Integrated Performance Report

Transcription

1 Mid Essex, Southend and Basildon Hospitals Joint Working Board - 9 th May 18 Integrated Performance Report March 2018

2 Mid Essex, Southend and Basildon Hospitals Joint Working Board - 9th May 18 Contents Section Content Page Performance Overview Introduction by CEO 3 Domain Scorecards Quality of Care 4 Operational Performance 8 Workforce, Leadership and Improvement Capability 15 Finance and Use of Resources 23 Estates and Facilities 30

3 Mid Essex, Southend and Basildon Hospitals Introduction by CEO March 2018 The NHS Improvement (NHSI) single oversight framework was implemented from October 2016, with an update provided in November The framework helps identify NHS providers' support needs across five themes: quality of care finance and use of resources operational performance strategic change leadership and improvement capability NHSI monitor providers performance under each of these themes and consider whether they require support to meet the standards required in each area. NHSI segment individual trusts into four categories according to the level of support each trust needs. Where improvements in performance are required, NHSI develop a package of support with the provider to help them achieve this. All three Trusts are currently within segment 3. The Single Oversight Framework ( places Providers into Segments based on NHS Improvement s judgement of the seriousness and complexity of issues faced by each Provider. Joint Working Board - 9th May 18

4 Mid Essex, Southend and Basildon Hospitals Joint Working Board - 9th May 18 Quality of Care Celia Skinner & Diane Sarkar (CQC Safe, Caring, Excellent, Well Led) March 2018

5 Mortality Performance Crude Mortality Rate - Basildon Crude Mortality Rate - Mid Essex Crude Mortality Rate - Southend 2016/17 Rate Threshold 2016/17 Rate Threshold 2016/17 Rate Threshold 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-1 7 Oct-17 Nov-17 Dec-17 Jan-18 Feb-1 8 Mar-18 Jan-18 Feb-18 Mar Month Rolling Crude Mortality Rate 2.52% 2.50% 2.49% Q1 (April, May, June 2017) Q2 (July, August, September 2017) Number of deaths Number of mortality reviews conducted 0.0% % Structured Judgement Review Completed Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-1 7 Oct-17 Nov-17 Dec-17 Jan-18 Feb-1 8 Mar-18 Jan-18 Feb-18 Mar Month Rolling Crude Mortality Rate 2.55% 2.62% 2.65% Number of deaths with an element of avoidability Basildon % 3 Mid-Essex % 1 Southend % 2 Basildon % 0 Mid-Essex % 2 Southend % 0 Q3 (October, November, December 2017) 0.0% Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-1 7 Oct-17 Nov-17 Dec-17 Jan-18 Feb-1 8 Mar-18 Jan-18 Feb-18 Mar Month Rolling Crude Mortality Rate 2.90% 2.91% 2.94% Number of deaths Number of mortality reviews conducted % Structured Judgement Review Completed Number of deaths with an element of avoidability Basildon % 4 Mid-Essex % 1 Southend % 1 Most recent national SHMI publication for Oct-Sept 17 was : SUHFT (1.13) improving, MEHT (1.10) and BTUH (1.07). SHMI proxy via HED for the 12 months up to Dec 17: SUHFT (1.10), MEHT (1.07) and BTUH (1.06). Crude mortality measurement has now been standardised across the three trusts. Commentary Mortality SUHFT BTUH MEHT SHMI to Sep Higher than expected As Expected As Expected Actions / Mitigations Structured reviews through paper-based systems at all 3 sites, compliant with minimum 25% of deaths. Converting to electronic platform and unified process in April 2018, which will enhance reporting and collation of learning. Deaths with degree of avoid ability, local learning in place. No new CQC alerts Medical Examiners working at all 3 sites performing first review of all deaths. Commissioned external review by West Suffolk on SUFT report still awaited Quality of Care Page 5

6 Infection Control, Never Events and Other Quality Performance Performance / Commentary Actions / Mitigations Infection Control Group Infection Control meetings now established to ensure a co-ordinated approach, to share best practice and lessons learned. This forum will also provide the platform for reporting and areas of non-compliance. Review of reporting arrangements/standardisation and assurance methodologies in progress to ensure compliance with mandated requirements. MEHT A risk summit meeting was for infection and pressure ulcer management by the CNO with Matrons / ADoNs to understand challenges and identify actions to improve performance. Enhanced support has been provided on 2 wards (Rayne and Heybridge) with an Infection Prevention Nurse on the ward. Initial review has demonstrated good progress with action plans and outcomes. A further review by NHSI has been agreed for May in conjunction with SUHFT SHUFT DIPC from SUHFT in the process of selection for the NHSI Executive Development Programme Follow up review by NHSI to be undertaken in May 2018 BTUH BTUH finished year at 28 C Diff against target of 31 BTUH finished 2017/18 with 6 MRSA bacteraemias with 3 being deemed unavoidable. Review of all cases and plan to introduce electronic assessment on track for Q1. Never Events There was 1 reported never event for March at SUHFT Quality of Care Page 6

7 Harm Free Care Maternity Each site has the opportunity to save 10% on our maternity CNST premiums if we can demonstrate compliance against 10 key indicators. This would be a significant saving across the MSB. As part of the monthly Head of Midwifery meetings with the Chief Nursing Officer our compliance against the standards has been reviewed and work is in progress to achieve full compliance. A report will be presented to the June JWB. Quality of Care Page 7

8 Mid Essex, Southend and Basildon Hospitals Joint Working Board - 9th May 18 Operational Performance Yvonne Blucher Dorothy Hosein Clare Culpin (CQC Responsive) March 2018

9 Accident and Emergency 4 Hour Standard - MEHT Performance Commentary Actions / Mitigations April month end performance of 85.3%. Overnight breaches in minors remains a key focus as this is affecting performance. This has improved with re-engagement of the Middle Grades and some more senior support within the clinical site team overnight. Focused effort to deliver at least 10 discharges before 10. With an additional 6 discharges from the Emergency Village daily. (averaging 8) Bringing the week forward undertaken twice during March whereby largest discharges achieved on Wednesday not Friday. This has resulted in slightly better discharges numbers mid-week. 1x 12 hour trolley breach was declared as an SI relating to Mental Health capacity and associated transport issues Reviewed ESAT PDSA; Off-load cohorting; Ambulance Diverts (in x3; out x1). Current implementation is going well. Full Capacity protocol being revised to include Surgery, Summer Surge and preparation for Winter. This is aligned to the Bed Reconfiguration programme. Shift discipline and responsibility conversations with all medical staff. Need to refocus rota to meet demands +2hrs This is now embedded. Compliance checks for qualification status of long line and regular lines underway to reassure ourselves of CPD and Training needs. Strong focus on CQC preparation from whole team. Locum discipline is being tightened up. Check in and Check out process being reviewed to ensure we monitor activity and consider VFM going forward. 2 full time Consultants for ED have started in April. GP streaming volumes and pathways to be reviewed and focus on increasing volume. Revised admin pathway to discourage ED doctors from assisting GP activity. Minors focus on ZERO tolerance for breaches. New stretch of 98% minors performance in April Improved route for non-ev escalations and problem solving; early intervention preventing patient and pathways delays in place Exploring options for Mental Health to prevent 12 hour DTA breaches. Safety Summit across MSB has been proposed. Individual cases to be subject to targeted discussions. Review of Consultant and Middle Grade rotas; Interviewing 5 Middle Grades 23/3/18 and a further 2 other doctors in May. Confirmation of trainee posts give additional support with an additional post being supported by Deanery Focus on Easter Plan and Weekend resilience Operational Performance Page 9

10 Accident and Emergency 4 Hour Standard - BTUH Performance Commentary Actions / Mitigations cont. Improving care for emergency patients continues to be a Trust priority but remains fragile due to surges in demand and lack of capacity. In March 80.9% of patients were seen and treated/admitted within 4 hours. Quarter 4 performance has been constant between 80-85%. Issues The surges in attendances puts pressure in the system and although performance is maintained during the day it deteriorates into the night due to the demand on capacity. Each morning there is a residue of patients (15 20) in the department waiting placement. Staffing Remains a risk for Trust although all efforts made in recruitment, Bank and Agency bookings within a 6 week rota.. There are a growing number of stranded patients which are monitored daily and examined in detail weekly. The site has a comprehensive improvement programme for urgent and emergency care through the local transformation programme. The stepping up programme key areas of recovery are: - Reducing unnecessary admissions and attendances - Reducing length of stay and stranded patients. Although we understand the impact of operational capacity we continue to monitor and implement the following initiatives and mitigations: GP streaming in place and continues to work towards a trajectory of 45 patients per day. Medical Ambulatory service continues to pull patients through from the A&E, follow ups and GP referrals to support flow. Building work to enhance service in a purpose built area is due for completion end March 18., which will increase efficiency in the system. The frailty service at present operates out of CDU. A dedicated frailty ambulatory built area is under construction and due for completion end of March 18. This service will be developed with partners for an integrated service. To support ambulance handover we have developed and are continuing to implement an ED crowding protocol, Ambulance Handover and Rapid Assessment and Treatment (RAT) SOP with the aim to ensure timely ambulance handover and flow through the emergency department. Although operational capacity impacts on our ability, we have identified a dedicated area for cohorting patients to release the ambulance crews in a timely manner. Implementation of Full Capacity Protocol to support flow from the emergency department. Monitoring of both admitted and non admitted breaches, this is shared with the specialities for understanding and resolution through pathway design. Dedicated manager of day model now well established. Continuation of operationalisation of CUR to incorporate Red2Green and SAFER bundle with dedicated resource through introduction of the role Discharge Facilitators. Daily system wide conference calls to establish capacity in the system and escalate delays and issues. Weekly Multiagency robust reviews of stranded patient for all patients >7 day Length of Stay Weekend planning continues to develop with full engagement from all specialities Operational Easter Plan developed using lessons learnt from previous year. Operational Performance Page 10

11 Accident and Emergency 4 Hour Standard - SUHFT Performance Commentary Actions / Mitigations Performance dropped during March to 78.9%. There were 4 days during the month where the Trust achieved performance over 90%. There were 2 days where performance was above 95%. ED conversion rate remains at 31% on the rolling 4 week average once adjusted to remove AEC attendances this reduces to 29%. Timely discharges during the day remains a challenge - 49% taking place after 16:30. This has a clear impact on flow throughout the day. ED attendances have remained high throughout March 8,753. The Primary Care Streaming unit has taken an average of 14.6% of Minors attendances during March and is seeing 41 patients per day on average. Median Ambulance Handover time < 30 minutes for March was 94.8%. 47 black breaches were recorded during March however, there was a decreasing trend through the month and April is showing a further improvement. The Work streams reporting to Patient Flow Board continue to make progress. Late discharges are being addressed in part by the SAFER/R2G work and the provision of a larger discharge lounge for wards to decant patients. The Clinical Criteria for Discharge paperwork has been updated and the wards will be encouraged to use this at weekends, especially looking to the two May Bank holiday weekends. Capacity and Demand work is being finalised and producing recommendations in Medicine. Medicine and ED plans have been drawn up and are being actioned. A revised Discharge project is bringing together the various initiatives system-wide for focused action to prepare the system for Winter. Development of an integrated discharge team. Collaborative working across Directorates at the bed meetings is now helping to support ED performance. The new ambulance handover and cohorting protocol remains in place and is working well. To date the April performance figures are looking better than March and this trend is expected to continue. Operational Performance Page 11

12 Cancer 62 day Standard Performance Commentary Actions / Mitigations 2ww performance was maintained in month. Overall 62 day performance reduced in month with higher breaches driven by focus on reducing backlog. Key issues across the group: Significant diagnostic capacity challenge across the group in both endoscopy and cross sectional imaging (CT & MRI) Lung and Urology pathways remain a priority across the group. MEHT challenges also in Skin (plastics), Lower GI, Upper GI BTUH challenges also in Skin (Dermatology), Lower GI, Upper GI BTUH and MEHT recovery plans have been refreshed with oversight from NHSI. These incorporate clinical service improvements and operational performance management learning from the recovery process at SUHFT. We continue to work closely with NHSI, NHS elect, the cancer alliance and other partners to drive out delays and achieve faster diagnosis and treatment for patients. At MEHT, a fortnightly Cancer Transformation Board chaired by Managing Director and Medical Director are now embedded, providing focus and challenge. The Plastics service has demonstrated a step-change in response with the backlog halved since January. There is growing internal and external confidence in the position at MEHT and the ability to deliver compliance from September per current plan. The SUHFT performance is closely linked to timely referrals in from other Trusts. Locally, theatre availability is being prioritised for Urology and the service is working closely with referring Trusts to ensure 62-day compliant pathways can be achieved. National re-allocation guidance From April 2018 the national cancer waiting times (CWT) data submissions will be changed and at that time the formal published CWT performance data will reflect the NHSI national breach re-allocation rules. The impact of these rules on December performance would have been: December 2017 SHUFT MEHT BTUH Impact of breach re-allocation -0.6% -2.5% -1.8% At BTUH there has been investment in capacity and capability to deliver compliant cancer treatment including a number of additional Consultants, nurses and AHPs. Endoscopy capacity remains a significant challenge. BTUH have external support from IST to address this. The National Optimal Lung Cancer Pathway (NOLCP) project team has introducing a number of improvements at BTUH that will be shared across the group. Improvements seen in January and February not sustained in March. Performance recovery has been reset in April with renewed focus and support with the aim of delivering compliance from July as per current plan. Operational Performance Page 12

13 18 weeks Referral to Treatment Incomplete Standard Performance / Commentary Actions / Mitigations MEHT The Trust is not reporting national RTT figures, reporting will re-commence in August on July data. A detailed Action Plan to return to accurate reporting is in place, is 70% complete, with 13 ongoing actions. Progress is monitored through fortnightly meetings with Dorothy Hosein. The overall PTL size is steadily reducing as increased training and validation takes effect, it is now 13% lower than in February. Both the bookings & front of house Out-patient departments had a Fresh Start week that brought intensive training and system process re-design for a week. The next areas of focus are medical records & ward administrators. A separate plan for Ophthalmology cashing up is being drawn up in the service. The internal validation team have started and commenced their training. The external validation team have been extended to 31 st May to help train the internal staff. The DIEP recovery plan is progressing well and is ahead of trajectory. All departments continue to validate and book their longest waiting patients, the April validated position reduced by 2/3rds after intensive validation. Ophthalmology follow-ups are being dated and progress reported weekly to Site Directors. Issues Incomplete 52 week breach at month end MEHT Not reported BTUH Biggest Risk areas - Neurology and Respiratory Sleep SUHFT 9 Backlog Positions MEHT Please see actions/mitigations comment regarding the growth of the PTL following the implementation of Lorenzo BTUH 4,845 - Neurology, T&O, General Surgery, Respiratory and Sleep SUHFT 4,093 - Key areas ; Hot spots - admitted Orthopaedics, ENT and General Surgery, non admitted - Ophthalmology, Chest Medicine, Cardiology and Community Paediatrics BTUH Emergency pressures within the Trust have continued, resulting in elective beds being used for emergency admissions. This resulted in a further reduction of elective surgery being restricted to Urgent and Cancer. Joint surgery was restarted in early march but has stopped again to release beds to support the emergency flow. General Manager for RTT and Cancer Performance has been established to support recovery of performance. This role is currently established as an acting up opportunity to monitor the roles success and impact. Weekly Operational grip and control meeting with the Service Unit Managers from Specialty has been put in to place which will monitor the Utilisation of Out Patient and Theatres, as well as monitoring the recovery programme compliance. A RTT performance forecasting tool has been developed which is currently being populated by BIU. This will support proactive management with a corrective planning function. For 18/19 additional funds of around 2.5% have been included within commissioning plans to address RTT backlog and +52 week breaches. Work is on going to attribute this to the most pressing specialties. The CCG have commissioned additional elective capacity from Nuffield to also help with managing the backlog and 52+ week breaches. Lengths of stay are being reviewed across all surgical wards to support a reductions in line with the model hospital where out of range. This review also considers Stranded Patients (7+days) to ensure ward processes are effective. Improving both measures will support elective bed flow. SUHFT Action plan from the Day stay perfect week being developed, two work streams identified booking processes and theatre trials. Urology day stay patient arrival time has been amended to reflect the pre-operation preparation time needed. Review of Theatre template being undertaken to meet changing specialty level activity demands. Operational Performance Page 13

14 6 week Diagnostic Standard Performance / Commentary Actions and Mitigations Actions / Mitigations Southend Nurse recruitment is on-going, agency nurses continue to support existing workforce. Full electronic booking of patients is on track for April. Southend Compliance against the standard was achieved in all services. Locum Medical staff are now embedded within the Endoscopy team. Nurse endoscopist commenced in post. Mid Essex The main area of non-compliance remains non-obstetric ultrasound with performance of 74% The waiting list reduced significantly to 3,557 thus decreasing the denominator and adversely affecting performance despite the number of breaches decreasing. The main factors contributing to non compliance are as below: Spike in referrals from March 2017 linked to a change in community ultrasound provision creating an ongoing backlog of approximately 740 patients Sonographer, radiologist and radiographer staffing shortages Endoscopy capacity issues Mid Essex Ultrasound: Ongoing recruitment of sonographers and consultants (substantive and locum/agency) Specialist bank rate uplifted Outsourcing to Chelmsford Medical Centre 6 sessions per month currently unable to increase Exploring further outsourcing although other providers have limited capacity BTUH and Southend consultant radiologists undertaking weekend sessions for MEHT Additional weekend sessions being worked by sonographers Additional community sessions being commissioned by CCG Training posts in place Validation of waiting lists / backlog Endoscopy: Continuing efforts to recruit locum staff Additional in- house sessions offered to existing staff and those who have recently left the organisation BTUH Full additional day of scanning every Friday from March Additional Consultant capacity from 5th March Joint appointment with Ipswich out to advert (nil cost) Additional weekend and bank holiday capacity being sourced Recovery will be achieved by April, however with the mitigating action it is likely that March performance will improve BTUH Cardiac MRI breaches continue to drive the failure to deliver the 99% standard. Capacity gap arose due to unplanned 3 month absence of Consultant Specialist Radiologist (50% of workforce cover). Additional Ad Hoc sessions being provided in conjunction with CTC and requiring additional outsourcing to deliver. Recovery plans for March have been compromised due to a spike in monthly referrals from 76 to 135 which has absorbed entire additional capacity planned. Operational Performance Page 14

15 Mid Essex, Southend and Basildon Hospitals Joint Working Board - 9th May 18 Workforce, Leadership and Improvement Capability Mary Foulkes (CQC - Well Led) March 2018

16 Agency Ceiling Performance SUHFT MEHT BTUH Mid & South Essex KPI Mar-17 Mar-18 KPI Mar-17 Mar-18 KPI Mar-17 Mar-18 KPI Mar-17 Mar-18 Agency Spend (as a % of the pay bill) 5.7% 10.27% 11.92% 8.3% 10.71% 11.13% 5.5% 3.17% 5.68% 6.5% 7.97% 9.46% Medical Locum Target (actual) spend 000) ,073 1, ,453 2,304 2,503 SUHFT March has seen increased agency spend to 11.92% from 10.65% in February of pay bill. Agency cost increased by 32% from January to March 2018 Meetings to challenge the locum pay expectations and to encourage them to transfer to bank or to a substantive post Successfully encouraging three consultant retirees to register on the bank MEHT March has seen an reduction in agency spend to 11.13% (11.82% in February) The increased cost of 2,219k in March was 760k adverse to the ceiling. Ceased using high cost off framework agency BTUH At the end of the financial year the agency spend was 12,646,000 which was above the target The medical and agency spend was less that the outturn position in 16/17 Vacancies are the main driver for the high agency spend so efforts are being made to control agency through retention activities, cessation of agency spend on Sunday, focussing on reducing sickness absence Workforce, Leadership and improvement capability Page 16

17 Recruitment Performance SUHFT MEHT BTUH Mid & South Essex Vacancy Total Nurses Consultants Other Medical KPI Mar-17 Mar-18 KPI Mar-17 Mar-18 KPI Mar-17 Mar-18 KPI Mar-17 Mar-18 7% 7.13% 10.55% 7% 13.55% 15.65% 7% 9.29% 11.91% 7% 10.14% 12.78% Actual Actual Actual Actual 1,379 1,810 7% 11.38% 12.81% 7% 16.05% 20.67% 7% 13.90% 15.85% 7% 13.93% 16.66% Actual Actual Actual Actual % 6.53% 10.69% 7% 11.54% 11.31% 7% 5.78% 4.71% 7% 8.18% 9.01% Actual Actual Actual Actual % 12.81% 15.85% 7% 10.89% 16.06% 7% 11.79% 9.71% 7% 11.79% 13.95% Actual Actual Actual Actual SUHFT March has seen increased in registered nurses vacancies and a reduction in consultant vacancies 171 Medical offers (excluding Deanery doctors) have been made since January 2017 to end of March Medical offers due to start in May, June and July 2018 MEHT March has seen a small increase in consultant vacancies (from 28 in February to 30) Ten Nurse open days planned in the next six months. 84 HCAs recruited/offered at 3 open days so far this year. Three further events planned. Attendance at 3 job fairs and 4 job boards over next six months. BTUH March saw a slight increase in registered nurse and consultant vacancies Hard to fill areas are trying new approaches to advertising and content of open days to include visits or an educational element Areas with high vacancies and turnover have introduced practice facilitators who provide training and education to their ward colleagues, enriching their development Page 17

18 Turnover Performance SUHFT MEHT BTUH Mid & South Essex KPI Mar-17 Mar-18 KPI Mar-17 Mar-18 KPI Mar-17 Mar-18 KPI Mar-17 Mar-18 Total 9.50% 12.38% 12.55% 9.50% 16.07% 18.55% 9.50% 15.69% 13.73% 9.50% 14.75% 14.91% Actual Actual Actual Actual 1,634 1,702 Turnover 9.50% 11.44% 13.52% 9.50% 15.90% 18.66% 9.50% 14.38% 11.92% 9.50% 14.02% 14.64% Nurses (rolling over 12 months) Actual Actual Actual Actual Consultants 9.50% 10.33% 7.57% 9.50% 5.50% 4.99% 9.50% 9.53% 3.88% 9.50% 8.36% 5.42% Actual Actual Actual 19 8 Actual SUHFT Voluntary turnover decreased slightly in March Stay Plans will be monitored at a Ward/department level and managers given a 3 month turnover target Pre-retirement programme begins April 2018, with a streamlined Retire & Return process, workshops, a return to us talk and a 30 minute pension advice session for all staff due to retire within 24 months. BTUH March saw a slight increase in registered nurse and consultant vacancies The pipeline of overseas nurses continues to provide new starters Hard to fill areas are trying new approaches to advertising and content of open days to include visits or an educational element Areas with high vacancies and turnover have introduced practice facilitators who provide training and education to their ward colleagues, enriching their development MEHT The rolling 12 month turnover rate at the end of March was 18.55%, a small reduction on February, which was Page 18

19 Statutory and Mandatory training Performance SUHFT MEHT BTUH Mid & South Essex KPI Mar-17 Mar-18 KPI Mar-17 Mar-18 KPI Mar-17 Mar-18 KPI Mar-17 Mar % 12.38% 12.55% 9.50% 16.07% 18.55% 9.50% 15.69% 13.73% 9.50% 14.75% 14.91% Total Actual Actual Actual Actual 1,634 1,702 Turnover 9.50% 11.44% 13.52% 9.50% 15.90% 18.66% 9.50% 14.38% 11.92% 9.50% 14.02% 14.64% Nurses (rolling over 12 months) Actual Actual Actual Actual % 10.33% 7.57% 9.50% 5.50% 4.99% 9.50% 9.53% 3.88% 9.50% 8.36% 5.42% Consultants Actual Actual Actual 19 8 Actual SUHFT Statutory and mandatory training has reduced slightly from 86.51% in February 2018 to 86.29% in March MEHT Overall compliance for end of March was 86.33%, a reduction on February (86.79%); 3.13% lower that the same month last year. BTUH Mandatory training compliance reduced slightly from 84.33% in February to 83.93% in March Due to vacancies and high levels of activity in the hospital releasing staff can be harder particularly in the winter months. Page 19

20 Appraisals Performance SUHFT MEHT BTUH Mid & South Essex KPI Mar-17 Mar-18 KPI Mar-17 Mar-18 KPI Mar-17 Mar-18 KPI Mar-17 Mar-18 Appraisals 90.0% 72.40% 78.05% 90.0% 69.09% 77.67% 90.0% 91.59% 89.21% 90.0% 78.99% 82.37% SUHFT The Appraisal compliance rate has slightly reduced from 78.47% in February 2018 to 78.05% in March 2018 (0.42%). Aged appraisals (18 month +) continue to be a focus. From March 2018 a rolling figure will be reported. The March report identified 36 aged appraisals outstanding. These continue to be escalated to Directorate Boards by the HR Business Partners. MEHT The overall appraisal rate increased by 2.89% in March to 77.67% from 74.78% in February. On going support to utilise the supervisor self-service functionality, in regard to uploading appraisal dates continues. POD have made available additional resources to support appraisals, however provision and accessibility is limited due to MEHT intranet BTUH The appraisal compliance rate increased slightly from 88.91% in February 2018 to 89.21% in March HR BPs continue to work with Divisions and teams to address areas of low compliance. Divisions are reporting on their compliance levels at their performance reviews. Page 20

21 Sickness Absence Performance SUHFT MEHT BTUH Mid & South Essex KPI Feb-17 Feb-18 KPI Feb-17 Feb-18 KPI Feb-17 Feb-18 KPI Feb-17 Feb-18 Sickness Absence Sickness Absence (1 month) Sickness Absence (12 months) 3.5% 3.73% 3.88% 3.5% 4.24% 4.74% 3.5% 4.09% 4.33% 3.5% 4.03% 4.32% 3.5% 4.10% 3.82% 3.5% 3.99% 4.43% 3.5% 4.16% 3.90% 3.5% 4.08% 4.05% SUHFT Sickness Absence slightly increased to 3.88% YTD in March 2018 from 3.81% in February 2018 (0.04%). This is a reduction on last years rate of 4.10%. MEHT February s Sickness figure of 4.74% is lower than January s figure of 5.60%. The 12 month figure is also slightly higher at 4.43%. Top 100 reports are analysed and actioned. Targeted training is currently being planned in specific areas to support managers and supervisors. BTUH The sickness absence rate reduced in February to 4.33% from the January rate of 4.94% The rolling 12 month sickness absence has seen an improved positron Page 21

22 Commentary AGENCY SPEND All three trusts have controls and monitoring in place to limit agency spend and encourage each division to take actions to reduce the overall costs. In the June JWB meeting a summary will be presented on the timeframes to minimise the impact of the top highest cost and longest serving agency workers and locums. RECRUITMENT PLAN All three trusts have recruitment plans to reduce the vacancy rate. In June a recruitment and temporary staffing committee will have the first meeting and will have senior representations from the nursing and medical divisions. The JWB will receive a bi-monthly report. RETENTION IMPROVING ENGAGEMENT The NHSI retention action plans will be monitored at the Group Retention committee. The Group staff survey action plans have been developed including, staff listening events which begin in April and will continue in May. CEO video on zero tolerance to bullying and harassment followed by other Group activities which organised by a workstream including representatives from staff side, POD and HR The first you said we did communications will go out this month informing staff of the Group approach to Freedom to Speak Up where following a pilot is SUHFT, the service will be rolled out to BTUH and MEHT. This service provides access to a 24/7 advice line and an independent Guardian who will be on site. In addition to overseeing whistleblowing cases, the service has escalated/mediated in Bullying & Harassment and other concerns raised by staff.

23 Mid Essex, Southend and Basildon Hospitals Joint Working Board - 9th May 18 Finance and use of Resources James O Sullivan (CQC Use of Resources) March 2018

24 2017/2018 Financial Summary Year-to-date Finance and Use of Resources Page 24

25 2017/2018 Agency Ceiling Performance Year-to-Date Finance and Use of Resources Page 25

26 2017/2018 Cost Improvement Programme Year-to-Date Finance and Use of Resources Page 26

27 2017/2018 Capital Expenditure Year-to-Date Finance and Use of Resources Page 27

28 2017/2018 Cash and Borrowing Year-to-Date Finance and Use of Resources Page 28

29 2017/2018 Use of Resources Metric Year-to-Date Finance and Use of Resources Page 29

30 Mid Essex, Southend and Basildon Hospitals Joint Working Board Estates & Facilities Management Paul Kingsmore (CQC Safe) March 2018 Final Submission (24/04/18)

31 Estates & Facilities Management Introduction: Whilst all EFM services across MSB are working towards meeting statutory and legislative standards, all 3 organisations have a combination of systems, processes and measurable targets and thresholds which prevent any easy comparable data set for assurance purposes. As part of the review and alignment of EFM services across MSB, best practice is being rolled out will which include the ability to consistently monitor and report on performance going forward. Catering Satisfaction Performance Commentary Actions/Mitigations MEHT 96.6% vs. Target = 95.0% SUH 96.7% vs. Target = 95.0% BTUH 96.0% vs. Target = 95.0% Sites have different satisfaction surveys but based on same themes BTUH and SUHFT undertaken by contractors and MEHT completed in-house. Survey comments are positive. Early launch of Spring menus at BTUH. Several other methods in which patient satisfaction is determined via direct patient contact from Patient Council ward visits (MEHT) and Director walkabouts (SUHFT). Quality monitoring team in place at SUHFT, ongoing PLACE Lite at BTUH and annual PLACE at all sites due in April-May 2018 which include food tasting and mealtime service assessment. Incident Investigations Performance Commentary Actions/Mitigations MEHT 28.2% vs. Target = 98.0% SUH 82.9% vs. Target = 98.0% BTUH 52.0% vs. Target = 98.0% MEHT and SUHFT use DATIX for reporting incidents, BTUH uses Safeguard and all have different categories when reporting. Incomplete report closures when actioned. Time required to investigate incidents can be a contributory factor as well as operational pressures. Overdue closure of incidents - targeted training being organised for Investigating Officers to ensure incidents are closed on system for accurate reporting data. Ongoing weekly incident summary reports being utilised to monitor open incidents. Management vacancies being recruited into at MEHT and BTUH will contribute to improved timely investigations in The position is challenged by the difficulty to recruit into Service Management vacancies. Estates & Facilities Management Page 31

32 Cleaning (Audit % by risk category) Southend Basildon Mid Essex In Month Position/Commentary In Month Position/Commentary In Month Position/Commentary Very High Risk 98.8% vs. Target = 98.0% Very High Risk e.g. Theatres Mar cleaning audits undertaken. High Risk 98.0% vs. Target = 95.0% High Risk e.g. Wards March cleaning audits undertaken. Significant Risk 92.3% vs. Target = 85.0% Significant Risk e.g. Clinics Mar cleaning audits undertaken. Very High Risk e.g. Theatres Mar cleaning audits undertaken. High Risk 96.9% vs. Target = 95.0% High Risk e.g. Wards Mar cleaning audits undertaken. Significant Risk e.g. Clinics Mar 18-5 cleaning audits undertaken. Actions/Mitigations Actions/Mitigations Actions/Mitigations Quality Management Team undertake management audits. Very High Risk 98.8% vs. Target = 98.0% Very High Risk e.g. Theatres Mar cleaning audits undertaken. High Risk 96.6% vs. Target = 95.0% High Risk e.g. Wards Mar cleaning audits undertaken. Significant Risk 92.1% vs. Target = 85.0% Significant Risk e.g. Clinics Mar 18 6 cleaning audits undertaken. Monitoring team undertake management audits. Audits were not undertaken in September due other operational pressures. Very High Risk 98.83% vs. Target = 98.00% Significant Risk 98.6% vs. Target = 85.0% Team leaders undertake technical audits Some audits were not undertaken in July due to other operational pressures. Consistent Actions/Mitigation Ongoing monitoring and areas failing audits are reviewed with actions to mitigate failures documented and implemented. Timely and multiple re-auditing of failed areas performed to ensure mitigating actions are suitable and sufficient. Regular review of audit criteria being conducted in line with national guidelines. Dedicated cleanliness monitoring role recruited in February 2018 to monitor across MSB consistently for further validation of audit process and results. Estates & Facilities Management Page 32

33 MEMS/BME (Medical Equipment Repairs) Southend Basildon Mid Essex In Month Position/Commentary In Month Position/Commentary In Month Position/Commentary Priority 1 - Critical 100.0% vs. Target = 85.0% Priority 2 - High 96.0% vs. Target = 85.0% 11 Critical (urgent) reactive calls in March (response and closure within 7.5 hours) 24 High reactive calls in March (response and closure of no more than 3 days (22.5hrs). Priority levels for reactive calls are not differentiated and recorded to date. 209 reactive calls in March. All repairs are allocated to an engineer and responded to within the same day. The senior engineer prioritises the jobs as they are reported from the Helpdesk and allocates them accordingly. Actions/Mitigations Actions/Mitigations Actions/Mitigations Repair turnaround times- from moment that repair is reported to when the medical device is repaired and returned to patient use Both response and repair times are within targets set by the National Performance Advisory Group -Clinical Engineering. Priority 1 - Urgent 84.6% vs. Target = 85.0% Priority 2 - Routine 98.3% vs. Target = 85.0% Updated reporting in March differentiates between Urgent (n. 74 ) and Routine (n. 234) reactive calls in March 18, total jobs (n. 666). When waiting for parts, the clock stops and therefore compliance reported is high although average repair times have been increasing YTD. Priorities for reactive calls are system assigned at time of reporting and escalate to the next priority level if not completed Potential increase of PPM schedules to meet CQC requirements which will replace previous risk based PPM scheduling. Review of establishment requirements to mitigate above. Reactive Calls 93.7% vs. Target = 85.0% An engineer co-ordinates internal/external call-outs as appropriate. Evaluation of F2 database required regarding stopping clock when repairs are awaiting parts as per BTUH reporting position - this change may require administrative support. Consistent Actions/Mitigation Priority 1 & 2 definitions differ between SUH & BTUH with MEHT working to define Priorities 1&2. Working group in place across MSB MEMs to progress with alignment of databases, priorities and processes. Estates & Facilities Management Page 33

34 Estates Maintenance (Reactive % achieved within target timescale) Southend Basildon Mid Essex In Month Position/Commentary In Month Position/Commentary In Month Position/Commentary Priority 1 - Urgent 91.3% vs. Target = 95.0% Priority 2 - Routine 73.0% vs. Target = 85.0% Mar 18 - Priority 1 46 reactive calls (Repairs completed within 4 hours.) Mar 18 - Priority reactive calls (Repairs completed within 24 hours) Condition of the estate requires high levels of reactive maintenance input. Actions/Mitigations Actions/Mitigations Actions/Mitigations Priority 1 & 2 target not being met - improved performance following changes to mobile devices improving task management. On-going updates and training. Sickness levels having an impact on staff availability focus on sickness management to increase availability Priority 1 - Urgent 94.0% vs. Target = 95.0% Priority 2 - Routine 92.0% vs. Target = 85.0% Mar 18 Priority reactive calls (Emergency calls are set for a 1 hour response time) Mar 18 Priority reactive calls (Urgent calls are set for a 24 hour response time) Official notification given to all contractors to go paperless from Mon 12th March sign off tasks will be on Helpdesk ipads. Identified not all emergency calls require a 1 hour response. Further investigation is under way. Workforce job adverts have now closed. Interview and selection process underway. Priority 1 - Urgent 100.0% vs. Target = 95.0% Priority 2 - Routine 99.1% vs. Target = 85.0% Mar 18 - Priority 1 32 reactive calls (2 hour response time and 24 hour completion). Mar 18 - Priority reactive calls (24 hour response and 48 hour completion). Allocation of prioritisation at time of request not consistent Classification of Urgent/Emergency Priority 1 jobs via the Helpdesk is under review to ensure that allocation of appropriate response time. Since Jan, the implementation of an alternative performance monitoring system of reactive works is providing more timely and accurate information on Retained Estate job performance. Consistent Actions/Mitigation Software (Pirana) is potentially being trialled at MEHT with a view to rolling out across MSB in order to standardise CAFM system and reporting. Estates & Facilities Management Page 34

35 Capital (Capital Expenditure) Southend Basildon Mid Essex In Month Position/Commentary In Month Position/Commentary In Month Position/Commentary Estates Capital 7.71M vs. Plan 7.70M Estates Capital 5.12M vs. Plan 7.67M Estates Capital 5.97M vs. Plan 6.02M MERP Capital 3.63M vs. Plan 3.93M MERP Capital 4.65M vs. Plan 4.64M MERP Capital 1.33M vs. Plan 1.33M Forecast estates capital expenditure BTUH spent 5.12M of the estates capital MEHT spent 5.97M of the capital overachieved by 10K in 17/18. allocation of 7.67 m for the 2017/18. allocation of 6.02m for 2017/18. DoH loan for Radiology was not approved Allocation spent included 1.3m on MRI Medical Equipment Replacement until March which caused delays for entire and 500K on UPS scheme. Programme Forecast expenditure for 17/18 programme limiting delivery of planned UPS committed 835K in 18/19. achieved. Included Linac ( 1.8m) purchase works within the financial year. Backlog Maintenance spent funded by PDC drawdown. PO for 2018/19/20/21 Cath lab against plan of refurbishments sent locking price before MERP spent its allocation of 1.33M increase saving 300k Actions/Mitigations Actions/Mitigations Actions/Mitigations Estates Capital projects - Full capital allocation spent in MERP achieved forecast, reduced capital requirement following tendering M12 - the project team, estates, MEMs and procurement receipted 6m of the programme. A phenomenal effort in response to the changed DH loan position. Radiology project equipment delivered in M m underspend for 2017/18 as DH loan approval being later than planned. Consistent Actions/Mitigation Group Director of Capital Projects recruited in February to drive standardisation and central capital programme forward. Estates Capital projects, MERP and Backlog Maintenance capital expenditure achieved in financial year. MRI scheme delayed due to contractual delay on Scanner purchase. Construction completed February 19th, Machine to be commissioned and operational 18 May. Estates & Facilities Management Page 35