chepstow to Bridgend and from Cardiff to Brecon. For VCC the South East Wales catchment population also includes the County Borough of Bridgend and lower part of Powys. We are also the only provider of some specialist services (e.g. Brachytherapy, Stereotactic Radiotherapy) to the people of South Wales. Although VCC is the main focus for service delivery, the non-surgical management of cancer patients across South-East Wales is complemented by peripheral outpatient clinics and by outreach chemotherapy clinics, led and managed by our staff. Our challenges- an overview The major challenges we face are: Increasing cancer incidence and social deprivation Increasing complexity of treatments and technologies Patients are living longer with cancer The NHS is under increasing financial pressures Incidence and Social Deprivation There is evidence of a positive correlation between deprivation and cancer incidence. Cancer incidence in the most deprived areas is 21% higher for men and 14% higher for women than reported for men and women from affluent areas. This is an issue of great concern for the South East Wales population we serve, as this catchment area contains some of the highest levels of social deprivation within Wales. The relatively high concentrations of deprived areas in the South East Wales Cancer Network area combined with a rising incidence of cancer points to a continuing need for investment to improve and expand cancer services provision at VCC. 11

52 Increasing complexity of treatment and technology As well as the rising incidence of cancer in Wales, there have also been considerable developments in clinical treatments and technology which has resulted in an increase in both the range and complexity of treatments that are available to patients. For example in radiotherapy, patients who used to be treated with simple planned treatments are now treated with highly conformal multi-field treatments including intensity modulated and image guided radiotherapy (IMRT/IGRT) which are now considered standard treatments for certain tumour types. Another example is in the field of lung cancer where patients may now be offered 2-3 lines of chemotherapy and targeted systemic treatments, where previously there were very few therapeutic options available. The challenge for us as a service provider is that these new treatments often take longer to plan and to deliver which in turn has an impact on the increasing resources (capital and human) required to treat patients. Patients living longer with cancer When planning and delivering our services, we need to take into account the increasing number of people surviving and living with or beyond cancer, rising at an estimated 3.2% per year (Maddams et al, 2008).It is very important that people living with and beyond cancer, their carers and their families have the support and services they need to take an active and leading role in their recovery, rehabilitation or ongoing care. Whilst these challenges are indeed significant, we at VCC are committed to providing the best possible services to patients in South East Wales, and see a number of opportunities to improve patient outcomes, which we will discuss in detail later in this report. 12

53 3.0 Cancer Incidence, Mortality and Survival Overview We are using three outcome indicators to measure and track how well cancer services are doing over time. These are: Cancer incidence rate Cancer mortality rate One and five year survival rate Outcome One Cancer incidence rate This measures how many new cases of cancer are found each year and tells us how well we are doing at preventing cancer in Wales. If we are achieving our objectives, we would expect to see over time: A slower rise in the rate of increase compared with what might be expected to happen in line with past experience. A reduced gap between the most and least deprived areas of our region. Incidence rates comparable with the best in Europe 1. Cancer Incidence Rates- European Age Standardised Rate Wales In addition, a recent WCISU report (2014) identified that the trend in the number of new cancer cases each year is still going up. There were 10% more new cases of cancer diagnosed in 2012 compared to the rate ten years ago. 1 Those countries with cancer registration and mortality covering the whole population 13

54 In terms of age, the number of cases in 2012 was higher than 2003 for all age groups from 60 years and older, except for the years group, which was only marginally lower. The largest rise of 34% was in the 65 to 69 age group. By 2012, two-thirds of all cancer cases were diagnosed in people aged 65 and over. There was little change in most age-specific cancer rates per 100,000 with no clear trends. This suggests that the increase in number of cases we observed is partly explained by people living longer and the ageing of the population. There is evidence that cancer becomes more common in more deprived areas. The incidence rate of cancer is 20% higher in the most deprived areas of Wales, compared to the least deprived that equates to around 80 extra cancer cases for every 100,000 people living in the most deprived areas (WCISU, 2014). As a specialist tertiary centre, our catchment area covers 2 Local Health Boards that have the highest level of deprivation in Wales. Approximately 40% of VCC s referrals are from Aneurin Bevan University Local Health Board and 20% from Cwm Taf Local Health Board, and given the link between social deprivation and increased cancer incidence, this presents us with a significant challenge in terms of demand. For the first time, bowel cancer is the most common cancer (WCISCU, 2014).This is thought to be due to an increasingly aging population. Increased awareness and the introduction of bowel screening may also be contributory. It has been predicted that referrals for common cancers will continue to rise over the forthcoming years, because: Common cancers such as prostate, large bowel and breast are being diagnosed in early, curable stages due to improved screening and education The population in Wales is rising year on year There are an increased number of elderly cancer patients surviving longer following diagnosis. For example, the Wales Cancer Intelligence and Surveillance Unit (WCISU) predicted that cancer incidence of the prostate, large bowel and breast in Wales will rise by 49%, 34% and 32% respectively by 20 compared to the reported levels in These tumour sites currently represent approximately 60% of workload at VCC and thus will have a significant effect upon the future demand for services at VCC. Outcome Two Cancer mortality rate This tells us how many people die from cancer each year 2. If our strategy is successful, over time we would expect to see: A continued fall in the rate of deaths from cancer. A reduced gap between the most and least deprived areas of our region. Mortality rates comparable with the best in Europe. 4 2 Expressed as an age standardised rate to allow comparisons between years and countries 14

55 Cancer Mortality Rate European age standardised cancer mortality rates (EASR) per 100,000 population under 75 years of age Wales There has been a significant decrease in mortality over the last 10 years. By 2012, mortality was around 174 per 100,000 people - that s 11% less than ten years before. This increased survival has led to a higher recurrence rate, requiring patients to have access to further lines of treatments that in the past have not been available to them. This has an impact on demand for us, as a tertiary specialist cancer centre. Cancer incidence is around 16% higher in men than women, but mortality is over a third higher (WCISU, 2014). Lung cancer accounted for almost 22% of all cancer deaths in The cancer mortality rate between the populations of the seven health boards varies. The mortality rates of the populations of the Hywel Dda and Powys areas are lower than the all Wales mortality, and Cwm Taf and Aneurin Bevan populations are higher. We need to take this in to account when planning our services, given that broadly 60% of our referrals are patients who reside in Aneurin Bevan and Cwm Taf. Outcome Three One and five year survival rate This measure shows us how many people are alive one and five years after they have been diagnosed with cancer. Survival is likely to be longer if the disease is detected early, the person is in relatively good health and the treatment is effective. If our strategy is successful, over time, we would expect to see: An increase in 1 and 5 year survival rates. A reduced gap between the most and least deprived areas of our region. 1 and 5 year survival rates comparable with the best in Europe. 4

56 All Wales- 1 year survival rates Percentage survival All Wales- 5 year survival rates Percentage survival Both 1 and 5 year survival rates are improving over time. As a specialist tertiary cancer centre, we play an important role in contributing to these three outcomes for our catchment population, through providing the best possible definitive and subsequent treatment for patients thereby providing the best chance of a cure. However, treatment is most effective and there is increased chance of survival if cancer is diagnosed as early as possible. Survival rates are also dependent on changing pattern of cancer types in the population, having access to the best treatments available for those who need them, age at diagnosis and health of the population in general (WCISU, 2014). Thus, collaboration across the health system is required in order to improve survival. In more deprived areas the chance of survival gets worse for both one year and five year relative survival. In Wales, one year survival in the most deprived areas is 17% less than in least deprived areas (WCISU 2014). For five year survival the difference is wider the chance of survival is 28% less in the most deprived areas compared to the least deprived. This is something that we at VCC and our partners need to take in to account when planning our services, to ensure early diagnosis and access to the best treatments for all of our population. 16

57 4.0 Our Approach to Tackling Cancer In 2012, we wrote our first Cancer Annual Report highlighting how we aim to deliver our responsibility to meet the needs of the people affected by cancer. The Welsh Government published Together for Health a Cancer Delivery Plan. It sets out: The population outcomes expected The outcomes from NHS treatment expected How success will be measured and the level of performance expected. Due to the nature of non-surgical cancer services, all the performance measures are reliant upon team working between the Local Health Boards and VCC (VCC). We have a key role in helping health boards achieve some performance measures for their patients, for example, access to trials, collection of tissue samples. Our priorities for cancer are: Detecting cancer quickly- Cancer is detected quickly at initial presentation and when it recurs. Delivering fast, effective treatment and care - People receive fast, effective treatment and care so they have the best chance of cure or improved quality of life. Meeting People s Needs - People are placed at the heart of cancer care with their individual needs identified and met so they feel well supported and informed, able to manage the effects of cancer. Caring at the End of Life - People approaching the end of life feel well cared for and pain and symptom free. Supported through- Improving Information This third annual report sets out the progress we have made against each of our priorities. 17

58 5.0 Detecting Cancer Quickly Performance Measure 1- The percentage of patients diagnosed at each stage 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% NR Stage 1 Stage 2 Stage 3 Stage As a specialist treatment centre, we do not have a specific role in diagnosing and detecting of cancer however, we are keen to work in collaboration with partners to improve the detection of cancer. Macmillan are establishing a Primary Care Oncology Programme of work with the appointment of GP Facilitators in all Health Boards and VCC. This will provide an excellent vehicle for strengthening the role of primary care and improving communication links. We are fully involved in the Programme discussions; The Lead GP has been recruited and is ensuring that they are fully linked in to the Transforming Cancer Services Programme. The stage at which patients are diagnosed is important. Whilst earlier diagnosis does not guarantee a better cancer outcome, it does open up a greater range of treatment options, many of which impact less negatively on a person s quality of life (CRUK, Saving lives, averting costs, 2014). We at VCC do have a role in the detection of secondary cancers. A primary cancer is where a cancer starts. Sometimes cancer cells can break away from the primary cancer and settle and grow in another part of the body. This new cancer growth is called secondary cancer. Secondary cancers are made up of the same type of cells as the primary cancer. So, a patient that has bowel cancer that has spread to the liver has primary bowel cancer with secondary cancer in the liver (CRUK website, 2014). 18

59 Development of Acute Oncology Services VCC has played an integral leadership role in the development of a hub and spoke Acute Oncology Service (AOS) for South Wales. An Acute Oncology Service refers to a service which brings together the expertise of clinicians in emergency medicine, acute medicine and cancer. Patients with cancer often develop symptoms resulting from a new cancer that might not have been diagnosed (newly presenting cancers) or may experience complications of their cancer or cancer treatment. Development of AOS is fundamental to ensuring that patients are assessed by the most appropriate person, diagnosed as quickly as possible and receive treatment rapidly. We formalised our Acute Oncology Hub in September 2012, with the aim of ensuring patients presenting with acute symptoms within VCC are treated rapidly and appropriately, and also to utilise expertise and experience by providing clinical support and advice regarding patients awaiting investigation for cancer diagnosis in outlying hospitals. We have worked in collaboration with and Aneurin Bevan University Health Board (ABUHB) in the development of their local Acute Oncology Service, launched in August 2013, which is the first pilot spoke within the South Wales model. Clinicians in ABHB have been able to link in with clinicians from VCC through the AOS hub and daily meetings, and gain specialist oncology input where required. ABHB have already been able to show clear outcome based improvements in patient care due to the streamlining of pathways and improved clinical management of acute oncological conditions such as neutropenic sepsis and metastatic spinal cord compression, and have also shown reduction in length of inpatient stays. We are also supporting, Cwm Taf and Cardiff and the Vale in the development of their acute oncology services. 19

60 6.0 Delivering fast, effective treatment and care 6.1 Access and cancer waiting times Our aim is to treat patients as efficiently and effectively as possible. As a treatment centre, we aim to meet and improve upon waiting time recommendations for the delivery of Radiotherapy and Chemotherapy treatment. Radiotherapy We actively monitor the percentage of patients starting radiotherapy treatment within 28 days (radical intent) and 14 days (palliative intent) from the decision to treat date. This measurement is based on the Royal College of Radiologist (RCR) recommendations (JCCO 1993). A 98% tolerance level for this target has been agreed with the Cancer Services Coordinating Group on behalf of the Welsh Government. Number of referrals commencing RT monthly & compliance with RCR targets; Oct 14 Nov 14 Dec 14 Jan Feb Mar Malignant Benign Total Apr May June July Aug Sep Oct Compliance with Radiotherapy Targets; Oct 14 Nov 14 Dec 14 Jan Feb Mar Radical Breaches Apr May June July Aug Sep Oct % within 28 days 93.7% 98.9% 99.5% 97.6% 94.0% 78.2% 96.0% 100% 99.6% 97.2% 99.0% 99.5% 99.5% Palliative Breaches % within 14 days 98.4% 100% 100% 98.0% 97.1% 76.1% 95.3% 100% 99.2% 99.3% 100% 98.0% 98.0% Emergency Breaches % within 2days 100% 100% 100% 100% 100% 96.8% 100% 100% 100% 100% 100% 100% 100% 20

61 Referrals vary from per month. All emergency patients were treated within target during this period. VCC experienced capacity issues between February and April this year but addressed this by increasing capacity through the use of agency staff. Evidence shows that fast, effective radiotherapy treatment enables the best clinical outcomes, and we have been successful in establishing a 14 day pathway from referral to radiotherapy treatment for radical Head and Neck patients, lung patients and neuro-oncology patients (thereby halving the current waiting times target) and in ensuring the delivery of optimum radiotherapy plans to 80% of the referrals. We believe that we are the only Cancer Centre to have achieved this. Chemotherapy The electronic Systemic Anti Cancer Therapy referral system, ecorma, has been in use since January The intent categories and timescales were agreed by our clinicians and are based on recommendations from the Joint Collegiate Council for Oncology (JCCO); Emergency referrals - should wait no longer than 5 days Non - emergency referrals - should wait no longer than 21 days The target is 98% compliance. Compliance with Chemotherapy Targets; Oct 14 Nov 14 Dec 14 Jan Feb Mar Emergency Breaches % Compliance 100% NA 100% 100% 100% 100% 100% 100% 100% 100% 100% NA 100% Apr May Jun Jul Aug Sep Oct Non- Emergency Breaches % Compliance 99% 99% 98% 97% 99.6% 98% 97% 99% 99.5% 99% 99.2% 99.3% 99.3% All referrals Breaches % Compliance 99% 99% 98% 97% 99.6% 98% 97% 99% 99.5% 99% 99.2% 99.3% 99.3% 21

62 100% patients received emergency treatment within 5 days. For 10/12 months we met our 98% compliance with the non-emergency waiting times targets, with the remaining 2 months reaching 97%. On average, 72% of patients are treated within 14 days and we plan to undertake pathway improvement work during 2016/2017 to increase this percentage further still. The vast and diverse SACT service continues to be at the forefront of chemotherapy developments and provides the very best care to our patients both within the centre and in outreach locations. During the past year, despite growing demand and pressure on the service, the chemotherapy waiting times targets were met and all approved NICE/AWMSG approved drugs were available for use. A chemotherapy specialist nurse was seconded to the South Wales cancer network chemotherapy project which has led to VCC piloting a chemotherapy toxicity screening tool. A chemotherapy preparation service has also been established whereby all preparation work takes place the day before the treatment is due in order to ensure that all relevant checks and processes have been undertaken. 6.2 Mortality Rates following treatment We are committed to eliminating preventable deaths following treatment and we have had no unexpected inpatient deaths during 20. In addition, time has been invested in developing a robust mechanism to routinely and consistently report on deaths within 30 days of chemotherapy. In order to ensure comparison with published data (NCEPOD 2008) Velindre calculates this as a quarterly % rates. 22

63 We are reassured that quarterly rates are in line with published data and literature. Routine reports have been designed for tumour specific site specific teams (SST s) to monitor and identify areas for learning and improvement, and to analyse this data in more detail. These reports are discussed in detail at each SST appraisal. For each patient we investigate whether the death was not unexpected, and due to progressive disease or whether the death was directly related to the chemotherapy treatment. These reports are also shared with the Divisional Director, Clinical Director, and the Trust Board via the Medical Director. Mortality reviews are undertaken on all inpatient deaths and if a patient s death is unexpected, or if further review is required these cases are referred to and analysis is undertaken by the Serious Clinical Incident Forum (SCIF) team. We are also in the early stages of developing the reporting of early post radiotherapy mortalities. 6.3 National Standards Individual Patient Funding Requests We have established a formal Individual Patient Funding Request (IPFR) Advisory Committee which ensures there is a formal process in place, following the principles of the All Wales Protocol, for reviewing all applications and determining whether they are clinically appropriate. Applications are reviewed on a weekly basis, and those that are deemed clinically appropriate, but that fall outside of our funding constraints are referred to the patients local Health Board. Participation in clinical audit Clinical audit continues to be pivotal in illustrating the high standards of care for patients delivered at VCC. The audit process is key in engaging staff to scrutinise and compare practice and care provided against recognised guidelines and outcomes. Our audits are extensive and pleasingly show results which compare favourably with published standards. These include evaluation of survival rates for patients treated at VCC and confirm favourable adherence to national guidance. These reports illustrate high levels of patient satisfaction with changes in service provision and demonstrate acceptable toxicity profiles from novel treatment modalities. This is underpinned by the ongoing role of the audit department to maintain the high standards of clinical data entry and validation. The importance of completing the quality improvement 23

64 cycle continues to ensure this ongoing process will continue to improve standards for all patients treated here. We fully participate in audits listed on the All Wales National Clinical Audit and Outcome Review Plan, including the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) audits and other national institutions, including the Royal College of Radiology (RCR):- National Bowel Cancer Audit National Lung Cancer Audit National Head and Neck Cancer Audit National Oesophago-gastric Cancer Audit National Prostate Cancer Audit (new audit being developed) The All Wales Breast Cancer Audit Fundamentals of Care Audit National Blood Transfusion Audits All Wales Integrated Care Priorities for care in the last days of life It also allows clear documentation of any recommendations and that these are implemented and their impact thoroughly evaluated. These results act as a driver for change to improve and maintain the quality of treatment and care. The clinical audit department itself has also successfully undergone an internal audit which highlighted that the department has a well- defined structure and quality framework consistent with the provision of a high quality service. This report also noted the increasing demands on the department within limited staffing resources and the need to ensure closer links with the Trust Quality and Safety Committee and Trust audit board to ensure alignment of key assurance and improvement processes. The importance of clinical audit and the processes which assess and maintain quality and safety of care have never been stronger in light of the recent Francis Report. The clinical audit department continues to work closely with each sitespecific team to ensure engagement with audit outcomes and incorporation into the continuous quality and safety cycle to drive change and improve patient outcomes. The department also continues to participate in both local and national benchmarking exercises including consultant and SST reports on death within 30 days of systemic anti-cancer therapy and hospital-acquired thrombosis rates. 6.4 Participation in Peer Review We have welcomed the introduction of peer review of cancer services in Wales and have actively participated in the process through the MDTs. Differences in access to advanced radiotherapy techniques and differences in pace of implementation of acute oncology services across South Wales have been highlighted as a result of this process. Maintaining adequate presence of oncology at increasing number of MDTs as well as delivering an increasingly complex oncology service to the rising cancer population for the LHBs in SE Wales will be challenging. It will need different ways of working, using different skill mixes and cross covering between teams. We have already made strides with this in the head and neck and urology teams. Work is 24

65 ongoing to do the same for the lung service as a result of the lack of resilience in the service highlighted in peer review. During 2016, we also aim to undertake a programme of service level benchmarking with Clatterbridge Cancer Centre who provide a similar service to a similar patient demographic across the Merseyside and the Wirral areas. This is a voluntary initiative for both organisations, and we are keen to share information, experience and learning. We look forward to presenting our progress in next year s annual report. Radiotherapy Services VCC is committed to improving access to up to date Radiotherapy (RT) techniques and implementing new Radiotherapy developments. VCC aims to deliver high quality radiotherapy in a safe, timely and efficient way to cancer patients of South East Wales and beyond. VCC works collaboratively across the cancer networks and 2 Welsh cancer centres and attends regular meetings where planning of radiotherapy services is discussed. This collaboration has extended during 20 to include shared understanding and reporting of radiotherapy incidents and errors and the learning associated with these. VCC continues to value the importance of staff development, training and research in radiotherapy and during 20 a significant increase in post graduate study has been seen within the therapeutic radiographer staff group. VCC, working alongside our educational partners, has supported staff to explore many different avenues of study and research. This will continue to be a significant driver for the future. Intensity Modulated Radiotherapy Treatment (IMRT) Intensity Modulated Radiotherapy Treatment (IMRT) is one of the major advances in radiotherapy in the last decade, and has the potential to reduce the long-term side effects of radiotherapy in certain cancers. 25

66 IMRT is being developed as part of a 5 year phased programme (established in October 2011) which aims to treat 35% of radical patients with IMRT by year 4 (20). As the graph above demonstrates we are well on our way to achieving our delivery plans. National evidence suggests that more patients would benefit from being treatment with IMRT/VMAT and in the coming months we aim to develop a new stretch target for the use of IMRT in line with this national guidance. Image Guided Radiotherapy (IGRT) Image Guided Radiotherapy (IGRT) is any imaging at the pre-treatment and treatment delivery stage that leads to an action that can improve or verify the accuracy of radiotherapy A number of radiotherapy clinical trials open at VCC require advanced IGRT as standard including daily on line imaging for HYBRID and the use of fiducial markers and the use of fiducial markers and dose painting for BIOPROP. During 20 VCC has increased its use of IGRT through these clinical trials and local initiatives. Stereotactic Body Radiation Therapy (SBRT) and Stereotactic Radiosurgery (SRS) Stereotactic radiotherapy is a special class of high precision radiotherapy that has historically been applied to treatment of intra-cranial tumours. Treatment delivered within a single fraction is termed stereotactic radiosurgery, while treatment over a (small) number of fractions is known as stereotactic radiotherapy. In recent years extra-cranial techniques have advanced to the point at which stereotactic body radiotherapy (SBRT) offers significant advances in treatment efficacy in certain sites, predominantly non small cell lung cancer. SBRT is typically used for small lung cancers in patients who are unable to have surgery, either due to the location of the tumour or other health conditions that could make surgery risky. In 2013, the Welsh Government awarded VCC 4.6 million to 26

67 replace a current linear accelerator (linac) with a machine capable of delivering a specialised stereotactic RT service for South Wales. This specialist equipment also delivers stereotactic radiotherapy and radiosurgery for the benign and malignant disease within the brain. It has enabled VCC to treat patients who previously would have been treated at the Gamma Knife Centre in Sheffield, allowing Welsh patients to be treated in Wales for the first time. Varian Truebeam STx installed 2014 This equipment was installed and commissioned during 2014 and during 20 we developed our service. The first patients were treated in November 2014 with the first benign conditions treated from January 20. Between April 2014 and October 20 we have treated a total of 128 patients using the SBRT technique. 27

68 Varian Truebeam STx control area VCC was also awarded funding of 180k from Velindre Trust charitable funds to develop and deliver stereotactic radiotherapy to secondary liver disease incorporating treatment of oligometastatic disease and management of respiratory motion. This has allowed us, during 20, to deliver SBRT to patients with liver cancer for the first time. Image Guided Brachytherapy (IGBT) Brachytherapy is a specialist form of radiotherapy which places radioactive sources inside or close to tumours and has proven to be a highly successful treatment for a variety of cancers including cervical, endometrial and vaginal and prostatecancers. Image guided brachytherapy for gynaecological malignancies is regarded as the international gold standard and VCC is in progress with a project which will allow us to meet these exacting standards. Conclusion 20 has been a challenging year for radiotherapy with an increasing demand for our service. This is anticipated to continue for the foreseeable future and our forward planning will need to reflect this need. We are extremely proud to look back over 20 and see all of our achievements in improved patient care and treatment techniques, a few of which are outlined above and look forward to providing more services and better care in

69 6.5 High quality clinical research The delivery and management of high quality research is a strategic priority within Wales, and viewed by the Trust as the 2nd priority after clinical care. Research drives changes in healthcare, enabling us to translate innovation into practice and provides our patients with the best in care and quality, often allowing access to treatments that would otherwise not be possible. Key achievements in 20 There have been a number of exciting developments in the management of prostate cancer, led by Velindre Researchers, strengthening our position as a leader in research within Wales. The results of three studies, led at VCC by Professor Malcom Mason and Dr John Staffurth, are considered some of the most significant advancements in the treatment of prostate cancer. STAMPEDE: identified a chance in drug treatment that improves outcomes. CHHiP: Largest ever study of prostate radiotherapy, results have shown a significant improvement in outcomes through the halving of toxicity and relapse rates. PR07: the results confirmed the importance of radiotherapy as the treatment mechanism for prostate cancer There have been a number of other publications in peer reviewed journals in the fields of head and neck, oesophageal cancer, and in palliative care that are supporting the advancement of medical care. The developmental side of research is being led within the Medical Physics department, with publications to support their technical advancements. 29

70 Performance against National Targets As a research active centre, we are key contributors to the local and national cancer recruitment targets. % Patients recruited in to high quality clinical trials- All Wales Data 25.0% 20.0%.0% 10.0% 5.0% All Wales North South East South West 0.0% Nationally, recruitment into research projects is steadily increasing over time. At VCC, this downward trend has been recognised to be related to a change in the design and scale of cancer studies as new types of research questions are posed. The decline over time is related to a shift in the nature of cancer trial design, with a move away from large scale, high volume trials to smaller, low number studies to address focused clinical questions. This change has been noted nationally and across the UK. 30

71 1200 Number of patients recruited at VCC / / / / / / /20 Early Phase Trials Participation in Early Phase trials provides patients with access to novel treatments, often in situations where there are no other treatment options. This service is a first for Wales; previously, Welsh patients have needed to travel to English Cancer Centres to access these treatments. The early phase team recruited 35 patients into 7 trials during 2014/ and are planning further expansion, and collaboration with colleagues at other centres. Radiotherapy In terms of radiotherapy-based trials, this has been another good year for the Radiotherapy Research Department with over 100 patients recruited since April and a projected year-end recruitment of 120+ into predominantly complex, phase 2 & 3 studies. This year we are also involved in 2 two-centre collaborative studies with Clatterbridge and Guy s and St Thomas s Hospitals as well as having a Chief Investigator, John Staffurth, in a three-centre collaborative study which is led from VCC. We maintain our position as a top-10, or higher recruiter, in the UK for all National trials in which we are involved. Looking forward it is likely that recruitment numbers will fall as the trend towards highly-complex advanced Radiotherapy trials incorporating multi-parametric MRI, PET and sophisticated Planning and treatment imaging accelerates. These trials require a great deal of work to set-up, in conjunction with the Physics and Radiotherapy Dept, due to the rigorous Quality Assurance Programmes that have to be completed before our acceptance by the Trials Centres. These are highly significant in introducing sophisticated and cutting-edge Radiotherapy techniques and practices and are a mark of Velindre s standing in the UK Radiotherapy arena 31

72 that we are asked to participate in such advanced trials. These trials are prestigious and mark VCC as one of the leading cancer centres in the UK In addition to trial recruitment it is worth noting that we are also pivotal in one of the most important parts of a trial and that is the long-term Follow-up of patients who have taken part. Without effective Follow-up there will be no robust outcome data. Currently, we look after about 600 patients from different trials from as far back as years ago. Additionally, Dr Tom Crosby was invited to bid for a charitable donation from the Moondance Foundation, and successfully secured 1.5 million, which was then matched by the VCC Charity. The money will be used to support a multi-professional team to undertake R&D, service improvement, and establish new treatments and therapies radiotherapy. Governance The R&D team support our Investigators to achieve 100% of the Welsh Government Key Performance Indicator: provide NHS permission to open to recruitment within 40 days of submission. Work is ongoing, in collaboration with internal departments and external stakeholders, to continue to improve process and working practice to ensure an efficient, effective, high quality service is provided. Examples of continuous improvement include working collaboratively with R&D offices to set up overarching agreements that have reduced time to start recruiting, and cross-organisational support for the handling of tissue samples; both changes reduce timeframes and open up swifter access for all Health Board patients. 32

73 6.6 Tissue donations to the Wales Cancer Bank The percentage of people diagnosed with cancer who consent to donate samples to the Wales Cancer Bank - All Wales 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% * * There are no WCISU data for 2014, therefore the data attached used 2014 Welsh Cancer Bank data against 2013 incidence data. The collection of tissue for the majority of tumour sites takes place within the Local Health Board setting; however, there is a focus on collecting tissue in VCC from patients with upper G.I., breast, gynaecological, colorectal patients and melanoma and prostate patients who have been treated with radiotherapy. 33

74 7.0 Meeting People s Needs We are committed to ensuring that all patients are cared for with dignity and respect and will ensure that services are planned and delivered around the patient and their individual needs; this culture within the hospital is often described by patients, carers and families as the Velindre Way and a patient with head and neck cancer likened their NHS experience as delivered by a Grand-Prix winning team to beat the world! Some of our key, patient focused initiatives and achievements during 20 include: The Welfare rights advisor assisted more than 350 people affected by cancer to claim grants and benefits to the value of 1,618, in a 12 month period. (This is an increase from the 1,339, 846, 70 accessed for patients by the advisor in 2014). The supportive care team assistant completed a pilot study which ran for three months as agreed with clinical audit and the sub-group of the inpatient Site Specific Team. The aim was to collate data on any immediate concerns for patients and families following discharge from First Floor and any signposting to community services to improve support and hopefully decrease the need for re-admission. All patients were offered the service and only those who consent will be contacted. To date 88% of patients discharged from First Floor/Active Support Unit Ward were contacted prior to discharge, all patients were offered a telephone call and a contact card with details of how to get in touch with the supportive care team on a dedicated phone line. 47% of patients/carers requested the followup call and 100% received the call back. Following the senior nurse meeting it was agreed that the call-back service would be fully integrated into discharge care for patients and carers. The patient and carer information and support manager and Dementia and Cognitive impairment support nurse have been leading on a programme of work that including pathways and easy read resources for VCC patients with learning disabilities. They have been nominated for a national nursing award for this work and so far are successfully through to the finals results to be 34

75 announced in October 20. They are linking in with other Health boardss to help identify a patient with a learning disability and their carers before they come to VCC. In addition the patient information coordinator is looking into the use of easy read resources for pharmacy to help carers identify the right tablets/capsules for patients when the carer has to give the medication. The supportive care lead nurse had a publication accepted in Bereavement care in January 20: Bull and Pengelly (2014) I'm not the only one : a collaborative approach to developing a children and young person's bereavement group Cruse bereavement care Vol 33 No.3 pp The information and support coordinator has improved the capacity of the Look Good Feel Better programme by 50%. The Children s book Caring for my family with cancer, written by the supportive care lead nurse was successfully launched on May 5 th 20 by the Minister for Health Mark Drakeford AM In conjunction with Cardiff University, the Dementia and cognitive impairment supported a successful research application project on dementia and cancer and the management and outcomes for patients. The project is now completed and its findings eagerly awaited Patient experience 35

76 The NHS in Wales has adopted a service user experience framework which identifies the three key determinants of a Good service user experience (based on national and local published evidence) First and Lasting Impressions Receiving care in a Safe, Supportive, Healing Environment Understanding & Involvement in Care These three domains can be used to support the use & design of a range of feedback methods to help us understand the patient experience. It is recommended that a mixture of methods is used wherever possible in order to obtain a balanced understanding. The framework also includes a set of core questions which are used across all NHS organisations in Wales. At VCC, we have face-to-face conversations with our patients based around these core questions. These conversation opportunities enable us to capture the data in a meaningful way, where any issues identified can be discussed openly & often dealt with immediately. The Framework in Action What s in it for our patients? 36

77 Offering a means for patients to express their thoughts, wishes, ideas & personal experiences reinforces the patient-centred approach to our work and empowers patients to make their voice heard. What s in it for our staff? Patient feedback gives us as staff an opportunity to understand what care is like from the patient s perspective. Hearing patients talking about their experiences in their own words helps us to see care through their eyes and hear about the things that are most important to them. What s in it for Velindre? Patients are at the heart of everything we do. Feedback both good and bad - is fundamental to the way we shape our service for today & tomorrow. How are we listening? We undertake the National Survey on a monthly basis. We are currently training more staff to get involved & conduct these patient interviews. It is clear that over recent months the ability to deliver a significant number of completed surveys has been difficult due to other work pressures. It is hoped that by increasing the number of staff members involved, we can share the workload and increase the number of interviews carried out. Response by staff members approached to take part has so far been very positive and it is hoped that eventually we will have staff from each department conducting these important conversations. In addition to the National Survey, we also capture experience information via Patient Stories. These stories can be produced in various formats written, video, digital story, audio and graphic. Our Social Media channels offer a further means for patients and their families to comment on their experience at VCC as well as the placement of Comment Cards in key areas of the hospital. We are also lucky to have a passionate and dedicated Patient Liaison Group. What are our patients telling us? Over the last year scores against the All Wales Survey remain at a high level (please see graph below). Real time feedback systems are being investigated with a view to drafting a specification requirement. 37

78 Additional digital stories have been developed and a process is currently under development to ensure the stories are heard and used in the appropriate settings. 100% 80% 60% 40% 20% 0% Patients' Overall Experience Nov-14 Dec-14 Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Rated 9 or above % Target Please note: no data for April due to a shortage in the number of staff able to undertake surveyssubsequently, additional staff volunteers were recruited to undertake surveys. At Velindre we care about our patients experience. We want to be the very best at what we do and provide the best possible care and treatment for our patients. There are a number of ways we can measure this, but the thoughts and opinions of our patients and their families, as the main users of our service, really do count most of all. We asked: Was there anything that we could change to improve your experience? Patients said: Better TVs please I needed a map to find my way around Changing my stoma bag is easier with a mirror Waiting times on the monitors would be good We made some changes: Additional TVs purchased for the day unit Clear signage & maps introduced to make it easier to find your way Mirrors & shelves fitted in Outpatient toilets to improve facilities for patients with stoma bags. (These will also be fitted in the remaining toilets) Display screens have been fitted in Outpatients & Radiotherapy reception areas. These will soon be showing waiting times following some staff training. 38

79 Don't know what I would do without my chemo at this ungodly hr, absolutely amazing & the most comforting person #lucky #NHS On Tuesday my dad lost his four year long battle, he fought hard and was so positive til the very end, one thing that will stay with me is how much he thought of you guys and how well he was treated whilst he was being treated at velindre, a huge thank you for looking after my dad and giving me the time to make wonderful memories that my family will never forget, he's an angel in heaven now and you are his angels on earth Sincere thanks to all the fantastic doing such amazing work. Living with the impact of cancer The cancer story is changing. There are currently 2 million people living with or beyond cancer in the UK. That figure is set to rise to 4 million by It s a reason for celebration that more people than ever are surviving after a cancer diagnosis but we know the impact of cancer does not suddenly stop when treatment is over. People who have finished cancer treatment tell us they often have difficulties financially, emotionally, practically and medically. We know that far more can be done to improve the lives of cancer survivors. Support for people living with or beyond cancer should not finish after treatment but should continue into a phase of supported aftercare. People who have finished treatment tell us they have difficulties returning to normal life. They may: struggle emotionally, needing to adjust to changes that treatment has made to their body have to cope with short-term and long-term side effects of their cancer or its treatment have to live with the knowledge that their cancer cannot be cured, even though they feel healthy have difficulties accessing information about their condition or any after effects they may experience struggle financially as the household income decreases experience problems returning to the workplace. Following the Welsh Cancer Patient Experience Survey (Macmillan Cancer Support, 2014), feedback provided by Velindre patients showed high levels of satisfaction with the overall care received, leading the way across Wales in many areas, but some room from improvement in how we care for our patients holistically; providing written care plans and improving access to information. VCC and Macmillan Cancer Support have collaborated to develop the Person Centred Care Pathway, which is 39

80 underpinned by a proactive and preventative model of care that identifies needs and enables patients and their families to access support through treatment and into recovery. The pathway empowers patients and develops their psychological resilience, whilst enabling professionals to work more effectively and efficiently across disciplines. It also ensures that all patients are able to experience and live by Macmillan s nine outcomes and access all components of Macmillan s Recovery Package. The Recovery Package is a series of interventions ensuring that all Velindre patients will have access to individualised and dynamic assessments of their needs and care planning and will be provided with information to support them, their carers and their family s needs. This includes; ensuring all patients are aware of their Key Worker and receive Holistic Needs Assessment and Care Planning that assesses holistically Introduction of Treatment Summaries to improve communication with secondary and primary care teams about the patient s cancer treatment Ensuring patients have the opportunity to attend a Health and Wellbeing Clinic which offers support and information from professionals and local services. Empowering patients by ensuring the right Information and Support is available, both in the clinical environment and from home Embedding Physical Activity into the cancer care pathway for patients through the Macmillan Activity Promotion Programme and the National Exercise Referral Scheme. Patient engagement has been crucial in the development of the pathway. Focus groups have been held with several patient groups and have been invaluable given that patients are the ones who experience our services first hand and they offer a unique and highly relevant perspective. Patients report the pathway as empowering, easy to navigate and that the pathway promotes and facilitates self-care through resilience building. As the project enters its second year; the person centred care pathway will continue to grow in strength as; Holistic Needs Assessments are implemented across as site specific teams; working in collaboration with other local health boards and primary care teams Treatment Summaries are rolled out to all sites 40

81 Information is refocused on the needs of the individual, ensuring that duplication is reduces across the system and that information resources are designed to meet the changing needs of our patients. This includes the ongoing developments and sharing of tools such as the Velindre Information Portal and Central Referral System for holistic care services. Reference: Welsh Government, Macmillan Cancer Support. (2014). Wales Cancer Patient Experience Survey Metastatic Cancer Patients Consultants and their teams at VCC are working towards new models and pathways for delivery services for patients with metastatic cancer and we have established a metastatic multi-disciplinary team. Within VCC the weekly Hepatobilary (HPB) multi-disciplinary team (MDT) meeting has now effectively taken on a South Wales network role of reviewing patients with metastatic colorectal cancer with spread to the liver which might be amenable to curative surgery. A similar service is in development for patients with metastatic colorectal cancer ensuring patients have access to equitable, high class care. A challenge now is for information systems (e.g. CANISC) to be able to collect data for such patients in a way similar to those patients presenting de novo. 41

82 8. Caring at the end of life One of the main areas of focus has been the national End Of Life Care Delivery Plan as set out by Welsh Government. Our Palliative Care teams based in Velindre NHS Trust and in Cardiff and Vale University Healthboard have been central to much clinical work, but have also contributed to structural planning activities during 2016, including palliative and End_of-Life-Care aspects of Shaping Our Future Wellbeing (C&V UHB) and Transforming Cancer Services (Velindre NHS Trust). Welsh End Of Life Board agendas including Advance Care Planning, DNACPR (Do not Attempt Cardiopulmonary Resuscitation), IT infrastructure and development of the new Care Decisions at the End Of Life guidance have been progressed. For instance, the roleout of the new Care Decisions at the end of life decision support aid has started and will run through Palliative care teams have also assisted in the delivery of Acute Oncology Services, which is an emerging area in Oncology and shows promise in helping patients to be identified at an earlier point in their care trajectory, as requiring palliative care involvement. Other important surrogate performance areas, including timeliness of referral data, MDT, patient feedback and peer review are listed below. Registration of all new patients, and their first assessment as a minimum, onto the CANISC palliative care module All patients continue to be registered via Canisc as the main Patient Administration System in VCC. Audit of Canisc data shows that VCC is 100% compliant with the standard for all urgent specialist palliative care referrals to be seen within 48 hours and in fact continue achieving under 24 hours consistently. Demonstrate full Multi Disciplinary Team (MDT) working with weekly MDTs meetings, using the CANISC MDT programme as appropriate and working with other providers Specialist Palliative Care Teams hold weekly MDT s with information recorded onto Canisc via the MDT module. This includes planning and documenting MDT decisions so that other teans can access them easily, but aspects such as bereavement care for families can also be planned. Ward round meetings occur daily to plan care for palliative care patients at VCC. All patients who are discharged, in addition to their routine hospital discharge letter also have a letter to GP and other providers detailing palliative carer involvement and advance care planning decisions. Participation in an agreed service user evaluation programme The I Want Great Care patient and carer feedback process has been updated and modernised. Both clinical and management teams receiving the evaluation reports. 42

83 Palliative Care Teams in Velindre and C+V UHB are receiving detailed patient and carer feedback via this tool. Participate in a Wales wide Palliative Care Peer Review programme The peer review programme has not progressed to inspection of VCC service as yet, but a task and finish has been established in Velindre to prepare for the review of our palliative service. This group is developing documents and strategies to maintain and secure lines of referral into and out of palliative care teams. An All Wales Palliative Care Referral form exists and is used extensively in Velindre. Establishment of an End of Life strategic partnership group with all relevant local palliative care providers, delivering a specialist palliative care service that reflects the recommendations of the Palliative Care End Of Life Board that liaises through representation at the Palliative Care Implementation Group (PCIG) VCC is part of the Cardiff & Vale Palliative Reference Group and has representation on PCIG. There has been cross-cover support of consultants into voluntary sector providers (Marie Curie Hospice and George Thomas Hospice). VCC is fully represented on PCIG. Support to relevant third sector providers to enable their participation in the full use of the CANISC palliative care module, through robust ongoing IT support. Dedicated medical resource for Canisc development with leadership from Dr Victoria Wheatley, palliative care consultant in Cwm Taf. Technical support challenges persist and these are beyond the cancer centre s control. Support research initiatives in collaboration with the Wales Clinical Trials Unit and train staff at all grades in the importance of research participation. The Specialist Palliative Care Team at VCC remain enthusiastically involved in research, for example a multi-centre trial to evaluate strong opioids (TVT: An international, multicentre, open randomised parallel group trial comparing a two step approach for cancer pain relief with the standard three step approach of the WHO analgesic ladder in patients with cancer pain requiring step 2 analgesia) Velindre are also recruiting into a multicentre trial focussing on hydration at the end of life with Dr Nikki Pease and principal investigator. Dr Anthony Byrne is involved in a lung cancer decision support tool study called PACT, which will PACT: Development of an intervention to support 43

84 lung cancer patients and their clinicians when considering systemic Anti- Cancer Therapy. Ensure that case loads of specialist palliative care providers are appropriately managed to maximise services to meet need and to empower generalist services in primary and secondary care to support patients in the palliative phase of disease to live well and die well. No referrals have been delayed. 24/7 advice to generalist services available including out-of-hours domiciliary visits when there has been a clinical crisis for a patient at home. All patients at Velindre who are assessed by Palliative Care have a POS-S assessment, cross-checking a number of different symptoms. The education programme for General Practitioners remains popular (Cardiff University Short Course which is hosted by VCC) and there are plans to potentially develop this and roll it out to other professions. TalkCPR project Velindre have been part of a Wales wide project to create resources to facilitate better communication surrounding CPR and DNACPR decisions for palliative patients and their carers. This large project, with roll-out of 4 communication videos hosted on the talkcpr.wales (English language) website and talkcpr.cymru (Welsh language website and videos) has been taken on my the Bevan commission as an Exemplar project, and also been nominated for a NCPC national award, as well as a Patient Excellence award from the Royal College of Physicians. More info is available here Metastatic Spinal Cord Compression project Work on this large project is not complete, but has now led to a video being published. Dr Nikki Pease led on the work with this video and it was produced with Macmillan. This video is for patients and carers and aims to create an understanding of symptoms and red flags that may indicate that someone may develop spinal cord compression. PACT Study: In addition: Seven day/week specialist palliative care nursing continues to show significant benefits for patients, families and staff. The Welsh government s Together for Health Delivering End of Life Care document acts as a plan for the coming years on how we can strive to diminish the distress caused by terminal illness to patients and their closest. 44

85 The Access to Palliative Care Bill has been set up and tabled by Prof the Baroness Finlay in the House Of Lords during 20 and will help enshrine palliative care as a patient right, when and where appropriate. It is another step towards more uniform availability of this service across the UK. Many referrals to palliative care are now being received via the daily Acute Oncology Service meetings, where often very unwell community and in-patients are discussed, and this has contributed to increased patient numbers and acute referrals. We plan to do a review of palliative input into AOS during 2016 and 2017, as part of a project called Earlier Palliative Care, which has attracted some funding from the Cancer Innovation Fund. The Palliative Care Implementation Board has set minimum levels of funding for specialist palliative care services, which require clear funding streams. The ongoing challenge will be to provide care for patients in their preferred place of death when they are dying, and to be able to react in a timely fashion when and if this preference changes. Too much preoccupation with dying at home as an indicator of a good death deflects attention from improving the quality of care elsewhere. Because people die in all settings, and will continue to do so, the aim is to seek to optimise the care of patients not only at home, but in care homes, hospitals, and hospices. Regarding patients wishes and priorities for their care, it is difficult to find personal answers to such questions in public surveys. Palliative care teams and colleagues will need to encourage a continuing exchange and conversation between patients and their various health professionals and caregivers, all along the illness trajectory. With the renewed emphasis on early palliative care, the quality of care from the beginning to the end will be a focus for Velindre NHS Trust Palliative care teams in VCC already provides significant support to patients, families, ward staff and the wider community teams, both statutory and Third Sector, in this respect. 45

86 9. Improving Information People affected by cancer have significant information needs, not just in terms of their treatment but in terms of their financial and emotional needs. They consistently highlight the need to improve communications between themselves and all relevant agencies. We are very fortunate to have a dedicated and proactive Patient Information Manager on site who makes themselves available to signpost information to patients, carers and relatives. They also maintain the Patient Information Centre, which holds information in various forms on all aspects of the patient pathway, from information on what is cancer to what side effects to expect from certain drugs, advice on travelling abroad and information for families on coping with bereavement. Information in other languages and easy read information for patients with a learning disability is also available as a bespoke service from the patient information manager. All information is also easily accessible to patients and carers on the VCC Internet Site. We recognise the importance of working in partnership with cancer survivors, their carers and the Third Sector to ensure effective signposting to sources of information and support and we are pleased that a number of organisations are available within our outpatients departments on certain days throughout the month to provide information and advice to our patients. Care and Repair hold sessions, providing advice regarding falls at home. A number of support groups also visit outpatients linking into the relevant clinics. Currently there are support groups for ovarian cancer, prostate, breast and brain. Carer s centres from Bridgend and Cardiff visit outpatients once a month provide information and signpost. VCC s patient information manager visits carers on the wards to offer advice and signpost AND a stand each year for Carer s week, offering support, information and signposting carers. There are patient information screens at the Cancer Centre, giving information to patient/carers/family members on all aspects of the cancer journey. The information will also be available on all inpatient television screens as a patient information channel, once the new ward is open. The look good feel better pamper session has increased from last year from 10 ladies a month to 40 a month and the headstrong service see 3 patients a week to show ladies how to use headscarves and various hats in the event that they lose their hair during their treatment. Regular information days are conducted in prominent positions throughout the hospital, for example, during sensory loss week, professionals from Action on Hearing loss and various charities on sensory loss attended the hospital to give sessions. 46

87 Reporting performance against National Cancer Standards, and cancer site specific clinical quality indicators to Boards at least annually The quality and performance of cancer services are reported routinely within the Trust. The primary responsibility for scrutiny and assurance is held by the Quality and Safety Committee and the Planning and Performance Committee on behalf of the Trust Board and this is done through the existing governance arrangements. The information provided is of a varied nature and focuses on the standards set out within the Cancer Delivery Plan, clinical outcomes and outputs, and patient safety and experience. The Committees and the Trust Board also receive information of a site specific nature on a routine basis and a summary of quality and performance annually. Publish regular and easy to understand information about the effectiveness of cancer services The Trust currently publishes information relating to the effectiveness of cancer services through the Annual Quality Statement and the Annual Report. We are currently looking at how information can be made easily available to patients, families, carers and a wide range of interested stakeholders. This will include the publication of all reports from the Quality and Safety Committee, Planning and Performance Committee and Trust Board and the development of our website to include a range of information which is meaningful and easy to access. The Cancer Centre has also started a programme of Site Specific Team (SST) appraisals. The SST's are multidisciplinary teams, (Consultant Oncologists, Junior Doctors, Nurses, Clinical Trials representatives, Radiologists, Pharmacy representatives, Medical Physics representatives, Allied Health Professionals, Clinical Audit etc) who focus on the treatment of cancer according to the location of the cancer in the body. There are currently 10 SSTs operating within VCC. The appraisal of each SST aims to achieve the following: Map out the current service Highlight elements of best practice Identify gaps in the service to inform action plan for improvement. Analyse performance Focus priorities for the future Within the appraisal document information regarding the service/workforce configuration is presented along with narrative outlining the service gaps, achievements and developments. 47

88 Performance of the service is then analysed, using survival as the outcome indicator, and sitting underneath, 10 performance measures, which are a mix of both nationally and locally determined indicators and link to a number of both national and locally determined strategic objectives. A different SST is appraised every other month (18-24 month rolling programme). SST meets with Clinical Director, Director of Cancer Services and SST support manager. The information in the appraisal document is used as a vehicle for discussion and an action plan is drafted between management and the SST. These documents are shared with the Senior Management Team and the Trust Planning and Performance Committee, and will soon be made available on the internet and intranet. 48

89 10. Conclusion and Focus for the next 12 months and beyond This year has been a busy one for VCC with much progress against the objectives outlined within the Cancer Delivery Plan. However, there are still improvements to be made to ensure patients of South Wales are accessing services comparable to the best in Europe, thereby ensuring the best possible clinical outcomes and quality of care. We cannot tackle these issues alone; we must focus our priorities and work closely with our partners in primary and secondary care, and the third sector in order to progress towards our shared vision for cancer services in Wales. Our key priority in the next 12 months will be developing our proposal for an optimum service model for cancer services in South East Wales that provides access to the best possible treatment and care, locally where possible, and centrally where necessary. This development is our main focus given the current challenges we are facing in treating our population due to growing demand, lack of physical space and given the drive to bring services closer to patient s homes. This will require close collaboration with our stakeholders to ensure a service that meets people s needs. We will also; Work closely with our stakeholders to develop our medium-long term Radiotherapy Strategy, thereby ensuring we have a plan to provide patients have access to cutting edge treatment and technology. Work closely with our partners in local health boards to increase primary oncology/home care/outreach services Work with collaboration with Health Boards to develop Acute Oncology Services across Wales, ensuring improvements are measured and learning shared. Promote and support research activities, in particular increasing access to high quality interventional and Phase 1 trials and consent to donation of tissue to the Wales Cancer Bank. Work with colleagues to support the implementation of service improvement methodologies to improve patient journey through all pathways, both the 31/62 cancer waiting times standards and for subsequent treatments. Review our Specialist Clinical Nurse provision and support across our tumour sites. 49

90 The achievement of these key priorities, along with many other important pieces of work as outlined within our Integrated Medium Term Plan, will take us a few steps closer to achieving our vision of excellence. 50

91 TRUST BOARD PATIENT LIAISON GROUP ANNUAL REPORT 20 Meeting Date: 28 th January 2016 Author: Sponsoring Executive Director: Report Presented by: Committee/Group who have received or considered this paper: Lesley Radley, Chair, Patient Liaison Group Andrea Hague, Director, VCC Lesley Radley, Chair, Patient Liaison Group Patient Liaison Group Trust Resolution to: (please tick) Approve: Endorse: Discuss: Note: Recommendation: The Board is asked to NOTE the annual report from the Patient Liaison Group (PLG) covering activities during 20. This report supports the following Trust objectives as set out in the Integrated Medium Term Plan: (please tick) Equitable and timely services Providing evidence based care and research which is clinically effective Supporting our staff to excel Safe and reliable services First class patient /donor experience Spending every pound well

92 2 PLG Annual Report 2014/20 1. Introduction / Background: The report reflects the work of the Patient Liaison members for Timing: The report covers activities during the financial reporting period 2014/ Description: The report is a summary of activities of the voluntary PLG, considering issues relating to Velindre Cancer Centre. 4. Financial Impact: None identified. 5. Quality, Equality, Safety and Patient Experience Impact: Aspects considered by the PLG contribute to the improvement of the quality, equality, safety and patient experience at Velindre Cancer Centre. 6. Considerations for Board / Committee: The Board is asked to note the activities of the PLG and continue supporting their involvement in continuous improvement at Velindre Cancer Centre. 7. Next Steps: Terms of Reference of the group remain unchanged from the group s establishment over 10 years ago. Both PLG members and Senior Management at VCC feel it timely to review the group s role and work undertaken and the how best use of skills of resources are in use. This will be an item of discussion with members and staff in the forthcoming months. Page 2

93 PATIENT LIAISON GROUP (PLG) ANNUAL REPORT This has been another very busy and productive year for the PLG with all our members contributing. Thanks as usual to Helen Davies for all her support and to Roger Pratt and Eleri Girt for their meeting notes. We were very pleased to welcome two new members this year: Edward Tapper who has been a patient and James Thompson who was a carer for his wife. They join the existing members who are Lesley Radley (Chair), Sue Youngman, Janet Pope, Malcolm Pope, Malcolm Griffiths, Ray Price, Roger Pratt, Keith Cass, Derek Ford, Barbara Burbidge, Helen Jeffreys, Eleri Girt and Sally Anstey. Although Derek has not been well enough to attend the meetings this year he has contributed to the Head and Neck Clinical Effectiveness meeting where he was able to compare his treatment for this cancer with his previous treatment. He is also involved in developing a patient story. PLG members have contributed to professional training for student nurses both at Cardiff University and the University of South Wales. Our members spoke to the students about their experiences both as patients and as carers. Feedback from the sessions has been excellent and they were able to question our members about all aspects of their illnesses and their care. We have also contributed to the Foundations of Care course at Velindre and more recently Lesley Radley has spoken to the SHO s at Velindre from her perspective as a nurse, patient, carer and chair of the PLG. Our monthly PLG meetings have been very well attended with regular updates and discussions with consultants, management, senior nurses, therapists and radiotherapy staff. We are also very pleased when members of the Board are able to attend and not only to hear the work we are involved in but also contribute to the discussions. Ray Singh and Steve Ham have attended on a regular basis. Our members have been involved this year in helping with the production of DVDs on Metastatic Cord Compression and DNACPR. The DNACPR DVDs were produced in two versions, one for patients and one for junior doctors. We have also commented on the new patient alert cards for chemotherapy. The other areas where we continue to have an input and my thanks go to all involved: Malcolm Pope organises the packing of the information bags on a regular basis as these are still very popular. Malcolm Griffiths and now Edward Tapper assist with the monthly radiotherapy evenings. Sue Youngman produces the newsletter. Edward Tapper and James Thompson have assisted with this year s annual audit.

94 This year we have contributed to many other groups at Velindre. The patient/carer voice is now heard and well accepted. Many of our members are involved with the Transforming Cancer Services programme which we all feel is vital for continuing excellent care for patients and their carers not just at Velindre but in the whole catchment area. We have noticed that we are being contacted more and more by colleagues at Velindre, and that we are able to contribute the patient s voice to their work. Conclusion Once again thanks to all for their input to the PLG this year. Next year we plan to meet with Lisa and Andrea to discuss various issues about how the group functions. We want to be sure that the work we do is effective and is the best use of our skills and resources. Signed: L.M. Radley Dated: December 2nd 20

95 PUBLIC TRUST BOARD HIGHLIGHT REPORT FROM THE CHAIR OF THE WORKFORCE AND ORGANISATIONAL DEVELOPMENT COMMITTEE Meeting Date: 11 th December 20 Author: Sponsoring Executive Director: Report Presented by: Committee/Group who have received or considered this paper: Sarah Morley, Executive Director of OD and Workforce Sarah Morley, Executive Director of OD and Workforce Harry Ludgate, Independent Member, Chair of the Workforce and OD Committee Workforce and Organisational Development Committee Trust Resolution to: (please tick) Approve: Endorse: Discuss: Note: Recommendation: The Board is requested to NOTE the contents of the report and actions being taken. This report supports the following Trust objectives as set out in the Integrated Medium Term Plan: (please tick) Equitable and timely services Providing evidence based care and research which is clinically effective Supporting our staff to excel Safe and reliable services First class patient /donor experience Spending every pound well

96 2 WOD Committee Highlight Report 1. INTRODUCTION / BACKGROUND: This paper had been prepared to provide the Board with details of the key issues considered by the Workforce & Organisational Development Committee at its meeting on the 11 th December TIMING The Workforce & Organisational Development Committee met on 11 th December 20 as part of its normal cycle of meetings. 3. CONSIDERATIONS FOR BOARD / COMMITTEE At the meeting, the Committee considered issues and can provide assurance to the Board on the issues delegated to them through the Trust Standing Orders relating to the following key items; The following key items were discussed; 3.1 POLICIES It was noted that the All Wales polices had been ratified out of committee. Pay Progression Policy Sickness Absence Policy Dignity Process Upholding Professional Standards in Wales 3.2 ADVISORY APPOINTMENT COMMITTEE TERMS OF REFERENCE The Committee received and approved the Advisory Appointment Committee terms of reference. 3.3 BUILDING EXCELLLENCE OD STRATEGY The Assistant Director of OD and Modernisation confirmed that the OD Strategy had been approved by Trust Board and provided an overview of the key elements contained within the document, including; values and behaviours; key principles and; a model outlining the key areas for activity. The Committee received details of the plans to move forward with the embedding of the values and in particular undertaking the baseline assessment exercise. The Committee expressed their continued support for this ongoing work and requested an overview of the activity and planned discussions at Workforce and OD Committee and Trust Board. 3.4 HEALTH AND WELLBEING FRAMEWORK The Committee received and formally agreed the Trust Health and Wellbeing Framework. An update was presented on the progress to date on the recommendations from the 2014/ Audit Report on maximising Health and Wellbeing of employees. It was noted that considerable progress had been made and a number of the actions were formally closed. The committee were also informed of the launch of the Health and Wellbeing Twitter page. Page 2

97 3 WOD Committee Highlight Report 3.5 PENSION TAX BRIEFING The committee received an update on the proposed communication to all Velindre NHS staff relating to the changes to the NHS pension and Tax in 2016 which will impact on the Life Time and Annual Allowances. Information and identified channels that employees can access to assist them to evaluate the impact that the changes may have on their pension will be shared early January It was noted from the Director of OD & Workforce that KPMG Accountants will be delivering briefing sessions for staff to offer advice. However, this may not address personal circumstances which will need to be discussed with independent financial advisors, although KPMG have written scenario papers to assist staff. The organisation needs to be clear about what help it can provide. It was suggested by the TU representative that the engagement of the Employee Assistance Programme also needs to be explored. 3.6 ALL WALES BLOOD SERVICE WORKFORCE AND ORGANISATIONAL CHANGE WORKSTREAM The Committee received an update on the progress being made by the workstream noting that the key points were that the recruitment of the North Wales Stock Holding Unit is scheduled to commence in January & February The Committee noted the progress made on the TUPE Due Diligence action plan was on track to achieve its project plan. The Assistant Director of WBS expanded with information about a footprint review at Talbot Green, the transition of the Donor contact working times and the readiness to launch the consultation process imminently. There will be a change to working hours for some staff to provide an 8.00am to 8.00pm service. Part of the recruitment drive is around there needing to be Welsh language cover at all times in the contact centre. There may be some changes to contracts and these changes will be managed under the Whitley short term protection policy. 3.7 NCC-C STAFF TUPE TRANSFER UPDATE An update was provided on the progress to date on the TUPE transfer arrangements to the Royal College of Obstetrics and Gynaecology (RCOG). It was reported that the RCOG continue to provide monthly updates and have visited NCC-C on a number of occasions to ensure that there is full engagement. One to one meetings had also been scheduled with RCOG representatives as part of the consultation process. 3.8 WORKFORCE PERFORMANCE REPORT The Assistant Director of Workforce (Interim) spoke about the increase in sickness levels and the need to go back to basics around managing people particularly around hotspots and short term sickness. The Senior Workforce Business Partners will be attending SMTs to present the areas of concern. The Director of OD & Workforce shared that Business Intelligence can give an immediate view of sickness in a team. Managers need to input the information into the self service system SMT s need to be talking to their managers to highlight the benefit from this function. The Chair noted that we are not where we need to be with mandatory and statutory training. However, the Assistant Director of Workforce (Interim) shared that the introduction of the Pay Page 3

98 4 WOD Committee Highlight Report Progression policy will pick this up along with PADRs as needing to be completed to progress through pay scales and the importance of personal accountability around these targets. 3.9 WORKFORCE AND OD KEY ISSUES The Director of OD and Workforce presented the highlight report to inform the Committee of key areas of importance and significance and in particular workforce issues outlined in the IMTP. The Committee was provided an update on the early work that had commenced on the workforce elements of the TCS. The Committee noted the contents of the report JUNIOR MEDICAL STAFFING The Assistant Director of Workforce (Interim) provided the committee with a detailed update on progress to date and future plans to address the Junior Doctor Staffing levels across VCC. Monthly meetings are being conducted by the Clinical Director and in addition to clinical representative s workforce and finance colleagues also attend. It was noted at the last 20 Deanery meeting that considerable progress had been made by Velindre to address a number of issues previously highlighted Nurse Revalidation The Chair noted that the wording on point 6 on the risk log needed to be amended from unclear. The Assistant Director of OD & Workforce updated that nurse revalidation communication has increased with Lisa Wilks taking up post. 4. NEXT STEPS The Trust Board is requested to NOTE the contents of the report and actions being taken. Page 4

99 PUBLIC TRUST BOARD WORKFORCE & OD UPDATE REPORT Meeting Date: 28 th January 2016 Author: Sponsoring Executive Director: Report Presented by: Committee/Group who have received or considered this paper: Workforce & OD Team Sarah Morley Executive Director of OD and Workforce Sarah Morley Executive Director of OD and Workforce Trust Resolution to: (please tick) Approve: Endorse: Discuss: Note: Recommendation: This report supports the following Trust objectives as set out in the Integrated Medium Term Plan: (please tick) Equitable and timely services Providing evidence based care and research which is clinically effective Supporting our staff to excel Safe and reliable services First class patient /donor experience Spending every pound well

100 2 Workforce and OD Update Report 1. Introduction / Background: The report reflects the specific workforce priorities required to ensure that staff are supported to excel. 2. Timing: This report covers the period December 20 to January Description: This report provides an update on the Workforce and OD elements of the Trust s Three Year IMTP Delivering Excellence and current workforce and OD issues of importance or significance. A Productive, Healthy Workforce: ESR Self-Service Although training in the use of ESR Self-Service has largely been completed across the Trust there are two groups of staff who have not yet implemented the system: WBS Collection Teams the Workforce team are awaiting confirmation of implementation from Donor Services, and will plan/deliver training according to blood collection timetables. VCC medical staff implementation discussions are ongoing between the Workforce Business Partner and VCC Clinical Director. The function s ESR hierarchy has been drafted, and is subject to approval prior to training and system implementation. Overall, some one-to-one training is still being delivered by members of the Workforce team, which is enabling new staff, or those who have missed training to learn about the system; and others to refresh their understanding of the system through targeted follow up or advice sessions. Use of the all the system s functionality remains piecemeal, with some staff/departments embracing self-service, while others are more reluctant to cast off paper-based ways of working. It is hoped that online activity will increase become more confident in their use of the system. IBM are completing preparations for the revised ESR Enhance functionality. Learning Management module has been viewed and will be more intuitive for users including much improved screen layouts and course management administration options. Velindre NHS Trust s role as a Pilot Site for ESR Enhance has been postponed due to a decision by IBM to delay national implementation. Learning Administration and Employee Self Service are the first modules of ESR being improved, and latest timescales indicate that these will be released to the Pilot sites in June A representative from Learning & Development is attending in January, the rollout and toolkit workshop in Sheffield in preparation for taking forward this revised and improved version. PADR Working Group Page 2

101 3 Workforce and OD Update Report The PADR Working Group is nearing the end of its 12 month tenure, and due to conclude its work in June The group is currently working on a range of actions to support embedding good PADR activity into day-to-day activities and prepare for the implementation of the NHS Wales Pay Progression Policy and Nursing Revalidation: Revising the Trust s PADR paperwork to align with the Trust s approved Values and to incorporate the requirements of the Pay Progression Policy and Nursing Revalidation. Working in partnership with Workforce and Informatics colleagues to communicate incremental dates to managers and enable alignment with PADR activity. Ongoing analysis of workforce metrics to draw performance correlations which relate to PADR activity. E.g. data suggests that a Velindre NHS Trust department is 71% more likely to achieve its sickness absence target (3.54% or less) if it achieves the IMTP PADR activity target (75% or more). Devising the Trust s Pay Progression criteria, which were approved by EMB in December 20. Furthermore, the group have supported a recent Internal Audit into PADR activity and will shortly be commencing a review/refresh of the Trust s PADR Policy in order to ensure it includes appropriate guidance to support implementation of the Pay Progression Policy, ESR Self-Service and Nursing Revalidation. Finally, membership of the group now includes Staff Side representation, with Margaret Thomas (UNISON) advising on 12 th January that she will join the group for the remainder of its tenure. Health and Wellbeing update The Organisation s Health and Wellbeing Framework was approved by the WOD Committee in December 20. The framework sets out the NHS National and Local drivers that articulate key workforce challenges relating to an ageing workforce, prudent Health care and organisational change. As a result of Dr Steve Boorman s review into What matters to staff in the NHS in 2008, the department of health developed the Five High Impact Changes that focuses on enabling NHS organisations to develop and embed health and wellbeing into and across the NHS. The five High Impact Changes are: 1. Developing Local Evidence Based Improvement Plans 2. With strong visible leadership 3. Supported by improved management capability 4. With access to better, local, high-quality accredited Occupational Health services 5. Where all staff are encouraged and enabled to take more personal responsibility By implementing the five High Impact Changes this will help: Improve the health and wellbeing of staff Reduce sickness absence levels Improve line manager capability Deliver improved patient care and outcome As our values underpin everything we do, the Health and Wellbeing Framework uses our organisational values and the five high impact changes to theme our actions to support the health and wellbeing of staff in the context of the evidence and best practices. Page 3

102 4 Workforce and OD Update Report Velindre NHS Trust s Organisational Development Strategy : Building Excellence: helping each other to be great Having been approved at December Trust Board work is ongoing to plan the next steps. Specifically this involves: The development of a communication and engagement plan to support the introduction of the Velindre NHS Trust Building Excellence Organisational Development Strategy, embed the Trust values within the organisation, and to enable a shared understanding of Strategy s key messages. Ongoing discussions with staff about the Strategy and values and behaviours including attendance at the WBS Staff Forum. Mapping out the programme of work over the next 12 months, and Starting to understand the baseline assessment. Partnership Working As we embark on a period of organisational and cultural change across the Trust, strong and effective relationships with staff and their representative organisations are increasingly important to ensure that staff voice is heard in everything we do. Continuing constructive dialogue with Trade Union Organisations at the Local Partnership Forum is important to ensure open and honest dialogue enabling the early resolution of issues as close to the source as possible. Following the Partnership Working, held in September 20, draft Standards for Partnership Working have been developed jointly to establish the expected contribution and behaviours to which both management and Trade Unions will adhere. The draft document which includes a partnership working pledge was approved by the Partnership Forum and is going to both SMTs for discussion prior to going to Executive Board. Electronic Rostering A business case went to Executive Management Board on 17 th December seeking agreement to the investment in an electronic rostering / workforce management system. This is intended to be deployed initially across various staff groups within the Velindre Cancer Centre and Welsh Blood Service. During January the Project Lead is attending WBS and VCC SMTs to discuss the business case, likely costs and application of the system including potential productivity benefits. A stakeholder meeting is planned at VCC to work towards a user requirement specification and a technical specification required to inform the procurement process. A Transformed, Modernised Workforce delivered through; Donor Contact Centre The WBS faces a huge modernisation agenda in order to support the establishment of the All Wales Blood Service whilst ensuring that existing donors receive an improved service and new donors are continuously recruited in order to maintain blood stock levels. Future blood collection activity is estimated to increase by approximately 25% with the introduction of North Wales and in readiness for the service change, WBS has recognised the importance of improved telephony and donor contact services to support the recruitment and retention of donors. Page 4

103 5 Workforce and OD Update Report The WBS is proposing to redesign both the Donor Relationship Management and Donor Records functions to enable the formation of a new and enhanced Donor Contact Centre at Talbot Green HQ. Donor data and activity levels across South Wales and NHSBT have been analysed alongside workshops with management, staff and their representatives and formal consultation in relation to these proposals commenced on 14 th December 20. Staff and their representatives have been provided with the opportunity to take part in engagement sessions and informal drop-in clinics throughout the month of December. Formal one-to-one meetings with staff and trade union colleagues commenced on 12 th January 2016 and the formal consultation period is due to end on 22 nd January Consultation has been carried out in line with the NHS All Wales Organisational Change Policy (OCP) and supports the principle of ensuring the WBS retains the valuable knowledge, skills and experience of its existing workforce. The WBS will be looking to recruit additional Donor Contact Centre Advisors to support the proposed new model and increase the availability of Welsh Language staff for donors. Implementation will commence following the consultation period and WBS will continue to engage with staff and work in partnership with trade unions throughout the process. N-CCC The Royal College of Obstetricians & Gynaecologists (RCOG) have undertaken a series of one to one meetings with NCC-C employees who will be transferring on 1 st April Monthly newsletters continue to provide updates and provide answers to questions raised as part of the pre-transfer engagement. To support the transfer and the working arrangements post transfer the RCOG have secured a 13 month lease on office accommodation within Brunel House, Cardiff. The RCOG are keen to trail the longer term working from home arrangements and have asked for volunteers to pilot pre transfer. The Assistant Director of Workforce will continue to attend the NCC-C team meetings and liaise with the RCOG Workforce lead to ensure that the actions detailed in the Due Diligence action plan are undertaken and completed in a timely manner. Andrea Jones, UNITE Representative will also be attending future meetings on behalf of the UNITE members. Transforming Cancer Services GE Healthcare Finnamore have worked with representatives of the Trust to construct a model based on the activity data and projections developed by the TCS Clinical Workstream as part of the proposed service model and staffing information from the General Leger. The model will map the workforce required to meet the activity projections by modelling the wte across a range of roles needed to deliver various units of activity e.g. an outpatient appointment. Introduction meetings have taken place with managers to show them the model, identify any adjustments required and to prepare managers for the modelling meetings. Modelling of the workforce and associated costs will be undertaken during the middle of January and a first cut of the workforce and associated costs will be made available by the end of January 2016, prior to discussion with the Health Boards. Meetings with Trust representatives are being scheduled to consider the first cut of the data prior to discussion with Health Boards. Further work will then be undertaken to refine the modelling, develop the workforce assumptions and scenarios and check the impact across services in preparation for the development of the workforce elements of the business case. Page 5

104 6 Workforce and OD Update Report Work has also commenced to scope the requirements of the strategic workforce plan. A workforce vision is being developed in line with the overall workforce vision for the Trust and the OD Strategy and a document which will articulate the workforce planning process, engagement and timelines for our staff, managers and partners. The terms of reference for the Workforce Education and Training Workstream are also to be reviewed to progress the workforce transformation activity beyond that of the development of the Business Cases, to include ongoing workforce modernisation and to ensure wider partnership working during this longer term piece of work. I A Skilled and Flexible Workforce facilitated by; Leadership Development: A paper outlining the plans for a third Leadership Development cohort was submitted to the EMB for approval in January 20. Following this, the invitation to apply will be issued via Divisional SMT s and all User by the end of January 2016, with the programme scheduled to commence in April. Further plans to create a Velindre NHS Trust Building Excellence Alumni to support ongoing support and development of leadership skills are also outlined in the EMB paper, and assuming approval will be implemented by 31 st March IQT training Three IQT Silver cohorts are scheduled to be delivered by the VCC Service Improvement team. Two delegate places will be made available to each of WBS and Corporate Division staff on each course. The Senior OD Business Partner has been working with the WBS and VCC Service Improvement teams to establish a collaborative and sustainable approach to IQT training for 2016 and Agreements are in draft format and a final meeting will be facilitated in late January 2016 to finalise plans. Each successfully completed IQT Silver Improvement Project is now being sent to the CEO for review and, assuming concept approval by the EMB at their January meeting, IQT Silver delegates will also be invited to join the Velindre NHS Trust Building Excellence Alumni group. NHS Wales Staff Survey The NHS Wales Staff Survey 2016 is being planned for national rollout in June A small Velindre NHS Trust implementation team is being established to include IT, Communications, Informatics, Workforce and Staff Side colleagues. Further information will become available over coming weeks/months. Work Experience: Foundation Programme Doctors taster weeks have been planned with 4 intakes in 2016 with a maximum 3 doctors per taster. An Open Day has been arranged in November 2016 to encourage FP doctors and Core Medical Trainees to choose Oncology as a career. Page 6

105 7 Workforce and OD Update Report In addition, structured medical work experience with 2 intakes organised for 2016 with 3 students per intake and ad hoc departmental work experience requests have been organised in conjunction with the identified departments. LIFT placements continue with 2 placements currently within Velindre Cancer Centre, 1 in Education and Development department and the other in Pharmacy. There is a potential porter placement in the new year. Due to the minimal administration support currently available within the Education and Development team, the promotion and co-ordination of LIFT placements will be fully restored once the Workforce and OD restructure has been fully implemented. Sickness Absence Training and Pay Progression To support the implementation of the new All Wales Sickness Absence policy, to date eight awareness/training sessions have been delivered to approx 100 managers/supervisors. The majority of the training sessions have been delivered in partnership with TU colleagues. Additional sessions are currently being scheduled for January & February. In addition, the sessions have also covered the implementation of the All Wales Pay Progression policy which has been developed to support the application of amendments to the Career and Pay Progression sections of the National Pay and Terms and Conditions which apply to Agenda for Change staff. The Pay Progression Policy needs to work closely with the Appraisal Process and therefore sets out some best practice principles for appraisal that the Trust should embed in their local processes. It has been agreed by EMB that core objectives for all staff will be implemented to support the PADR process and embed the Trust Values. The core objectives are: All Employees 100% compliance with your essential statutory training requirements as set out in the NHS Core Skills Training Framework Engagement with your own PADR in the past 12 months Sustained and meaningful commitment to personal objectives in line with the organisations IMTP and Organisational Values Manager/ Supervisor 100% compliance with your essential statutory training requirements as set out in the NHS Core Skills Training Framework 100% compliance for your team s essential statutory training requirements Engagement with your own PADR in the past 12 months 100% Completion for each member of your team with their PADR Sustained and meaningful commitment to personal objectives in line with the organisations IMTP and Organisational Values Demonstrable commitment to engage staff with the creation and delivery of IMTP objectives and align team activities / behaviours to Organisational Values It is important that all employees have an opportunity to contribute to the development of the services that they work within. Therefore, to ensure that all employees are aware of their departmental agreed objectives outlined in the Trust IMTP, there should be a clear link between Page 7

106 8 Workforce and OD Update Report the IMTP and employee and team objectives. To support the embedding of the Trust Values all employees should be able to demonstrate their understanding and commitment to work within the agreed framework. Managers will need to meet with their staff for the Pay Progression/PADR discussions before the employees incremental dates. As such, it has been agreed (All Wales) that the roll out of the policy to be undertaken in three stages: Band st April 2016 Bands 5 & 6 1 st October 2016 Remaining Bands 1 st April 2017 ESR data is currently being made available to managers so that they are able to schedule PADR meetings in line with employee s incremental dates. 4. Financial Impact: The paper has outlined initiatives (Pay Progression, Benefits Realisation of ESR, Electronic Rostering) to support the development of a productive and efficient workforce which will have a positive financial impact. 5. Quality, Equality, Safety and Patient Experience Impact: The four key outcomes of the Trust OD Strategy is: Values Driven culture; Excellent patient and donor experience; World class performance and productivity, and; Organisational flexibility and resilience. The interventions identified through the strategy will impact in these areas across the whole organisation. 6. Considerations for Board / Committee: The Board is requested to NOTE the contents of the report and actions being taken. 7. Next Steps: Work will continue as per agreed timescales for the different programmes of work. Page 8

107 TRUST BOARD HIGHLIGHT REPORT FROM THE CHAIR OF THE TRANSFORMING CANCER SERVICES IN SOUTH EAST WALES COMMITTEE Meeting Date: 19th January 2016 Author: Sponsoring Executive Director: Report Presented by: Committee/Group who have received or considered this paper: Carl James, Director of Planning, Performance & Estates/ Programme Director Carl James, Director of Planning, Performance & Estates/ Programme Director Paul Griffiths, Independent Member Transforming Cancer Services in South East Wales Committee Trust Resolution to: (please tick) Approve: Endorse: Discuss: Note: Recommendation: To note the contents of this report. This report supports the following Trust objectives as set out in the Integrated Medium Term Plan: (please tick) Equitable and timely services Providing evidence based care and research which is clinically effective Supporting our staff to excel Safe and reliable services First class patient /donor experience Spending every pound well

108 2 Highlight Report 1. INTRODUCTION / BACKGROUND: This paper had been prepared to provide the Board with details of the key issues considered by the Transforming Cancer Services Committee at its meeting on the 19 th January TIMING The Transforming Cancer Services Committee met on 19 th January 2016 as part of its normal cycle of meetings. 3. CONSIDERATIONS FOR BOARD / COMMITTEE At the meeting, the Committee considered issues and can provide assurance to the Board on the issues delegated to them through the Trust Standing Orders relating to the following key items; I. CONSIDERATION OF EXTERNAL/INDEPENDENT REPORTS/REVIEWS (e.g. WAO reports, HIW, WG policies/initiatives.). None. II. CONSIDERATION OF INTERNAL CONTROL ISSUES (e.g. Internal Audit Reports, system effectiveness, resource management.) None. III. IV. ITEMS ENDORSED BY COMMITTEE FOR FURTHER CONSIDERATION BY FULL BOARD (e.g. policies, business cases, reports.) None. TRUST RISK REGISTER (explicit reference should be made to the risks discussed and any direction agreed by the Committee to help mitigate/reduce the risk) The Transforming Cancer Services Programme Risk Register was discussed with a number of risks considered at length. TCS03: Loss of key staff during the programme. It was reported that the Programme Manager was required to undertake national work and an iterim replacement was now in place and whilst the substantive post is out to advert. TCS07: Inability to recruit Specialist Advisors within required timeframes. It was reported that the Trust still does not have access to financial advisors. They have been appointed through a national procurement exercise led by the Welsh Government and the Trust expected them to be available at the end of October 20. This has increased the risk of delivering the business cases in accordance with the programme timelines. Page 2

109 3 Highlight Report The Programme Director has written to the Welsh Government setting out the Trusts concerns and the potential programme delays that this may cause. P03-25: delay risk arising from lack of Welsh Standard Form. The Trust has been undertaking soft market testing with a number of high-profile contractors in order to stimulate market interest in the programme and infrastructure project. One of the main issues raised by the organisations we have met is the absence of a Project Agreement to allow them to understand the Welsh Government/Velindre NHS requirements to determine whether they will bid for the contract. Similarly, the Standard Form of Contract is not available as it is not yet able to understand the potential commitment of the project, the risks and all related matters. Potential bidders have been keen to ensure that they understand these issues and have raised concerns that they have nothing available to them to assess. The Programme Director has written to the Welsh Government setting out the Trusts concerns and the potential programme delays that this may cause. TCS21: Unable to reclaim VAT on advisors fees in full. Discussions are ongoing between the Trust and various partners with regard to the definition of the guidance and its interpretation. This is a national issue which the Welsh Government is aware of. V. OTHER ISSUES FOR BOARD CONSIDERATION None. VI. OTHER ISSUES FOR THE BOARD TO NOTE FOR INFORMATION The Board is asked to note the following information. a. Review of Terms of Reference of the Committee. The terms of reference of the committee are being reviewed. This is expected to conclude in March b. Emerging Issues. The committee received a presentation which highlighted a number of emerging issues which require resolution in order for the programme to progress the business cases. These include office and clinical accommodation, the location of the Trust headquarters, the potential for a seven day service amongst others. The programme team is currently assessing these to determine which are operational management issues and which require a Board decision. c. Clinical Service Model. The committee received a report which highlighted the successful conclusion of the initial clinical service design stage of the programme. This culminated in a conference held on the 12 th January 2016 which have wide stakeholder attendance including patients, Local Health Boards, third sector and the Welsh Government. The Committee also received a set of revised planning assumptions for each of the services. These will continue to develop as the modelling work comes to a conclusion. Page 3

110 4 Highlight Report 4. NEXT STEPS The Trust Board is requested to NOTE the contents of the report and actions being taken. Page 4

111 1 Month 9 Finance Report TRUST BOARD FINANCE REPORT MONTH 9 DECEMBER 20 Meeting Date: 28 th January 2016 Author: Sponsoring Executive Director: Report Presented by: Committee/Group who have received or considered this paper: Tony Virgo, Deputy Director of Finance Mark Osland, Interim Executive Director of Finance Mark Osland, Interim Executive Director of Finance Planning and Performance Committee Trust Resolution to: (please tick) Approve: Endorse: Discuss: Note: Recommendation: The Trust Board are asked to DISCUSS and NOTE the December Finance Report This report supports the following Trust objectives as set out in the Integrated Medium Term Plan: (please tick) Equitable and timely services Providing evidence based care and research which is clinically effective Supporting our staff to excel Safe and reliable services First class patient /donor experience Spending every pound well Page 1

112 VELINDRE NHS TRUST FINANCE REPORT MONTH 9 - DECEMBER 20 CONTENTS 1. Executive Summary 2. Divisional Performance 3. Summary of Hosted Organisations 4. Appendix 1 Summarised Financial Statement 5. Appendix 2 Summary of Budget Movements 6. Appendix 3 Performance Against Savings Plans 7. Appendix 4 Summary of Capital Programmes 1

113 1. EXECUTIVE SUMMARY The Trust submitted a balanced Integrated Medium Term Plan, covering the period to to the Welsh Government on 31 March 20. This was approved by the Minister on 2 June 20. The Trust set a balanced budget for each year of the Plan period and had a total annual revenue budget of 95m (excluding hosted organisations) for The Plan was prepared on the basis of no increase in core funding from Health Boards and consequently as a result of identified inflationary and service costs pressures is required to deliver 3.6m (5.5% of our controllable budget) of savings in Summary of Annual Budgets as at Month 9 Division Cancer Centre Welsh Blood Service Corporate Capital Charges/Non Delegated Sub Total Core Services Staff 000s 29,219 13,059 4,885 47,163 Non Staff 000s 27,247 17,005 (3) 5,347 49,596 Total 000s 56,466 30,064 4,882 5,347 96,759 Hosted Organisations 86, ,1 339,986 Total Revenue Budgets 133, , ,745 Capital Expenditure Limit (Exc Hosted Organisations) 11,869 SUMMARY OF PERFORMANCE TO MONTH 9 (Excluding Hosted Organisations) Key Financial Targets (Figures in parenthesis signify an adverse variance against plan) Year to Date Revenue Expenditure variance - Underspend 000s Rag Status 17 G Year to Date Variance Against Planned Savings Under achievement (654) R Year to Date Actual Capital Expenditure 2,801 G Public Sector Prompt Payment Performance 93% R 2

114 REVENUE EXPENDITURE Statutory Target To ensure net operating costs do not exceed total income. YTD Previous Month 000s YTD Current Month 000s Year End Forecast Income variance Expenditure Variance Pay Non Pay (899) (1,093) 0 Year to Date Net Revenue Expenditure Variance The reported net revenue expenditure position for Velindre s core services as at the end of December 20 is a surplus of 17k. This is a decrease of 21k from the previous month. After adjusting for the over achievement on income of 491k within WBS wholesaling activities, there is a cumulative positive variance of 301k on income. This relates primarily to an over achievement within clinical trials, drugs for private patients and income from CRW for research. The positive variance reported against pay costs at the end of December is a consequence of from reduced costs resulting from a number of vacancies which remain unfilled across the Trust and the transfer of costs of staff supporting the Transforming Cancer Services Programme. As reported previously the overall Trusts revenue position reflects contrasting positions within the individual divisions. An overspend within the Cancer Centre and Corporate is offset by a significant underspends within WBS. Further details are provided within section 2. SAVINGS YTD Previous Month 000s YTD Current Month 000s Variance against Planned Savings Schemes Under achievement (460) (654) 3

115 The Trust has set an overall savings target of 3.636m for the year with 2.774m planned to be delivered by the end of December. The shortfall to date of 0.654m is primarily associated with savings planned to be delivered within the Cancer Centre associated with service quality and efficiency reviews, procurement and the homecare chemotherapy project. The Chief Executive and a small group of Executive Directors and senior management are currently meeting fortnightly to continue the oversight of progress against the delivery plans and to determine further action that needs to be taken in both this financial year and for the next. Savings shortfalls have been built into the Trust outturn forecast. A detailed analysis of all our savings schemes is shown in Appendix 3. Year End Revenue Forecast Outturn The Trust continues to forecast a breakeven position to the end of March Key Risks and Opportunities The savings target for the year is very challenging. Work is progressing, as highlighted above, to develop additional plans. However it is unlikely that the savings plans identified at the beginning of the year within the IMTP for the Cancer Centre will be achieved. Departmental measures to absorb this year s pay increments are heavily weighted to ad hoc vacancy savings. Radiotherapy capacity remains a real challenge with the Trust continuing to rely on substantial levels of Agency staff. Expenditure on radiotherapy agency staff to month 9 is 465k. No assumption has been made for an increase in our baseline Income from our commissioners. However an amount of 396k has been built into the forecast outturn to reflect an increase in marginal activity. This is a key risk. Further opportunities to generate additional efficiencies and reduce costs above planned levels within the Blood Service are continuing to be identified. These are significant in the current year with the potential of offsetting the current forecast overspend within the Cancer Centre. 4

116 CAPITAL EXPENDITURE Administrative Target - To ensure that net Capital expenditure does not exceed the Capital Expenditure Limit (CEL) approved by the Welsh Government. - To ensure the Trust does not exceed its External Financing Limit The Trust has currently been issued a Capital Expenditure Limit (excluding hosted organisations and charitable funded capital schemes) for 20/16 of 11,869k. Approved CEL 000s YTD Spend 000s Year End Forecast 000s All Wales Capital Programme 8,829 2,306 8,829 Discretionary Capital Sub Total 3, , ,705 3, ,869 Charitable Funded Capital Schemes TOTAL 11,965 2,801 11,965 Uncommitted Discretionary Capital Funding 190k The current approved Capital Expenditure Limit of 11,869k incorporates funding from the All Wales Capital Programme 8,829k and discretionary funding of 3,040k. The Trust s discretionary capital allocation includes 1,500k for the pre-fabricated building and enabling works associated with the replacement of the linear accelerator in bunker 2. In addition, the Trust is expecting capital schemes totalling 348k to be funded by charitable donations. The discretionary capital budgets have 190k remaining available at the end of December. The actual expenditure at the end of December is 2,801k. There is a detailed programme in place to deliver against this overall CEL and we are confident the Trust will outturn on budget. More details can be found within Appendix 4. 5

117 Public Sector Prompt Payment Compliance Administrative Target To pay 95% of non NHS invoices within 30 days measured against number of invoices paid. YTD Previous Month YTD Current Month Public Sector Prompt Payment Performance 93% 93% An analysis of invoices paid within December 20, showed that there was an issue with some pharmacy batches. This contributed an in month decline against the target. In addition to this Accounts Payable (shared services) staff have cleared a significant backlog of invoices aged over 50 days. The in month effect of these was around 3%. These two issues contributed to the decline in the cumulative target. The cumulative performance would have been in line with last month if the above had not occurred A meeting has been organized between finance, pharmacy and shared services staff to understand the issues causing the failure to ensure there is no re-occurrence in future. An ongoing programme of work is being carried out to improve the efficiency of the P2P process. 2. Summary of Divisional Financial Performance Annual Budget Year to Date Budget In Month Variance Year to Date Variance Year End Forecast Variance Income Trust Cancer Centre Blood Service Corporate Total 52,435 38, ,131 23, ,341 8, ,758 71,

118 Expenditure Cancer Centre Blood Service Corporate Total 56,465 41,371 (124) (910) 0 30,064 21,855 (36) ,882 3,794 (5) ,411 67,020 (165) (774) 0 Capital Charges 4,970 4, Non Delegated Trust Total 0 0 (21) 17 0 Non Delegated Budget The Trust is currently holding a non delegated contingency balance of 377k. This has reduced by 110k during the month to reflect the transfer to VCC to cover the costs of the Linacc breakdown. Further consideration will be given to releasing additional non recurring funds as we progress through the financial year. Decisions to release further funding will take into account the overall Trusts financial position and be based on evidence of operational need. Detailed Divisional Income & Expenditure Performance Cancer Centre Cancer Services Annual Budget Year to Date Budget In Month Variance Year to Date Variance Year End Forecast Variance Income 31,131 23, Expenditure - Staff 29,219 21,897 (43) (132) 0 - Non Staff 27,246 19,474 (81) (778) 0 - Sub Total 56,465 41,371 (124) (910) 0 TOTAL 25,334 17,779 (121) (723) 0 7

119 The financial position for Cancer Services as at the end of December is an overspend of 723k against the divisions expenditure control limit. Income The cumulative favourable variance of 187k continues to be primarily made up of clinical trials drugs and private patient drugs overachievement of targets. Expenditure The cumulative staff overspend is a combination of an overspend within radiotherapy of 183k, (agency staff cost to date are 465k), Pharmacy overspend of 48k due to the non achievement of the staff CIP and the Private Patient office overspend of 21k as a result of covering for a member of staff on long term sick leave. These overspends are offset by staff vacancy savings in a number of other departments. The non pay overspend to date of 778k includes non achievement of savings plans to date of 646k plus departmental overspends in; Radiotherapy - 214k Physics - 196k General drugs - 125k These overspends are offset by numerous smaller underspends in other departments. Welsh Blood Service (WBS) Welsh Blood Service (WBS) Annual Budget Year to Date Budget In Month Variance Year to Date Variance Year End Forecast Variance Income 12,341 8, Expenditure - Staff 13,059 9, Non Staff 17,005 12,193 (109) (178) 0 - Sub Total 30,064 21,855 (36) TOTAL 17,724 12, The financial position for the WBS as at the end of December is an underspend of 729k against the divisions expenditure control limit. Income The favourable income variance of 598k includes: Wholesaling (offset by an overspend within non pay) - 491k WBMDR income - 69k Bone Marrow Hub - 77k Plasma sales - 20k FFP Income - 14k Renal activity ( 85k) 8

120 Expenditure The cumulative staff underspend of 309k is due to vacancy savings in numerous departments in excess of the vacancy savings target of 400k. At the end of December approximately 12 posts remain unfilled. The non staff overspend of 178k includes: Overspend on Wholesaling (offset by an over achievement in income) - 473k Underspends against all operational and support functions - 242k A major contributory factor to the significant underspends across all operational departments is a dip in demand plus the roll out and implementation of BECS which resulted in low activity and spend during this period. Corporate Services Corporate Services Annual Budget Year to Date Budget In Month Variance Year to Date Variance Year End Forecast Variance Income Expenditure - Staff 4,885 3,725 (1) Non Staff (5) 69 (4) (136) 0 - Sub Total 4,880 3,794 (5) 5 0 TOTAL 4,029 4, The financial position for Corporate Services as at the end of December is an overspend of 10,000. The staff underspend of 141k is due to the current level staff vacancies and the transfer of corporate costs for those staff supporting the Transforming Cancer Services Programme. The non pay overspend is mostly is due to the loss of income due to Public Health Wales now undertaking a number of corporate functions directly. 3. HOSTED ORGANISATIONS The Trust has a number of hosted bodies that form part of the overall Trust ledger and year end statutory accounts NHS Wales Informatics Service (NWIS), NHS Wales Shared Services Partnership (NWSSP), National Collaborating Centre for Cancer (NCC-C) and Health and Care Research Wales Workforce. 9

121 The hosting agreements with these organisations mean that the financial positions within the Velindre ledger and statutory accounts at the end of the financial will be breakeven. Summary of Hosted Bodies Budgets Hosted Budgets Annual Budget 000 NWIS 58,282 NWSSP 276,069 NCC-C 1,010 Health and Care Research Wales Workforce 4,625 Total 339,986 NWIS NWIS (Hosted) Annual Budget Year to Date Budget In Month Variance Year to Date Variance Year End Forecast Variance Income 58,282 41, Expenditure - Staff 20,579,040 (4) Non Staff 37,703 26,837 (97) (31) 0 - Sub Total 58,282 41,877 (101) 23 0 TOTAL As a hosted organisation the planned position to be reported in Velindre s books each month is breakeven. NWSSP NWSSP (Hosted) Annual Budget Year to Date Budget In Month Variance Year to Date Variance Year End Forecast Variance Income 276, ,229 (9) Expenditure - Staff 61,342 45, , Non Staff 214, ,019 (192) (1,859) 0 - Sub Total 276, ,229 9 (173) TOTAL

122 As a hosted organisation the planned position to be reported in Velindre s books each month is breakeven. Other Hosted Bodies Other Hosted Bodies Annual Budget Year to Date Budget In Month Variance Year to Date Variance Year End Forecast Variance Income 5,635 4, Expenditure - Staff 4,914 3,665 (2) (31) 0 - Non Staff (12) (30) 0 - Sub Total 5,635 4,161 (14) (61) TOTAL Other Hosted bodies includes: - National Collaborating Centre for Cancer and Health and Care Research Wales Workforce. The combined position for these hosted organisations as at the end of December is breakeven. 11

123 VELINDRE NHS TRUST Appendix 1 FINANCIAL STATEMENT FOR THE PERIOD ENDED 31st December 20 Budget Actual Annual < Current Period > < Cumulative > WTE WTE Variance Budget Budget Actual Variance Budget Actual variance Trust Income & Reserves Income (52,435,382) (4,553,683) (4,553,870) 187 (38,086,440) (38,088,123) 1,683 Staff Non Staff 5,807,760 5,249 5,673 (424) 4,693,460 4,695,559 (2,099) Total (46,627,622) (4,038,434) (4,038,197) (237) (33,392,980) (33,392,564) (416) Cancer Services Income (31,131,102) (2,514,632) (2,517,646) 3,014 (23,591,859) (23,779,210) 187,351 Staff ,218,732 2,444,620 2,487,5 (42,536) 21,896,356 22,028,429 (132,073) Non Staff 27,246,626 2,333,409 2,413,533 (80,124) 19,474,321 20,252,346 (778,024) Total ,334,256 2,263,397 2,383,042 (119,645) 17,778,818 18,501,564 (722,746) Welsh Blood Service Income (12,340,561) (1,013,691) (1,145,629) 131,938 (8,930,401) (9,528,792) 598,391 Staff ,059,440 1,120,708 1,047,562 73,146 9,662,066 9,352, ,233 Non Staff 17,004,682 1,374,438 1,483,982 (109,544) 12,193,077 12,370,775 (177,698) Total ,723,561 1,481,455 1,385,9 95,540 12,924,742 12,194, ,925 Corporate Income (850,980) (48,975) (58,207) 9,232 (704,070) (708,631) 4,561 Staff ,884, , ,043 (1,308) 3,724,758 3,584, ,5 Non Staff (463,770) (44,176) (40,686) (3,490) (331,242) (196,428) (134,814) Total ,570, , ,1 4,435 2,689,446 2,679,184 10,262 Hosted - NWIS Income (58,282,192) (4,366,251) (4,467,1) 100,900 (41,877,045) (41,899,575) 22,530 Staff ,579,062 1,695,328 1,699,450 (4,122),040,060,032,164 7,896 Non Staff 37,702,766 2,670,924 2,767,701 (96,778) 26,836,985 26,867,411 (30,426) Total (364) Hosted - NWSSP Income (276,069,067) (31,947,798) (31,938,491) (9,307) (192,229,307) (192,402,176) 172,869 Staff 1, , ,341,566 5,620,562 5,419, ,105 45,210,503 43,524,345 1,686,8 Non Staff 214,727,501 26,327,236 26,519,034 (191,798) 147,018, ,877,832 (1,859,028) Total 1, , (0) Hosted - Other Income (5,635,393) (459,334) (473,366) 14,032 (4,161,112) (4,221,878) 60,766 Staff ,914,457 4, ,846 (1,951) 3,664,650 3,695,286 (30,636) Non Staff 720,936 43,437 56,630 (13,193) 496, ,484 (30,049) Total (3) 1,109 (1,112) (26) (108) 82 TOTAL TRUST Income (436,744,677) (44,904,364) (45,4,360) 249,996 (309,580,235) (310,628,386) 1,048,2 Staff 3, , ,998,176 11,683,848 11,459, ,335 99,198,393 97,217,300 1,981,093 Non Staff 302,746,501 33,220,516 33,7,866 (495,350) 210,381, ,393,979 (3,012,138) Total 3, , (0) 21,019 (21,020) 0 (17,107) 17,107

124 Select Current Month Appendix 2 DECEMBER (Month 9) Reconciliation of Income and Expenditure Budget Movements Trust Income VCC WBS Corporate Trust Total Month 8 (Nov) DECL (52,424) 25,224 17,724 3,570 5,906 0 Month 9 (Dec) DECL (52,435) 25,334 17,724 3,570 5,807 0 Income budget Movement (11) (4) (4) Analysis Donated Depreciation additional WG funding (50) (50) Asset impairment WG funding Adjustment Increased Non Velindre Drugs income - offset with Non Pay IPP Funded drugs - offset with Non Staff Expenditure 0 (26) (26) CTU - Offsets with Staff Expenditure 0 (6) (6) Top Up Drugs - Offsets with Non Staff Expenditure Reduce staff recharge income - offset with Staff budget (11) (4) (4) Staff budget Movement 0 6 (11) 0 0 (5) Analysis CTU - Offsets with income Reduce staff budget - offset with income recharge 0 0 (11) 0 0 (11) 0 6 (11) 0 0 (5) Non Staff budget Movement (11) (99) (2) Analysis Donated Depreciation additional WG funding (50) Asset impairment WG funding Adjustment (39) 0 Reserve Funding for Linacc breakdown (110) 0 Non Velindre Drugs income - offset with Income 0 (18) (18) IPP Funded drugs - offset with Non Pay Expenditure Top Up Drugs - Offsets with Income 0 (10) (10) (11) (99) (2)

125 Appendix 3 VELINDRE NHS TRUST SAVINGS PLAN 20 / 16 Velindre Cancer Centre As at Month 9 Plan TOTAL 000 Recurrent Non-recurrent Grn Amb Red Grn Amb Red Plan Achieved Variance VCC-wide Departmental savings: Pay pressures funded by 1 departmental managers finding offsetting savings Recurrent vacancy/pay saving: Regular gap between 2 resignation & recruit, delays while managers redesign roles, maternity, sickness etc) (333) Other vacancy saving: Posts that are temporarily 3 open for non-recurring reasons (specific recruitment difficulties, to achieve financial savings, offset other costs, deliberate project slippage etc.) Management restructure: Opportunities with 4 management turnover/retirements etc (19) Service quality & efficiency reviews: Structured 5 assesments to identify where quality can be improved/maintained with fewer posts (removing duplication/waste etc) (225) Procurement controls: Step-change in approach to 6 procurement decisions with greater analysis, challenge and rationalisation (75) VERS: Removal of suitable, risk-assessed posts 7 through the Voluntaru Early Release Scheme (58) Income generation: Increase the income-generation 8 from assets through sales eg. MRI scanner, private (25) patients etc. 9 Homecare chemotherapy project: Utilising a national framework to deliver certain medicines more cost effectively to patients at home (109) TOTAL SAVINGS IDENTIFIED 2, ,845 1,199 (646) 1, Welsh Blood Service Plan TOTAL 000 Recurrent Non-recurrent Grn Amb Red Grn Amb Red WBS 1 Staff Inflation to be managed at department level Release Wage Award New Income Stream Opportunities (8) 4 Consolidated Delivery of Existing Income Budget setting departmental savings found Bleed target reductions TOTAL SAVINGS IDENTIFIED 1, (8) Corporate TOTAL Plan Recurrent Non-recurrent 000 Grn Amb Red Grn Amb Red 1 Staff Vacancies TOTAL SAVINGS IDENTIFIED TRUST TOTAL 3,636 2,774 2,120 (654)

126 VELINDRE NHS TRUST CAPITAL PROGRAMME 20/16 Appendix 4 SOURCES OF FUNDS 20/16 Spend To Budget Budget Dec- Remaining 000's 000's 000's All Wales Capital Schemes: VCC - Transforming Cancer Services in SE Wales 2,962 Less Pay Back of Discretionary Capital Funding Utilised by TCS in 2014/ (262) VCC - Transforming Cancer Services Budget 20/16 2,700 1,539 1,161 VCC - Replacement Linac In Bunker 4 (SBRT IT Database) VCC - Accommodation Sustainability SOP VCC - Replacement Linac in Bunker 2 4, ,227 WBS - All Wales Blood Service 1, VCC - Automated Medicines Ward Storage Cabinets VCC - IT Equipment to Support Welsh Clinical Portal Implementation Sub-Total All Wales Approved Capital Funding 8,829 2,306 6,523 Charitable Schemes: Velindre Donation - Wireless Controller Velindre Donation - TexRad Software Velindre Donation - Digital Polymerase Chain Reaction Equipment Sub-Total Charitable Donations Discretionary Capital Schemes: VCC - Pre-Fab Building on VCC Site 1, ,487 VCC - First Floor Ward Phase VCC - Upgrade to Existing Chemotherapy Prescribing System VCC - Disaster Recovery & Resilience Improvements PSBA VCC - Replacement of Two Pharmacy Isolators VCC - WC & General Areas VCC - Linear Accelerator Treatment Board VCC - Pharmacy Air Handing Unit VAT Repayment WBS - BECS Replacement Phase WBS - Lamda Jets WBS - Replacement Fuel Tanks VCC - Haematology Analyser VCC - Letter Folder and Inserter VCC - Fire Alarm Detection Replacements and Re-Zoning of Panels VCC - Door Access Controls VCC - Replacement of Oxygen Supply Plant VCC - Roof Works to Front Entrance VCC - Environmental Improvement Pipe Work Insulation in Ducts VCC - Medical Records Printers VCC - UPS for Server Node Room VCC - Hospital Wide Communication System Phase Trust - Mobile Device Management ( access via phones/tablets) VCC - Two Radiological Multi-Meters VCC - Radium 223 Therapy VCC - Brachytherapy Licenses IT - Laptops/Desktops/Licenses (Revenue to Capital Transfer) UNALLOCATED (potentaily IT - Servers/Laptops/Networks/Desktops/Licenses) Sub-Total Discretionary Allocation 3, ,641 TOTAL SOURCES OF FUNDS 11,965 2,801 9,164

127 TRUST BOARD DELIVERING EXCELLENCE PERFROMANCE REPORT PERIOD 8 Meeting Date: 28 th January 2016 Author: Sponsoring Executive Director: Report Presented by: James Houston Planning & Service Development Manager Carl James Director of Planning, Performance & Estates Carl James Director of Planning, Performance & Estates Committee/Group who have received or considered this paper: Trust Resolution to: (please tick) Approve: Endorse: Discuss: Note: Recommendation: The Trust Board are asked to Note the Delivering Excellence: Integrated Planning and Performance report and to Discuss the performance measures highlighted. This report supports the following Trust objectives as set out in the Integrated Medium Term Plan: (please tick) Equitable and timely services Providing evidence based care and research which is clinically effective Supporting our staff to excel Safe and reliable services First class patient /donor experience Spending every pound well

128 2 [Report Title] 1. Introduction / Background: 1.1 The purpose of the Delivering Excellence: Integrated Planning and Performance report is to provide the Board with an update on Trust wide delivery against the key performance metrics and against the strategic objectives set out in the 3 year Integrated Medium Term Plan (IMTP). 2. Timing: 2.1 The reporting period of the performance report is November Description: 3.1 The report contains key performance metrics for Velindre Cancer Centre, Welsh Blood Service and for Corporate Services. 3.2 The report has been structured to categorise all objectives and performance metrics under 5 of the key strategic themes that underpin the Trusts IMTP. 1. Equitable and timely access to services 2. Safe and reliable services 3. Supporting our staff to excel 4. First Class Patient / Donor experience 5. Spending every pound well 3.3 The performance metrics are also sub-divided by a three-tiered Level system as explained below. Level 1 - National measures; - Measures requested by WG monthly; - Measures and plan objectives which if not achieved, risk patient / donor safety; - Measures and plan objectives which if not achieved, risk reputational damage; - Measures and plan objectives which hold key strategic importance for the Trust; - Measures and plan objectives that if not achieved, would significantly risk ability to achieve financial balance by year end; Level 2 - Divisional priorities; - Core measures and objectives; - Divisional service development priorities; Level 3 - Specific measurable KPIs or objectives associated with projects or departments 3.4 The underpinning governance procedures that support collation of this report include the Executive Management Board (EMB) reviewing the full service level performance reports and agreeing the performance metrics to be raised within the Trust Board performance report. Page 2

129 3 [Report Title] 4. Financial Impact: 4.1 There are no direct financial implications as a result of this report. 5. Quality, Equality, Safety and Patient Experience Impact: 5.1 The current performance reporting and monitoring system is predicated upon identifying performance issues and supporting effective decision making at service and operational levels to drive forward continuous improvement in the quality, equality, safety and experience for our patients. 6. Considerations for Board / Committee: 6.1 The following performance metrics have been highlighted as requiring further discussion or action. Performance Metric Description Page Reference Number Priority 2 Improve Radiotherapy capacity 30 VCC 001 / 002 / 003 Compliance with Radiotherapy waiting times VCC 116/117 Linear accelerator uptime 33 VCC 017/018/019 Compliance with Chemotherapy waiting times VCC 005 Radiotherapy access - MALTHUS 36 VCC 143/144 Hand hygiene compliance VCC 108 Radiotherapy Delivery Unit (DU) recommendations 38 WBS - % Part bags Part bag donations WBS Unsuccessful Unsuccessful Venepuncture 44 Venepuncture COR 006 PADRs 40, COR 007 Optimise staff attendance 41, Next Steps: 7.1 It is recognised that there is an opportunity to review, refine and further develop the performance management framework and the supporting performance reporting systems across the Trust over the coming months. 7.2 The immediate steps are to undertake a peer review of current arrangements through engaging with key stakeholders across the Trust to fully understand what currently works well and to identify opportunities to drive forward improvement. The output of this piece of work will help to inform a draft performance management framework and a specification for future performance reports. Page 3

130 Delivering Excellence Integrated Planning and Performance Report for Trust Board At a Glance Reporting Period- November 20 0

131 Contents Keys... 3 Section 1- Velindre Cancer Centre; At a Glance... 4 Patient Story... 4 At a Glance Summary - Service Performance Status... 5 Equitable and Timely Access to Services... 5 Safe and Reliable Services... 8 First Class Patient Experience Supporting our Staff to Excel Level 3 Highlighted Measures At a Glance Summary Progress against 3 Year Plan Objectives At a Glance Summary - Quality Improvement Section 2 - Welsh Blood Service; At a Glance... The Welsh Blood Service... At a Glance Summary - Service Performance Status Equitable and Timely Access to Services Safe and Reliable Services First Class Donor Experience Spending Every Pound Well Supporting our Staff to Excel At a Glance Summary Progress against 3 Year Plan Objectives At a Glance Summary - Quality Improvement Section 3 Support Services; At a Glance At a Glance Summary - Service Performance Status Workforce and Organisational Development Estates Research and Development At a Glance Summary Progress against 3 Year Plan Objectives At a Glance Summary - Quality Improvement Section 1 Velindre Cancer Centre

132 Progress against Strategic Priorities Equitable and Timely Access to Services Our Key Performance Metrics Safe and Reliable Services Quality Improvement Supporting our Staff to Excel Our Key Performance Metrics Section 2 Welsh Blood Service Progress against our Key Performance Metrics and Our Plans Safe and Reliable Services Section 3 Support Services Progress Against Key Performance Metrics and Our Plans Workforce and Organisational Development Our Key Performance Metrics

133 Keys Service Performance Green Red Target achieved this month Target not achieved this month Delivery against Plan Green Amber Red Actively managed processes proceeding as planned- no major risks or issues identified Problems have surfaced, considered manageable in the normal course Serious problems have surfaced- make Senior Management Team aware Closed Purple Grey Major issues remain unsolved- on hold until resolved- senior executive engaged Deliverable activity at feasibility/initiation stage Risk Status Likelihood and impact of non- achievement. 3

134 Section 1- Velindre Cancer Centre; At a Glance Patient Story 4

135 At a Glance Summary - Service Performance Status Equitable and Timely Access to Services Level 1 Metric VCC % of patients commencing radical radiotherapy within 28 days VCC % of patients commencing palliative radiotherapy within 14 days VCC % of patients commencing emergency radiotherapy within 2 days VCC % Linear Accelerator Uptime VCC % Patient Disruptive Uptime VCC % of patients commencing emergency chemotherapy within 5 days VCC % of patients commencing non emergency chemotherapy within 21 5 Dec 14 Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Assuring Committee Highlight Report 100% 98% 94% 79% 96% 100% 100% 98% 99% 100% 100% 97% P&P % 99% 97% 88% 97% 100% 100% 99% 100% 98% 98% 100% P&P % 100% 96% 100% 100% 100% 100% 100% 100% 100% 100% 100% P&P 32 94% 98% 98% 96% 96% 98% 93% 95% 93% 91% 95% 95% P&P 33 99% 100% 99% 98% 99% 99% 96% 99% 99% 96% 99% 98% P&P % 100% 100% 100% 100% 100% 100% 100% 100% No emergency referrals Page No. 100% 100% P&P 34 98% 97% 100% 98% 97% 99% 100% 99% 99% 99% 99% 100% P&P 34

136 Metric days VCC 118- All SACT referrals within turnaround Dec 14 Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Assuring Committee Highlight Report 98% 97% 100% 98% 97% 99% 100% 99% 99% 99% 99% 100% P&P N/A Page No. Level 2 6 Metric Dec 14 Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Assuring Committee Highlight Report VCC 119- SALT inpatients seen within 2 100% 100% 100% 100% 66% 75% 100% 64% 77% 79% 80% 65% P&P N/A working days VCC 120- Complementary therapies inpatients 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% N/A within 2 working days P&P VCC 121- Dietetics inpatients within 2 100% 100% 100% 100% 100% 52% 100% 77% 100% 88% 100% 85% P&P N/A working days VCC 122- Physiotherapy inpatients within 2 100% 94% 100% 100% 100% 76% 100% 100% 100% 100% 100% 100% P&P N/A working days VCC 123- Occupational Therapies inpatients 100% 100% 83% 100% 100% 100% 100% 77% 44% 77% 80% 57% P&P N/A within 2 working days VCC 124- Inpatient therapies seen within 1 87% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% P&P N/A working day (MSCC) VCC 125- Speech and Language Outpatient therapies seen within 4 100% 100% 100% 100% 100% 64% 100% 91% 79% 81% 86% 85% P&P N/A weeks VCC % 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% P&P N/A Page No.

137 Metric Complementary outpatient therapies seen within 4 weeks VCC 127- Dietetics outpatient therapies seen within 4 weeks VCC 128- Physiotherapy outpatient therapies seen within 4 weeks VCC 129- Occupational outpatient therapies seen within 4 weeks VCC 130- CR Inpatients (within 1 working day) VCC 131- CT Inpatients (within 1 working day) VCC 132- MRI inpatients (within 1 working day) VCC 133- US inpatients (within 1 working day) VCC 134- CR Outpatients (within 7 days) VCC 135- CT Outpatients (within 7 days) VCC 136- MRI Outpatients (within 7 days) VCC 137- US Outpatients (within 7 days) Dec 14 Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Assuring Committee Highlight Report 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% P&P N/A 100% 94% 100% 100% 100% 76% 100% 58% 92% 88% 100% 83% P&P N/A 100% 100% 83% 100% 100% 100% 100% 100% 36% 100% 100% 31% P&P N/A 98% 94% 99% 96% 98% 100% 100% 100% 99% 99% 100% 100% P&P N/A 100% 100% 100% 100% 100% 100% 100% 100% 100% 98% 100% 100% P&P N/A 100% 100% 100% 100% 100% 100% 100% 100% 100% 66% 86% 100% P&P N/A 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% P&P N/A 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 98% 100% P&P N/A 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% P&P N/A 100% 100% 100% 100% 98% 100% 99% 100% 99% 100% 96% 100% P&P N/A 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 99% P&P N/A Page No. 7

138 Safe and Reliable Services Level 1 Metric VCC 025- Death within 30 days of chemotherapy Dec 14 Jan Feb Mar Apr May Jun Jul Metric under development Aug Sept Oct Nov Assuring Committee VCC 032a- 0 C.diff cases Q&S VCC 032b- 0 MRSA cases Q&S VCC 032c- 0 MSSA cases Q&S Q+S Highlight Report Page No. N/A N/A N/A N/A VCC Velindre hospital acquired pressure ulcers VCC unexpected inpatient deaths VCC % Compliance with CAUTI insertion care bundles VCC % Compliance with CAUTI maintenance care bundle Q&S Q&S 92% 93% 93% 100% 50% 83% 97% 100% 75% 75% 100% 92% Q&S 81% 100% 92% 89% 100% 100% 100% 100% 94% 100% 100% 100% Q&S N/A N/A N/A N/A VCC % compliance with CVC insertion care bundle 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Q&S VCC % compliance with skin 100% 100% 100% 100% 95% 83% 100% 64% 100% 77% 100% 77% Q&S care bundle VCC 034a 90% patients to have a documented 54% 48% 61% 52% 56% 58% 48% 69% 56% 68% 85% 75% Q&S N/A N/A N/A 8

139 Metric thromboproxphylaxis risk assessment on admission VCC 034b 100% eligible patients prescribed thromboprophylaxis Dec 14 Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Assuring Committee 100% 100% 100% 100% 100% 100% 96% 96% 100% 100% 100% 100% Q+S Highlight Report Page No. N/A Level 2 Metric VCC % hand hygiene compliance (averagenon inpatient areas) VCC % hand hygiene compliance (averageinpatient areas) VCC 036- Mortality Review of 100% of inpatient deaths VCC 038- Reduce treatment incidents and errors in radiotherapy Dec 14 Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Assuring Committee Highlight Report 67% 94% 76% 78% 78% 82% 78% 82% 94% 98% 69% 93% Q&S % 99% 68% 87% 100% 100% 33% 75% 83% 91% 99% 91% Q&S 37 Measure not reported 100% 100% 100% No inpatien t deaths 100% No inpatien t deaths Metric under development Q&S N/A Q&S Page No. N/A 9

140 First Class Patient Experience Level 1 Metric VCC 044- >80% patient overall experience rated 9 and above Dec 14 Jan Feb Mar 88% 69% 81% 94% Apr Data not collected May Jun Jul Aug Sept Oct Nov Assuring Committee Highlight Report 100% 100% 75% 86% 80% 93% 85% Q&S N/A Page No. Level 2 Metric VCC 046- On the day waiting times in outpatients less than 20 minutes VCC % of palliative care patients have an POS-S or equivalent assessment within 24 hours of referral Dec 14 Jan Feb Mar Apr May Jun Jul Aug Sept 45% 35% 49% 58% 44% 44% 44% 57% 48% 47% 50% Oct Nov No data provided Assuring Committee Q&S Highlight Report N/A N/A N/A N/A 100% 100% 100% 100% 100% 100% 100% 100% Q&S N/A Page No. N/A Supporting our Staff to Excel Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Assuring Highlight Page Metric 14 Committee Report No. COR % 61.4% 56.9% 57.7% 38.2% 39.8% 46.7% 57.7% 57.6% 57.2% 56.3% 59.2% 61.5% WoD 45 PADR Rate COR % 3.76% 3.91% 3.90% 3.61% 4.22% 3.58% 3.89% 3.98% 4.10% 4.23% Data is always 2 WoD 49 10

141 Equitable and Timely Access to Services Sickness absence rate months behind Level 3 Highlighted Measures Metric VCC 146- Antibiotic Prescribing- 100% compliance with documenting duration/review date Dec 14 Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Assuring Committee Highlight Report 27% 18% 40% 77% 71% 44% 71% 67% 50% 88% 100% 84% Q&S N/A Page No. At a Glance Summary Progress against 3 Year Plan Objectives Strategic Theme 11 Objective Level Status VCC 004- Develop a strategic plan for radiotherapy services including advanced radiotherapy VCC 005- Increase radiotherapy access to the appropriate rate for patients with cancer within our resident population Forecast Status Risk Assuring Committee Highlight Report Page No. 1 P&P N/A 1 P&P N/A VCC 008- Repatriate all appropriate activity from England and increase the provision of SBRT and SRS 1 P&P N/A VCC 020- Patients to receive parental SACTs as close to their homes as possible within environment which are appropriate for safe administration VCC 083- Disaster Recovery Plans (DRP) in place to support service in the event of an incident, ensuring a clear process in place in line with timely resolution 1 P&P N/A 1 IM&T N/A VCC Increase access to IMRT 2 P&P N/A VCC 007- Develop the use of Image Guided Radiotherapy (IGRT) techniques across tumour sites 2 P&P N/A VCC 019- Reduce waiting times for chemotherapy 2 P&P N/A

142 Safe and Reliable Services Strategic Theme 12 Objective Level Status VCC 022- Strengthen links with primary care: Review processes by which patients can receive care within local communities and utilise local resources VCC 023- Strengthen links with primary care: Review processes by which patients can receive oncology services in primary care 2 VCC 031- Review of Clinical nurse specialists and key workers to ensure appropriate service provision VCC 082- Support infrastructure in situ including sufficient capacity and resilience for the provision of continuous service VCC 085- Explore technology to underpin service in line with service improvements, and change in workflows/practices Forecast Status Risk Assuring Committee Highlight Report Page No. 2 P&P N/A Currently being put through the change control processduplication P&P N/A 2 Q&S N/A 2 IM&T N/A 2 IM&T N/A VCC 024- Establish an e-prescribing system which allows transfer of patient care across organisational boundaries. Implement an e prescribing solution for solid 1 IM&T N/A tumours at VCC VCC 040- Development of Acute oncology services across SE Wales 1 P&P N/A VCC 089- Implementation of the Individual Health Record (IHR) which will provide immediate electronic access to a summary of a patient record held by their GP 1 IM&T N/A VCC 090- Implementation of Welsh Clinical Portal (which includes Medicines Transcriptions and Electronic Discharge (MTedD)) with National Test Requesting 1 IM&T N/A and Results Reporting (TRRR) VCC 093- Implementation of the Welsh Care Record Service (WCRS) which will enable the storage and management of clinical documents supporting a single 1 IM&T N/A view of a patient s record VCC 039- Improve oversight of medication related errors to comply with NHS Wales standards 2 Q&S N/A VCC 088- Implementation of National Image Sharing- Vendor Neutral Archive (VNA) Project to support the care of cancer patients via cross organisation image 2 IM&T N/A sharing VCC 091- Implementation of the Welsh Clinical Communications Gateway (WCCG) 2 IM&T N/A VCC 092- Investigate the utilisation of IT solution/s such as the Community Care Information System, to support processes and enable closer working with local 2 IM&T N/A authorities VCC 094- Implementation of the redeveloped MDT module 2 IM&T N/A VCC 095- Implementation of the National Catering IT Solution (NCIS) for all of NHS 2 IM&T N/A

143 Supporting our staff to excel Providing Evidence Based Care and Research First Class Patient Experience Strategic Theme Wales. Objective Level Status Forecast Status Risk Assuring Committee Highlight Report Page No. VCC 012- Evaluate current radical waiting times targets for specific patient groups N/A 2 P&P including patients with lung ca and neuro-oncology patients VCC 013- Implementation of Royal College or Radiologist guidance on N/A 2 P&P management of interruptions for category 2 patients VCC 028- Ensuring that patients who take oral SACTs are able to make fully N/A 2 Q&S informed decisions to facilitate medication adherence VCC 045- Ensure that people living with and beyond cancer have a personalised N/A assessment, information and care plan and are empowered to manage their condition 2 Q&S VCC 057- Increase the number of patients that die in their preferred place of and N/A 2 Q&S who access their preferred place of care VCC 096- Provision of free internet service to patients and visitors 2 IM&T N/A VCC 101- Maintain required standards for timeliness and completeness of clinical N/A 1 IM&T coding in line with targets set by the Welsh Government VCC 014- Implement image guided brachytherapy for appropriate gynae cancer N/A 2 P&P patients VCC 029- Introduce and evaluate use of oncotype testing 2 Q&S N/A VCC 045- Development of an organizational informatics function to inform service N/A improvement plans, benchmarking, mandatory returns, data extraction and validation 2 IM&T VCC 097- Improving the data quality within the electronic patient record- Provision N/A 2 IM&T of accurate and up to date information by the Medical Records Department VCC 099- Implementation of the National Intelligent Integrated Audit Solution N/A 2 IM&T (NIIAS) VCC 100- Implementation of Mobile Device Management Solution 2 IM&T N/A VCC 012- To review and agree appropriate workforce establishment for Junior N/A 1 WoD Medical staffing VCC 106- Support new ways of working to support increasing demand and new N/A 1 WoD service model in Radiotherapy VCC 104- Ensure that staff have undertaken IQT silver are provided with the N/A 2 WoD opportunity to develop these skills within their current role VCC 105- Embed ESR Self Service across the service 2 WoD N/A 13

144 At a Glance Summary - Quality Improvement Objective Level Status Forecast Status Risk Assuring Committee Highlight Report VCC 108- Take forward recommendation in Delivery Unit (DU) Report into Radiotherapy Services 1 P&P 39 VCC 109- Complete a review of Pharmacy services 2 Q&S N/A VCC 110- Review working processes for junior doctors 2 WoD N/A VCC 111- Review nuclear medicine processes 2 Q&S N/A Page No. 14

145 Section 2 - Welsh Blood Service; At a Glance The Welsh Blood Service

146 At a Glance Summary - Service Performance Status Equitable and Timely Access to Services Level 1 Metric 250 new Bone Marrow Volunteers (BMV) registrations per month Dec 14 Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Assuring Committee Highlight Report P&P N/A Page No. 16

147 Safe and Reliable Services Level 1 Metric 100% whole blood supply meeting demand 100% of platelets supply meeting demand 98% of commercial product requests met 90% deceased donor typing / cross matching reported within 6 hours (quarterly metric) 100% delivery of Haemotopoietic Stem Cell (HSC) internal targets stakeholders in full 100% facilitation / import of HSC products for patients in 17 Dec 14 Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Assuring Committee Highlight Report 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 110% 116% P&P N/A 113% 121% 113% 108% 136% 119% 109% 110% 108% 105% 116% 112% P&P N/A 99.6% 99.6% 97.7% 97.7% 97.95% 98.4% 99.36% 97.93% 99.7% 92% 97% 99% P&P N/A 100% 100% 100% 100% Quarterly measure 189.5% 63.2% 42.1% 105.3% 77.5% 58.1% 116.3% 116.3% 97% 174% 97% 116.3% P&P N/A 171.3% 257.1% 0% 171.3% 35.3% 106% 106% 141% 71% 177% 106% 71% P&P N/A P&P Page No. N/A

148 Metric Cardiff and Vale UHB 90% Anti-D & - C Quantitation results provided to customer hospitals within 5 working days (quarterly 90% routine antenatal patient results provided to customer hospitals within 3 working days 80% samples referred for red cell reference serology work up provided to customer hospitals within 2 working days Dec 14 Jan Feb Mar Apr May 95% 97% 100% 99% 97% 98% 96% 96% 86% 85% 99% 87% Jun Jul Aug Sept Oct Quarterly measure Quarterly measure Quarterly measure Nov Assuring Committee P&P P&P P&P Highlight Report Page No. N/A N/A N/A Level 2 Metric 60% red cells issued less than 14 days old 3% part bags collected 2% unsuccessful venepuncture Dec 14 Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Assuring Committee Highlight Report 81% 84% 81% 69% 33% 45% 75% 66% 66% 79% 76% 79% Q&S N/A 4% 3.9% 4.6% 4.3% 5% 4.7% 4.2% 3.4% 4% 3% 3% 4% P&P 49 2% 1.5% 1.7% 2% 1.6% 1.5% 1.9% 2% 2% 2% 2% 2% P&P 51 Page No. 18

149 First Class Donor Experience Level 1 Metric 70% of blood donors scoring 9/10 for satisfaction with overall service 100 % of concerns answered within 30 days Dec 14 Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Assuring Committee Highlight Report 78% 76% 77% 78% 79% 72% 67% 67% 71% 77% 77% 77% Q&S N/A 85% 90% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Q&S N/A Page No. Level 2 Metric Whole Blood: 1.25 units collected by WTE per hour Apheresis: 2. Average Adult Therapeutic Dose (ATD) per Donation Dec 14 Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Assuring Committee Highlight Report P&P N/A P&P N/A Page No. 19

150 Spending Every Pound Well Level 1 Metric Dec 14 Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Assuring Committee Highlight Report Page No. <7% time expired platelets <0.5% volume of waste (red cells) <6% total losses prior to issue 2.6% 4.8% 3.8% 1.8% 8.4% 2.5% 4.0% 6.2% 4.1% 3.0% 2.4% 6.4% P&P N/A 0% 0.1% 0% 0% 0.3% 0.1% 0.05% 0.0% 0.1% 0.0% 0.0% 0.0% P&P N/A 8.7% 8.7% 8.9% 8.6% 8.8% 3.2% 4.4% 4.4% 4.2% 4.4% 4.6% 4.7% P&P N/A Supporting our Staff to Excel Level 1 Metric 80% PADR Rate 3.54% Sickness absence rate Dec 14 Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Assuring Committee Highlight Report 70.0% 65.7% 77.2% 73.2% 76.5% 69.8% 73.1% 74% 80.4% 78.7% 74.4% 67.4% WoD N/A 4.65% 4.75% 4.80% 5.96% 6.29% 6.08% 5.54% 5.48% 5.57% 5.61% Data is always 2 months behind WoD Page No. N/A 20

151 Safe and Reliable Services Equitable and Timely Access to Services At a Glance Summary Progress against 3 Year Plan Objectives Strategic Theme Objective Level Status Forecast Status Risk Assuring Committee Highlight Report Page No. Implement new service design model to support realisation of an All Wales Blood Service (AWBS) 2 P&P N/A Improve performance against regulatory requirements 1 P&P N/A Maintain external regulatory compliance- MHRA HTA 1 Q&S N/A EFI WMDA Existing Systems Maintenance & Support 1 IM&T N/A Implementation of a new Blood Establishment Computer System (BECS, e PROGESA) 1 Phase (1) completed IM&T N/A Implementation of an All Wales Laboratory Information Management System (LIMS)- Leader and Customer- Blood Transfusion Module WTAIL Module 1 IM&T N/A Retain wholesaling license 2 Q&S N/A IM&T infrastructure improvement programme 2 IM&T N/A Operational Project Delivery Programme (Software &Infrastructure) 2 IM&T N/A Extend external accreditation to include: FACT Joint Accreditation Committee- ISCT Europe (JACIE) for WBMDR) Ensure transition from CPA to UKAS ISO & 189 accreditation for External Quality Assessment schemes and Medical laboratories respectively 2 Q&S N/A Develop and implement cross departmental and organisational processes for quality management 2 P&P N/A Develop new Platelet Production Strategy in response to SaBTO recommendation to remove 80% apheresis target and use of additive solution 2 P&P N/A 21

152 Supporting our staff to excel Spending Every Pound Well Providing evidence based care and research First Class Donor Experience Strategic Theme for the suspension of platelets Objective Level Status Forecast Status Risk Assuring Committee Highlight Report Page No. Continue to improve satisfaction ratings from customer hospitals 1 Q&S N/A Continue to improve donation experience 1 Q&S N/A Keep abreast of advancements in technology for WTAIL 2 IM&T N/A Continue to review and develop our collection sessions and the way we interact and manage our donors: Roll out donor Self Assessment (SAHH) Roll out online donor appointment system Roll out online self donor record management 2 IM&T N/A Develop a Research and Development Strategy for the Service 1 R&D N/A Lead the development of Collaborative Blood Management Strategy for Wales 1 IM&T N/A Improve optimisation of Estates Infrastructure 2 P&P N/A Establish a new Education and Development Strategy for the WBS aligned with Velindre Cancer Centre To ensure workforce elements of the creation of an AWBS are delivered in compliance with employment legislation 2 WoD 2 All Wales Programme Board To deliver new service models through an engaged and empowered workforce 2 WoD N/A To ensure optimal flexible working patterns to support new service models 2 WoD N/A To develop a flexible laboratory workforce using Modernising Scientific 2 Careers WoD N/A Develop capacity, capability and leadership to deliver strategic change to 2 support continuous service improvement WoD N/A Develop talent management and succession planning within the service to 2 support organisational development WoD N/A N/A N/A 22

153 At a Glance Summary - Quality Improvement Objective Level Status Develop a detailed SI approach and plan. Define how this integrates with the major programmes of work as well as into the governance and operations of the organisation Conduct a full review of the Collections Service activities to establish the best model in terms of efficiency, productivity and donor experience. Develop a prioritised implementation plan aligned with the all Wales Blood Service and BECs work programmes Increase staff engagement and empowerment in service improvement activity. Achieved through a combination of formal training, project involvement as well as awareness raising and visualisation of information Scope and secure WBS business intelligence requirements to ensure our operations are underpinned by highly effective and efficient management data to support and ensure continuous service improvement Forecast Status Risk Assuring Committee Highlight Report Page No. 1 Q&S N/A 2 Q&S N/A 2 Q&S N/A 2 Q&S N/A 23

154 Section 3 Support Services; At a Glance At a Glance Summary - Service Performance Status Workforce and Organisational Development Level 1 Metric COR % Sickness Absence rate (Trust Wide) COR % PADR (Trust Wide) COR % Sickness Absence rate (Corporate Services) COR % PADR (Corporate Services) Dec 14 Jan Feb Mar Apr 4.10% 4.22% 4.22% 4.47% 4.92% 4.47% 4.49% 4.52% 4.63% 4.71% May Jun Jul Aug Sept Oct Nov Data is always 2 months behind Assuring Committee Highlight Report Page No. WoD % 48.9% 56.1% 61.1% 61.7% 60.5% 61.0% 63.6% 66.8% 66.9% 62.5% 60.9% WoD % 4.18% 4.14% 4.49% 4.43% 4.31% 4.44% 4.45% 4.58% 4.42% Data is always 2 months behind WoD % 44.2% 37.0% 37.1% 34.0% 47.4% 46.3% 53.1% 50.5% 58.6% 55.5% 57.8% WoD 53 24

155 Estates Level 1 Metric Dec 14 Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Assuring Committee Highlight Report COR 024a- Electricity (kwh) P&P N/A COR 024b- Gas (kwh) P&P N/A COR 025a- Electricity (CO2) P&P N/A COR 025b- Gas (CO2) P&P N/A COR 026- Water Usage (m3) P&P N/A Page No. Research and Development Level 2 Metric VCC 059- Provide patients with timely access to the latest anticancer treatments through Phase 1 and other clinical trials Aug 14 Sept 14 Oct 14 Nov 14 Dec 14 Jan Feb Mar Metric Under Development Apr May Jun Jul Assuring Committee R+D Highlight Report Page No. N/A 25

156 Research and Development Estates Workforce and Organisational Development At a Glance Summary Progress against 3 Year Plan Objectives Area Objective Level Status Forecast Status Risk Assuring Committee Highlight Report COR 001- Robust OD approach to service and workforce modernisation in plan 1 WoD N/A COR 005- Support staff to undertake all Mandatory and Statutory Training 1 WoD N/A COR 002- Workforce and OD Department aligned to priorities of the organisation 2 WoD N/A COR 003- Ensure appropriate skills and behaviours in the workforce 2 WoD N/A COR 008- Develop capacity, capability and leadership to deliver strategic change 2 WoD N/A COR 009- Further develop partnership working approach with Trade Union staff and representatives 2 WoD N/A COR 011- Optimise use of workforce technologies 2 WoD N/A VCC 103- Nurse Revalidation 2 WoD N/A COR 022- Undertake a review of the Trust s Statutory Compliance across divisions and hosted organisations. Achieve and maintain a Trust Statutory 1 P&P N/A Compliance Target of 90 %. COR % of Trust properties certified to ISO14001 by the end of 20 and all Trust hospital sites to be certified to ISO14001 by the end of P&P N/A VCC 065- Develop an R&D strategy for VCC 1 R&D N/A Page No. VCC 067- Continue to develop the Phase 1 Programme through collaborations with Industry VCC 070- Increase recruitment to radiotherapy clinical trials VCC 071- Continue to develop the national leadership position of the RTTQA group VCC 073- Address ability to support a wide range of technical activities, specifically elating to ability of support depts. to include R&D in daily workload VCC 075- Further strengthen governance and assurance arrangements for R&D 26 1 R&D N/A 1 R&D N/A 1 R&D N/A 1 R&D N/A 1 R&D N/A

157 Area Objective Level Status VCC 077- Increase recruitment into clinical trials activity in line with and beyond national targets where possible VCC 078- Increase tissue collection for the Wales Cancer Bank Forecast Status Risk Assuring Committee Highlight Report Page No. 1 R&D N/A 1 R&D N/A VCC 064- Achieve financial strength and sustainability (R&D) VCC 060- Actively promote the benefits of participating in research VCC 061- Engagement with all staff to embed value and understanding the importance and benefits of research in health care VCC 062- Job enrichment through exposure to research for staff not directly involved in delivery VCC 068- Maintain leadership position at cutting edge VCC 069- Develop Radiotherapy Research Institute VCC 072- Create a multi-disciplinary research and support team that underpins and strengthens activity across campus VCC 074- Review infrastructure and resources (space, training & support, IT, business services etc) VCC 079- Invest in clinical researchers through time and capacity VCC 081- Develop strategic collaborations and engagement 2 R&D N/A 2 R&D N/A 2 R&D N/A 2 R&D N/A 2 R&D N/A 2 R&D N/A 2 R&D N/A 2 R&D N/A 2 R&D N/A 2 R&D N/A 27

158 At a Glance Summary - Quality Improvement Objective Level Status Forecast Status Risk Assuring Committee Highlight Report COR 013- Establish a Trust wide improvement programme steering group to ensure a strategic and coordinated approach to service 2 Q&S N/A improvement COR 014- Develop a VIP community of Service Improvement practitioners and managers sharing knowledge, experience and best 2 Q&S N/A practice COR 0- Redesign and promote VIP branding of improvement work (to encompass WBS, Corporate services and VCC) 2 Q&S N/A Page No. COR 016- Develop criteria to support prioritisation of improvement programmes COR 017- Formalise IQT training strategy to support 25% increase in the number of staff trained in IQT at bronze and silver levels 2 Q&S N/A 1 WoD N/A 28

159 Delivering Excellence Integrated Planning and Performance Report for Trust Board - Further Information Reporting Period- November 20 29

160 Section 1 Velindre Cancer Centre Progress against Strategic Priorities Priority 2: Improve Radiotherapy Capacity Primary Responsibility for Assurance: Planning and Performance Committee Month Status Apr May June July Aug Sept Oct Nov Dec Jan 16 Feb 16 March 16 Story behind progress and performance: Actions: Waiting times have improved over recent months as a result of additional radiotherapy linac capacity being provided and utilizing agency staff to address increased demand. An external review by the Delivery and Support Unit (DSU) has been received and a working group is established to review services and processes. Plans are being developed to address radiotherapy capacity in (i) Short term (ii) Longer term e.g. a business case for additional linacs As outlined above, a Senior team working group is working through DSU report action plan and a joint workshop between VCC and the DSU was undertaken in October with positive discussions regarding the future service model. Discussions are ongoing but as yet no firm plans are in place to improve the situation Key messages : Accountable manager: Resources will be required to support the business case process which has yet to be agreed. This remains outstanding. Director of Cancer Services 30

161 Equitable and Timely Access to Services Our Key Performance Metrics Level 1 VCC 001/002/003- Compliance with Radiotherapy Waiting Times Primary Responsibility for Assurance: Planning and Performance Committee 31

162 Progress against actions within the IMTP: Month Status Apr May June July Aug Sept Oct Nov Dec Jan 16 Feb 16 March 16 Story behind progress and performance : Action(s) and dates for improvement: Risks and Issues: Accountable manager: Demand has been increasing and performance is being maintained through the support of agency radiographers. A paper has been developed outlining the size of the current and projected shortfall in capacity, together with option to address this. A workshop to explore the issues was held at the end of October. Patients will be adversely affected by lack of available capacity, machine reliability and delays to or breaks in treatment which is likely to worsen over time. Although the compliance with targets is currently green and on target, the risk is that this will not be sustainable as the year progresses and the demand increases. Director of Cancer Services 32

163 VCC 117/116 -Linear Accelerator Uptime Progress against actions within the IMTP: Month Status Apr May June July Aug Sept Oct Nov Dec Jan 16 Feb 16 March 16 Story behind progress and performance : Action(s) and dates for improvement: Risks and Issues: Accountable manager: Linac uptime was above tolerance in November despite a number of significant issues. Work is ongoing to develop a measure capturing the effect of downtime on patients. The age profile of the department is a current risk. The need to continue to use LA6 clinically may result in further breakdowns. Director of Cancer Services 33

164 VCC 017/ 018/019- Compliance with Chemotherapy Waiting Times Recommendations Primary Responsibility for Assurance: Planning and Performance Committee 34

165 VCC % SACT delivery within 14 days (stretch target) Progress against actions within the IMTP: Month Status Apr May June July Aug Sept Oct Nov Dec Jan 16 Feb 16 March 16 Story behind progress and performance : Action(s) and dates for improvement: Risks and Issues: There were 232 referrals, 100% of the referrals commenced treatment within the 3 week recommended timescale. 69% of SACT referrals were treated within 14 days. There were 3 SAFF breaches within the month all due to late referals from the Local Health Boards. Preferred option for Docetaxel business case agreed (to provide a service to treat an estimated additional 250 patients per annum with Docetaxel due to survival and quality benefits of the drug). Business case was discussed by EMB on 17 th December 20- seeking clarity on ATTWC cohort funding route. In terms of horizon scanning, there is potential for approval of other chemotherapy drugs that will have a significant financial and capacity requirements. These are being discussed with the relevant SST lead with a view to wider discussions on how the step change is managed throughout the service. Accountable manager: Deputy Director of Cancer Services 35

166 VCC 005- Increase radiotherapy access to the appropriate rate for patients with cancer within our resident population Primary Responsibility for Assurance: Planning & Performance Committee Progress against actions within the IMTP: Month Status Apr May June July Aug Sept Oct Nov Dec Jan 16 Feb 16 March 16 Story behind progress and performance : Action(s) and dates for improvement: Risks and Issues: Accountable manager: This project is not yet underway. A bid was submitted to the Cancer Pathway Innovation fund to provide project support which was successful. The process of securing a project manager can now begin. The plan is to utilize MALTHUS, a recognized tool to assist in modelling radiotherapy uptake, to pursue this work. To date it has been difficult to identify a resource to undertake the work. Recruitment of a project manager can now begin. Recruitment of a project manager Director of Cancer Services 36

167 Safe and Reliable Services Level 2 VCC 143/144- Average hand hygiene compliance Primary Responsibility for Assurance: Quality & Safety Committee 37

168 Story behind progress and performance : Action(s) and dates for improvement: Risks and Issues: Accountable manager: 38 Scores represent an average score drawn from 2 audits per month. A 0% (no corresponding bar) reflects a non submission of audit data. The IPC Team continue to work with individual teams as necessary to improve compliance with audit and data submission deadlines and compliance overall. Monthly data set now sent to all dept/ward managers monthly with identification of those groups non compliant with HH to enable actions to be taken. Additional training for auditors has been provided. Data now presented by ward and department to allow further identification of trends by area. Failure to submit 1 of 2 monthly ward audits reduces overall % as given as an average Increased risk if: 1. Failure to comply with HH policy. 2. Failure to submit audits. 3. Lack of resilience in the absence of those staff undertaking the audits. 4. Training of new auditors not done 5. Failure to challenge poor HH practice Head of Nursing

169 Quality Improvement Level 1 VCC 108- Take forward recommendations in Delivery Unit (DU) Report into Radiotherapy Services Primary Responsibility for Assurance: Planning & Performance Committee Progress against actions within the IMTP: Month Status Apr May June July Aug Sept Oct Nov Dec Jan 16 Feb 16 March 16 Story behind progress and performance : Action(s) and dates for improvement: Risks and Issues: Accountable manager: DU recommendations are in various degrees of action and completion. A full report is being made available to the planning and performance committee on a regular basis. As per agreed action plan Outcomes and actions from the one day workshop held in October are to be incorporated into a single document Some recommendations are still under discussion and some are still to be commenced. Director of Cancer Services 39

170 Supporting our Staff to Excel Our Key Performance Metrics COR 006- PADR rate Story behind progress and performance : The current PADR compliance rate for VCC is 55.81% (November 20) a slight decrease on October s figure 57.16%. There is shortfall from the 75% target. The PADR working Group met in October where monitoring and reporting was again discussed. PADR compliance information is now being sent to all managers on a weekly basis, which also details the shortfall against the 75% compliance target. The working group discussed the importance of compliance, especially in view of the links with the new Pay Progression policy. A new revised PADR Recording Quick Guide has also been introduced, which has been circulated to managers. Further information has also been issued to managers to remind them of the importance of completing all stages in ESR to ensure that the data is captured correctly. Action(s) and dates for improvement: Risks and Issues: Accountable manager: 40 Monthly monitoring and reporting at VCC SMT and direct to managers. Managers have indicated that the data is not accurate in ESR and not reflecting an accurate position on PADR activity. These queries have been addressed with concerned managers and issues identified and resolved. The PADR Working Group has mapped the process and has identified a potential risk of PADRs not being processed in ESR if managers do not complete all steps in the process. The Quick Guide should help address this. Director of Cancer Services

171 COR 007- Sickness absence rate Story behind progress and performance : VCC October overall sickness rate is 3.95%, this is a decrease from September sickness rate which was 4.84%. The number of staff within the different stages of the All Wales Sickness Policy is as follows at VCC: initial discussion 35, first formal 10 second formal 3 and final stage 1. Long term sickness has reduced while short term sickness absence has remained the same. The Workforce team at VCC continues to meet with managers, particularly in high sickness areas, to review cases and agree action plans. The Workforce team has also been delivering training to managers, across all divisions regarding the changes in the revised Sickness Absence Policy and also focusing on the key areas of sickness absence management. Anxiety/stress/depression remains the top reason for sickness episodes, with injury/fractures remaining the second highest reason. Action(s) and dates for improvement: Risks and Issues: Accountable manager: 41 Managers will be regularly reminded (through monthly SMT, departmental surgeries and when reviewing sickness cases) of the importance of the correct sickness forms/templates being accurately completed and that stress risk assessments are completed at an early stage. There is evidence that sickness absence (informal and formal) interviews are taking place, but this is not consistently evident in terms of documentation. The importance of completing the correct templates for each stage of the Sickness Policy is being reinforced in the training and meetings with managers. Director of Cancer Services

172 Section 2 Welsh Blood Service Progress against our Key Performance Metrics and Our Plans Safe and Reliable Services Level 2 % Part Bags Primary Responsibility for Assurance: Planning and Performance Committee Progress against actions within the IMTP: Month Apr May June July Aug Sept Oct Nov Dec Jan 16 Feb 16 March 16 Status Story behind progress and performance : Action(s) and dates for improvement: 42 Part bags are defined as donations that have failed to progress or been stopped before reaching minimum allocated volume. Part bags may be influenced by staff performance at venepuncture but are also determined by an additional variable that is less within the parameters of our control i.e. a donation may need to be discontinued because the donor feels unwell or does not want to continue. New venepuncturists are continuing to train however, on the teams where these staff are working an increase in part bags over target has not been significant which is a credit to the new starters and the training. Initial scoping shows a higher level of vaso vagal events on Mobile Donor Clinics which are leading to donations having to be stopped early. More work to follow on this. Detailed work has been undertaken to breakdown the detail of this metric to help target the required actions to improve performance levels.

173 In November 8058 donors attended of which 7047 were bled. 3.64% resulted in Part Bags: - 59 were attributed to slow bleed - 6% due to syncope / impending syncope - 22% due to bruise / discomfort - 3% due to equipment failure Further work will be undertaken as part of the wider Service Improvement programme planned for Collections to focus activity specifically on those elements within the parameters of our control to influence. Risks and Issues: Accountable Manager: As Collection staff build familiarity with changing processes we will anticipate the overall numbers of successful bleeds to decrease to return within target. % Part Bag rates have a direct impact on overall blood packs available for issue to customer hospitals. 14 new venepuncturists have now commenced employment - 11 of whom are currently undertaking venepuncture in various stages of supervision. Medical Director 43

174 Unsuccessful Venepuncture Primary Responsibility for Assurance: Quality & Safety Committee Progress against actions within the IMTP: Month Apr May June July Aug Sept Oct Nov Dec Jan 16 Feb 16 March 16 Status Story behind progress and performance : Action(s) and dates for improvement: Risks and Issues: Accountable manager: There has been a small increase in FVPs in October/November 20 and increases have been seen on the teams with the trainee venepuncturists which are to be expected. Support continues for these new staff. The action plan remains in place, including monitoring and supervision of venepuncturists, along with individual performance management and support as required. Maintaining this target for venepuncture is essential in ensuring sufficient blood is delivered to meet service need. Medical Director 44

175 Section 3 Support Services Progress Against Key Performance Metrics and Our Plans Workforce and Organisational Development Our Key Performance Metrics Level 1 COR 006- Ensure all staff have a PADR Primary Responsibility for Assurance: Workforce & OD Committee 45

176 Progress against actions within the IMTP: Month Status Apr May June July Aug Sept Oct Nov Dec Jan 16 Feb 16 March 16 Story behind progress and performance : Trust-wide PADR activity levels at the end of October 20 have dropped slightly across all three Divisions in comparison to the previous month: Sep- Oct- Difference Trust-wide 66.9% 62.5% -4.40% VCC 61.4% 57.0% -4.40% WBS 78.7% 74.1% -4.60% Corporate 58.6% 56.0% -2.60% 2014/ monthly activity levels (presented below) illustrate the changing picture of PADR activity in each Division: 46

177 When plotted as an SPC Chart 2014/ monthly activity levels create a Median of 60.67%, which is just less than % short of the 75% target. Furthermore, the upper control limit calculated by this SPC identifies that, based on current practices, the Trust is unlikely to achieve a PADR activity level of higher than 68%: Action(s) and dates for improvement: 47 The Trust s PADR Working Group continue to work on a range of ideas to support, encourage and enable increased PADR activity. Actions implemented recently include: Weekly departmental reporting to Divisional SMT s. Inclusion of a PADR advert in the October edition of the TrustTalk staff newsletter. Intranet upload of case studies of good practice from high-performing departments. Definition of three criteria against which pay increments will be awarded when the NHS Wales Pay Progression Policy is implemented (subject to

178 EMB approval in December 20). Work which is ongoing includes: Creation of How To Guide to support MSS/SSS use of the ESR Business Intelligence tool for local PADR activity analysis. Review of the Trust s Induction Policy to define objective setting and PADR requirements for those staff in their first year of employment. Guidance for managers having PADR conversations with staff who are at the top of their band. Exploring a range of metrics/measures which have the potential to demonstrate the positive impact of PADR for patients and staff. Aligning the Trust s PADR paperwork with the organisational Values: Accountable, Bold, Caring, Dynamic. Furthermore: The Trust is awaiting an Internal Audit Report into PADR processes in order to explore the efficacy of current processes. The Trust s CEO is being proactive at discussing Divisional and departmental PADR activity in monthly 1-to-1 meetings with Divisional Directors and direct reports. The Trust is currently in the final stages of developing its Organisational Development Strategy. PADR will be one of the means by which this strategy is made live within the organisation. Significant scrutiny continues to be given to PADR processes, reporting and activity in all areas and at all levels of the organisation. Risks and Issues: It remains challenging to ensure PADR is a high departmental priority in all areas of the Trust. Failure to improve PADR rates will have a direct impact on the All Wales Pay Progression process. Accountable OD & WF Director manager: 48

179 COR 007- Optimise staff attendance Primary Responsibility for Assurance: Workforce & OD Committee 49

180 Progress against actions within the IMTP: Month Status Apr May June July Aug Sept Oct Nov Dec Jan 16 Feb 16 March 16 Story behind progress and performance : Action(s) and dates for improvement: As a result of the Health and Wellbeing Facilitator leaving post in July 20 it has been decided that sickness management support to managers and employees will be provided from the Workforce team across the Trust. Support continues to be provided from the Workforce department to managers across the Trust in the management of sickness absence. 50 A number of key areas have been allocated individual Workforce support to continue with sickness absence management action plans. The Senior Business Partner, VCC has taken up the Trust lead role of Health and Wellbeing. This will include developing workplace initiatives and awareness campaigns to assist with improving the health and wellbeing of all employees. The Health and Wellbeing lead will be attending quarterly meetings (first on 8th October 20) at the Cardiff & Vale Employers Network Forum. Representatives of the group are from the public, private and Voluntary sectors. The topic for this particular forum will be MENTAL HEALTH IN THE WORKPLACE. This will provide the Trust with an opportunity to share good practice across all service sectors in Wales. Collaborative working has commenced with Public Health Wales to maximise and publicise health promotions including publicity and information to all employees on National and regional campaigns. Management training on the new All Wales Sickness Absence policy will be undertaken during November. 6 training dates have been scheduled and advertised. The training will conducted in partnership with WFOD and Trade Union colleagues. Risks and Issues: Not achieving the WG target of 3.54%. Not achieving the 1% reduction in sickness absence as requested by the Minister Increase the usage of Self Service by managers to ensure up to data is available. A number of actions have been agreed by the ESR Project team to address this issue. High sickness absence has a direct impact on the services that we provide and often results in additional financial pressures to cover the absence through bank or overtime. In addition the absence of a team member often puts pressure on colleagues to cover the work. This often has a negative impact on the quality of services and staff moral and wellbeing. Accountable WF & OD Director manager:

181 1 Making Prudent Healthcare Happen TRUST BOARD MAKING PRUDENT HEALTHCARE HAPPEN Meeting Date: 28 th January 2016 Author: Sponsoring Executive Director: Report Presented by: Committee/Group who have received or considered this paper: Emma Stephens, Head of Business Support Unit Steve Ham, Chief Executive Peter Barrett-Lee, Professor of Breast Cancer Studies & Medical Director None Trust Resolution to: (please tick) Approve: Endorse: Discuss: Note: Recommendation: The Trust Board are asked to DISCUSS & NOTE the Minister s letter (Appendix 1) and the actions arising following the Prudent Healthcare Team Wales Event. This report supports the following Trust objectives as set out in the Integrated Medium Term Plan: (please tick) Equitable and timely services Providing evidence based care and research which is clinically effective Supporting our staff to excel Safe and reliable services First class patient /donor experience Spending every pound well Page 1

182 2 Making Prudent Healthcare Happen MAKING PRUDENT HEALTHCARE HAPPEN 1. Introduction / Background: As part of Welsh Government s continuing commitment to Prudent Healthcare, the Minister for Health and Social Services hosted a one-day event on December 14 th 20, to focus on this issue. Each health board and NHS Trust was invited to set out and discuss the content of their Prudent Healthcare plans, specifically: The practical steps being taken to organise services around the Prudent Healthcare principles both in specific services and across the whole system; The measurable impact this is having; How Velindre NHS Trust is taking advantage of the key national programmes around Prudent Healthcare; and Our plans to systematise Prudent Healthcare over the next three years as evidenced by the refresh of our Integrated Medium Term Plan (IMTP). As part of this process, Velindre NHS Trust submitted a paper (Appendix 2) summarising the key aspects of our Prudent Healthcare Plan. 2. National Prudent Healthcare Plan In addition to supporting health boards and NHS Trusts across Wales to focus on their own organisation s Prudent Healthcare activity, the event was also designed to help Welsh Government formulate its thinking around a national Prudent Healthcare plan. On a national basis, key themes and messages to emerge from the day included the need to consider: The importance of communication for staff and the public to set out what Prudent Healthcare means in practice; Support for Choosing Wisely Wales; Making use of the National Programmes available; Changing the focus to outcomes as opposed to measures; Remodel workforce plans (as set out in our IMTP) aligned to the principle of only do what only you can do ; and Redesign outpatient services. Welsh Government will develop national actions around all of these points and will expect to see evidence of the action we are taking to progress these as part of our 2016 IMTP refresh submission. 3. Next Steps Since attending the Team Wales event, Velindre have taken a number of steps to progress our Prudent Healthcare activity including: Page 2

183 3 Making Prudent Healthcare Happen The EMB will review the IMTP to ensure that Prudent Healthcare Principles are embedded in all that we do; NICE Guidelines and standards will be reviewed by each SST in the Cancer Centre; The Choosing Wisely in Oncology is being led by Professor Barrett-Lee and a patient information leaflet and South Wales workshop is planned for March Action Required The Trust Board are asked to DISCUSS & NOTE the Minister s letter (Appendix 1) and the actions arising following the Prudent Healthcare Team Wales Event. Following review, the Velindre Team Wales Event paper is required to be re-submitted to Welsh Government by 20 th February for publication on the Making Prudent Healthcare Happen website. Page 3

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186 Making Prudent Healthcare Happen 1.0 Introduction Velindre NHS Trust welcomes the opportunity to set out our continuing plans and ambitions to place the principles of Prudent Healthcare (PHC) at the centre of our core business. The following is intended to provide a high level road map of our journey, the plans and measures we have in place together with the challenges and opportunities that lie ahead of us. The foundations of our PHC activity are firmly rooted in the refresh of our Integrated Medium Term Plan (IMTP), anchored by our five year framework, Delivering Quality, Care and Excellence. Our guiding aims are to continually improve the quality, safety, effectiveness and efficiency of our services, provide evidenced based care and research, and spend every pound well. 2.0 Organisational level PHC invites us to challenge the status quo and reassess the way in which we think about how we operate. The very fabric of our organisation needs to be tailored to foster and engineer PHC, demanding a change in culture that will develop and enable new ways of working, establish new relationships with our stakeholders and mobilise our capacity and capability to deliver the health service of the future. As a Trust we are committed to achieving this and have developed an Organisational Development (OD) Strategy, Building Excellence that will seek to launch a planned and systematic approach to create the right environment, opportunities and support for our staff to embed PHC in the way in which we deliver and develop our services. Building Excellence is based on a set of shared values and behaviours following Trust wide stakeholder engagement, namely: BE Accountable BE Bold BE Caring BE Dynamic = BEING Excellent They will provide the basis for a common language enabling a collective conversation across the organisation and will underpin a series of strategic interventions designed around the principles of PHC including: Values based recruitment reinforced through induction; Aligning personal appraisal development review discussions to reinforce our values and remove barriers; Interactive communications with staff throughout the organisation via consistent messaging and tactile communications products e.g. 3D products placed in office/communal areas used as a rotating interactive method of getting staff to think about the values and how they relate to the work that they do; Reinforcement of our values within in-house training and development. 1