Balanced Score Card Review of July 2015 Data

Balanced Score Card Review of July 2015 Data

Balanced Scorecard Finance Patient Access Quality & Safety Human Resource Management

Finance

Finance Report - July 2015 Actual outturn YTD July 2015 Group budget 164.2m (2014 159.9m) Group actual expenditure 164.1m (2014 167.7m) Group actual surplus 138k ( 2014 deficit: 7.8m) CUH Budget 154.2m (2014: 148.6m) CUH /SMOH actual expenditure 154.6m ( 156.0m) CUH /SMOH actual deficit 375k (2014 7.4m) Mallow Budget 10.0m (2014: 9.7m) Mallow actual expenditure 9.5m (2014 10.3m) Mallow actual surplus 514k ( 2014 deficit 560k)

Forecast 2015 Group Budget 282.58m (2014 284.9m) Group projected expenditure 282.2m ( 284.2m) Group Projected Surplus 358k ( surplus 0.7m) CUH Budget 265.3m (2014: 262.8m) CUH projected actual 265.4m ( 265.2m) CUH projected Deficit 79k ( 2.4m) Mallow Budget 17.3m (2014: 17.5m) Mallow Projected Actual 16.8m ( 16.8m) Mallow Projected Surplus 461k

CUH Summary Budget v Actual Expenditure June 2015 Pay k Non-Pay k Income k Total CUH -106-777 831-52 SMOH -5 5-0 CUH-SMOH -106-782 836-52 Mallow 66-82 110 94 Total -40-864 946 42

CUH Budget v Actual Pay YTD - June 2015 2015 Actual Budget k k Variance k % Variance 2014 Actual k v 2014 Variance k Medical/Dental 31,818 32,095-270 -1% 31,271-824 Nursing/Midwifery 43,227 43,834-607 -1% 44,018 184 Paramedical 15,969 15,925 44 0% 15,968 43 Housekeeping 5,984 6,598-614 -10% 6-240 Catering 1,972 1,970 2 0% 2,065 96 Portering 3 2,878 65 2% 3,011 133 Administration 8,837 8,908-71 -1% 8,889-19 Other Staff 1,736 2-103 -6% 1,751-88 Total 112,486 114,047-1560 -1% 113,330-716

CUH Actual Non-pay Expenditure k YTD July 2015 v 2014

CUH Group Surplus / (Deficit) percentage %

CUH Debtor days July 2015

CUH AGENCY COSTS k 2013 July 2015

CUH Agency Costs June 2015

CUH Average Nursing & HCA Agency WTE s per Week 2013-15 CUH Average Specials /Other Nursing & HCA Agency WTE s per Week 2014-15

Cost Containment Plan

Patient Income 2013 July 2015

Consultant Private Insurance Claims O/s Consultant claims at 31 st July 2015 Consultants at 13 th Aug No of claims Value k HARTY, JAMES 202 776,353 ANDREWS, EMMET J. 108 411,390 TAYLOR, COLM 73 239,871 DODDAKULA, KISHORE 26 231,414 KEARNEY, PETER 107 212,325 REIDY, DECLAN 42 171,449 O'REILLY, SEAMUS 165 169,477 CLARKSON, MICHAEL 27 149,874 MCSWEENEY, NIAMH 38 126,721 GUERIN, SHANE 8 124,723 SWEENEY, BRIAN 99 123,134 O'BROIN, EOIN 76 120,899 KELLY, PETER 49 120,282 REDMOND, PAUL 24 105,728 KHAN, HAMID 26 104,662 O'LEARY, PAULA 36 101,539 BORAN, SINEAD 33 101,376 PLANT,WILLIAM 50 101,201 TOTAL 3,591,584

Mallow Budget v Actual YTD June 2015 Budget Actual Variance % Variance Pay 7,530 7,485 45 0.60% Non Pay 2,149 2,436-287 -13.40% 9,679 9,921-242 -2.50% Income -1,113-1,788 675 60.70% Total 8,566 8,134 433 5.00%

Patient Access

CUH Weekly INMO Trolley Report Week ending 14 th August 2015

Daily Trolley Numbers June August 2015 (23/8/2015)

Ambulance Turnaround Times (June)

ED 6hr & 9hr Target (17 th August) (9hr 77.4% - 6hr 59.6%) R

Delayed Discharges - 2015 January August (18 th August) 30 25 20 1514 10 10 23 17 24 22 18 15 17 17 18 11 19 14 21 19 21 18 20 20 13 13 10 17 17 22 16 18 15 14 12 12 5 0

Inpatient Day case Waiting Lists

Total Waiting List 14/08/2015 Wait category 0-3 Months 3-6 Months 6-8 Months 8-12 Months 12-15 Months 15-18 Months 18-24 Months 24-36 Months Grand Total ACTIVE 383 221 75 142 77 67 31 1 997 PREADMIT 176 41 10 7 3 3 6 1 247 SUSPENSION 40 4 2 3 2 1 52 599 266 85 151 83 72 38 2 1296 ACTIVE 206 104 33 68 21 10 3 1 446 PREADMIT 107 28 1 7 2 145 SUSPENSION 17 1 1 19 330 132 35 75 22 12 3 1 610 929 398 120 226 105 84 41 3 1906

18 Month Breaches (54)

18 Month Breaches by Speciality 30 30 25 20 15 10 6 5 2 4 1 1 3 2 4 1 0 G Fulton B O'Reilly C Burke M Hewitt J Coulter P Kelly C Brady E Andrews M McCourt P Redmond Vascular Gynae. Gynae. Gynae. Gynae. Cardiology Gen Surgery Gen Surgery Gen Surgery Gen Surgery

15 Month Breaches - December 2015 (313) Cardio Th 7 Cardiology 10 Pl Surgery 11 G Surgery 51 Respt 3 Urology 15 N/Surgery 1 Vascular 73 Gynae 142 0 20 40 60 80 100 120 140 160

15 Month Breaches by Specialty

Outpatient Waiting Lists

Patients in breach of the 18m deadline- 30 th June

Patients Currently in Breach 0f 12mth Target

Medical Patients to be seen by the 31/12/2015 (1,382)

Surgical Patients to be seen by the 31/12/2015 (5,244)

Women and Children Patients to be seen by the 31/12/2015 (2,329)

Scope Waiting List

Scopes Routine June 2015 R

Medical ALOS (June Dashboard) G

New Patients Treated with Radiation Oncology - July 2015

Reason for Treatment Delay - July 2015

Quality & Safety

Time to Surgery (June Dashboard) G

ALOS Excluding LOS over 30 days (June Dashboard) G

Cancer KPI Breast-Lung-Prostate -Jan July

Serious Reportable Events (SRE s) 11 SREs communicated in 2015 7 communicated in July & August 3 environmental events serious disability for patient associated with a fall whist in hospital 3 care management events Maternal death, serious disability associated with a diagnostic error & stage 3 pressure ulcer after admission 1 surgical event Unintended retention of a foreign object post surgical procedure

Reportable Events

Re Reportable Events portable Events

Patient Experience - Complaints Complaints received - July 2015 9 Safe and Effective Care 6 Access 2 Dignity and Respect 2 Communication and Information 1 Accountability 1.73% of complaints investigated within 30 working days

Patient Experience - Complaints 3 Appointment 1 Alleged inappropriate behaviour 1 Delivery of Care 5 Treatment and Care 1 Accessibility / Resources 1 Hygiene 1 Admission 2 Medication 1 Parking 1 Communicatio n Skills 1 Human Resources

Risk Register Risk Register update in June 2015 49 Open Risk Assessments on register Update & amendments made to 11 risk assessments Closed 6 previously identified risks - CUH 16, CUH 31, CUH 44, CUH 45, CUH 46, CUH 49 Reopened 1, CUH 39 - Theatre Staffing Four new risks identified CUH 52, CUH 53, CUH 54, CUH 55 6 risk assessment escalated to CEO South / South West Hospital Group for consideration of additional controls CUH 17, CUH 39, CUH 52, CUH 53, CUH 54, CUH 55

Reducing Healthcare Acquired Infection (MRSA) (June Dashboard) G

Reducing Healthcare Acquired Infection- C diff (June Dashboard) G

Reducing Healthcare Acquired Infection (June Dashboard) G

National Early Warning Score National Early Warning Score programme extending to include sepsis recognition and treatment National sepsis screening tool and pathway Implementation on implementation Audit results indicate a decrease in compliance - a number of measures identified for improvements Mandatory online education nurses, NCHDs and consultants- you must do it to work here Commitment that NEWS score will be used in all patient handover e.g. ward, virtual hospital, bed management Commitment to ISBAR Support for an electronic tool Irish Maternity Early Warning Score - New Modified IMEWS Chart rolled out in CUMH, ISBAR sticker for IMEWS developed and in use

NEWS Implementation (June Dashboard) G

IMEWS Implementation (June Dashboard) G

HIQA Reports - Portlaoise Presentation at EMB and Executive Quality & Safety Committee Self assessment report submitted against S/SWH Group template Filling of permanent Director of Midwifery post, Clinical Director post and experience Risk Manager post Critical Care Capacity

Human Resource Management

Sick Leave July 2015 6.0% 5.0% 5.06% 4.45% 4.39% 4.0% 3.5% 3.5% 3.5% 3.5% 3.5% 3.5% 3.0% 3.08% 2.40% 2.0% 1.51% 1.0% 0.0% Med/Dent Nursing H & SCP Man. Admin Gen. Support Other

Staffing & Costs

EWTD Compliance

MRI Unit Paediatric Unit Mental Health Unit Project Acute Medical Assessment Unit Phase 3 & Endoscopy Unit Capital Projects Completed and operational Status Phase 1 - build programme commenced in July Phase 2 submitted for capital funding Completed and operational Completed and operational Radiation Oncology Unit Planning permission granted Enabling works to commence in November 2015 Cystic Fibrosis/ Respiratory Ward Blood Sciences Project Ward refurbishment completed operational from October Design Team appointed request for managed service approved Oncology Service Expansion of Day Unit plan signed off submitted for Philanthropic funding (ACT) Refurbishment of Ward 2D capital funding in place Medical Oncology Centre developing Statement of Need Ophthalmology Transfer phase 2 Helipad Step Down Unit Project group in place Interim helipad in place - final solution being assessed by CAA. Discussion has commenced on Procurement Process

Key Issues Recruitment of Nursing staff 31 beds closed Recognition of Budgetary performance Dependency on patient income 2016 Estimates Undergraduate Training costs - 6.5m per annum Management of Unscheduled Care Implementation of Change Programme Initiatives Scheduled Care Implementation of plan to meet waiting list targets Hospital Group approach to maximise capacity