Highland NHS Board 3 April 2012 Item 3.9 IMPROVEMENT COMMITTEE Report by Elaine Mead, Chief Executive The Board is asked to: Note that the Improvement Committee met on Monday 5 March 2012 with attendance as noted below. Note the Assurance Report and agreed actions resulting from the review of the specific topics detailed below and the Balanced Scorecard (attached). Panel: Mr Ian Gibson, Non-Executive Director, in the Chair Dr Ian Bashford, Medical Director Dr Iain Kennedy, Non-Executive Director Ms Elaine Mead, Chief Executive In Attendance: Ms Margaret Brown, Head of Service Planning Dr Paul Davidson, Clinical Director, Mid Highland CHP Mr Kenny Oliver, Board Performance Manager Ms Sarah Wedgwood, Non-Executive Director Miss Irene Robertson, Board Committee Administrator Apologies: Mr Garry Coutts, Mrs Linda Kirkland and Mr Colin Punler Respondents: Mr Bill Brackenridge, Chair, Argyll & Bute CHP (videoconference) Mr Mike Evans, Chair, Raigmore Hospital Mrs Gillian McCreath, Chair, South East Highland CHP Mr Okain McLennan, Chair, Mid Highland CHP Dr Roderick Harvey, Associate Medical Director, Raigmore Hospital Mr Derek Leslie, General Manager, Argyll & Bute CHP (videoconference) Mr Chris Lyons, General Manager, Raigmore Hospital Mrs Sheena MacLeod, General Manager, North Highland CHP (videoconference) Mrs Gill McVicar, General Manager, Mid Highland CHP Mr Nigel Small, General Manager, South East Highland CHP Dr Margaret Somerville, Director of Public Health (part meeting) Mr Nick Kenton, Director of Finance (item 1a) Ms Christian Goskirk, Long Term Conditions Manager (item 3) TOPICS DISCUSSED 1. Review of Board Assurance Report Actions a. Financial Position b. eksf Trajectories 2. Balanced Scorecard 2011 2012 2.1 Heat Targets a. All Cancer Treatments Endoscopy
2.2 Standards a. Complaints b. Same Day Surgery / Reducing Pre-operative Stay c. New Outpatient Appointment DNA Rates d. Waiting Times:- New Outpatient Waiting Times maximum wait 12 weeks Inpatient/Day Case Waiting Times maximum wait 9 weeks e. Dementia Registrations 3. Stroke Update 4. Integration Issues Measuring and Monitoring of Targets 5. Scottish Patient Safety Programme 6. Screening Data for Argyll & Bute Residents Being Screening in NHS Greater Glasgow & Clyde 7. Service Improvement Group Update 8. Risk Assessment for Highland January 2012 DATE OF NEXT MEETING The next meeting will be held on Monday 30 April 2012 in the Board Room, Assynt House, Inverness at 1.30pm. 2
IMPROVEMENT COMMITTEE ASSURANCE REPORT Meeting on 5 March 2012 The Committee s role and remit is to scrutinise NHS Highland s performance and ensure remedial action is taken, as required. 1 REVIEW OF BOARD ASSURANCE REPORT ACTIONS Issues/Risks Assurance Actions Chronic Pain Service: Sustainability of service. Funding issues. A solution has been agreed to ensure the service is maintained at the current level. Opportunities to be explored to further develop the service. Continue to explore opportunities for the further development of the service. Action: S MacLeod/C Lyons Financial Position Month 10 January 2012: Need to reduce reliance on nonrecurring savings. Considerable challenges in making savings in both revenue and capital expenditure. Issues around integration and implications for financial allocations and savings required to be made both by NHS Highland and the Highland Council. These will need to be aggregated. Financial risks associated in particular with care at home services. Issue raised in relation to the use of SESPS funding. Raigmore: The position remains extremely challenging, additional resources will be required to achieve financial balance. No unfunded posts in the system. Break even position continues to be predicted, provided there are no unexpected costs or year-end adjustments. Five year capital plan has been drawn up and submitted to Scottish Government. Asset Management Group meetings taking place to review/maximise assets. Financial structure will be in place on 1 April 2012 which will be refined over time along with the necessary financial reporting arrangements to provide assurance to the Board and the Improvement Committee. Strategic group to be established to oversee the Change Fund and investments made from benefits realised. Raigmore: A three year plan is being developed, based on the quality approach but acknowledging the need to take cognisance of what is affordable as well as desirable. Table 3 of the finance report to be amended to reflect the position in South East CHP in relation to carry forward of non-recurring resource. Action: N Kenton Report to be prepared for the April meeting of the Improvement Committee in relation to SESPS. Action: K Proctor Discussion planned for Board Development session in April. Action: N Kenton Report to be submitted to the April meeting of the Board detailing progress with the development of the recovery plan ensuring quality approach is maintained. Action: C Lyon 3
IMPROVEMENT COMMITTEE ASSURANCE REPORT Meeting on 5 March 2012 Resource will require to be identified to support the delivery of the plan. Work is ongoing to achieve further efficiencies, in particular around vacancy management. North CHP: Break-even will not be achieved in the current financial year.. eksf Trajectories: Revised trajectories to be developed to move the PDP work forward in the next year. Issue around bank staff who have several jobs undertaking a review for each post. North CHP: The updated financial plan provides a degree of assurance of achieving break even in the longer term. Savings will be realised from the service redesign work underway. Operational Units confident of meeting target by end March. With regard to bank staff, agreement to review multiple postholders only once would significantly contribute to the position. It was noted that other boards do not include bank staff in their figures. Update on achievement of target at April meeting of the Improvement Committee. Action: General Managers To explore options to ensure PDP work is undertaken in a more structured and planned way throughout the year. Action: General Managers The position with regard to Corporate Services, Facilities, etc to be confirmed. Action: E Mead/A Gent 2.1 BALANCED SCORECARD 2011 2012 HEAT TARGETS Issues/Risks Assurance Actions All Cancer Treatments Endoscopy Utilisation, Raigmore: Capacity issues. Threshold for referrals; variation in GP referral rates. Ongoing action to encourage referrals to other endoscopy units, where appropriate. Patient Focused Booking will assist in ensuring patients are seen in a timely manner. Detailed report to be prepared for April meeting of the Improvement Committee, to address proposals for sustainability of the service. Action: C Lyons 4
IMPROVEMENT COMMITTEE ASSURANCE REPORT Meeting on 5 March 2012 Impact of DNAs in terms of lost sessions. Effective management of DNAs will improve capacity. The introduction of the Theatreman system to record patient activity will enable more detailed reporting and analysis of endoscopy utilisation. 2.2 BALANCED SCORECARD 2011 2012 STANDARDS Issues/Risks Assurance Actions Complaints 20 day response target: Raigmore: Medical & Diagnostics Division not achieving 80% target. Clinical complexity of some complaints. Raigmore: As at end December 2011 overall Raigmore achieved the 80% target. Centralised monitoring will assist in ensuring quality and timeliness of responses. Training is being given in the use of the DATIX complaints module. Complaints referred to the SPSO are being monitored. To consider the introduction of the pro forma developed by Mid CHP across the area. Action: G McVicar / M Morrison Mid CHP: As at December 2011 67% achieved against the 80% target. Complex nature of some investigations, capacity issues / availability of key managers and clinicians. Mid CHP: Training has been provided for key staff. A pro forma has been developed to guide managers through the process ensuring their investigations and reports cover all the key issues. 5
IMPROVEMENT COMMITTEE ASSURANCE REPORT Meeting on 5 March 2012 Same Day Surgery / Reducing Preoperative Stay North CHP: Variation in rates, particularly in relation to laparoscopic cholecystectomy, inguinal hernia repair and anterior/posterior colporrhapy. Clinicians prefer to have patients stay overnight, even when this is not clinically necessary. For most procedures the CHP is either meeting or exceeding the target. Ongoing dialogue with clinicians around the issues/concerns with the three procedures identified. The issues to be referred to the Pan Highland Surgical Board. Consideration to be given to using local B&B accommodation instead of overnight hospital stays to allow patients to remain within easy reach of the hospital should any complications arise. Action: Pan Highland Surgical Board to take forward New Outpatient Appointment DNA Rates: Argyll & Bute CHP: Below trajectory. Impact of redesign work being undertaken in Medical Records. South East CHP: Fluctuating position with regard to Outpatient Psychiatry in North Highland, currently at 17% against the target of 13.9%. The target remains challenging. Argyll & Bute CHP: Series of actions in place to identify reasons for both general and mental health outpatient DNAs and improve their management and monitoring. It is anticipated that once the redesign work is completed and consistent application of the Patient Access Policy has been achieved the CHP will be on track to meet the target. South East CHP: North Highland s figures are very similar to the national average. Work is ongoing to improve the position, in particular roll out of text messaging alerts to patients. Discussions are taking place as to the feasibility of introducing patient focused booking into mental health services. Good practice / learning points from North Highland to be shared with Argyll & Bute CHP. Action: General Managers Discussion with PFB Team to identify any transferable actions from acute services. Action: N Small 6
IMPROVEMENT COMMITTEE ASSURANCE REPORT Meeting on 5 March 2012 Raigmore: High rate of DNAs in Paediatrics. Roll out of Patient Focus Booking (PFB) service. New Outpatient Waiting Times - maximum wait 12 weeks; and Inpatient/Day Case waiting times maximum wait 9 weeks, Raigmore: Position at end January 2012 showed breaches in both Outpatients and Inpatient/Day Cases, the majority occurring in Orthopaedics. Breaches also occurred in General Surgery as a result of the Clostridium difficile outbreak. Dementia Registrations Argyll & Bute CHP: Target not being met. January 2012 figures indicated a deterioration in the position from the December 2011 report. Raigmore: The implementation of PFB has generally led to a decrease in the numbers of DNAs across the specialties, with one or two exceptions. The high DNA rate in Paediatrics is a national issue. There is a special process within PFB that provides a safety net for DNAs for children. A high rate was noted in Diabetes. As this is a chronic condition and the number of new patients is very small, it is not an effective measure of performance. Action plans are in place to address capacity issues and clear the backlog. A zero breach position is predicted across all specialities - with the exception of Orthopaedics - in March 2012 for all outpatients and admissions. National funding will be provided to assist the position in Orthopaedics with the aim of ensuring there are no breaches in the first quarter of the new financial year. A range of measures is being taken. The CHP is continuing to work in partnership with Alzheimer Scotland. Additional link workers are being recruited to enhance post diagnostic support which it is hoped will assist performance in relation to registrations. Work to continue to achieve roll out of PFB across all specialties. Action: C Lyons The position to continue to be closely monitored. Action: C Lyon/R Harvey Position to continue to be monitored. Action: D Leslie 7
IMPROVEMENT COMMITTEE ASSURANCE REPORT Meeting on 5 March 2012 3 TOPIC: STROKE UPDATE Issues/Risks Assurance Actions Issue around collection of Scottish Stroke Care Audit (SSCA) data Trajectory against the HEAT target for the period ending 31 December 2011 was met. An action plan has been developed to ensure continuing improvement and achievement of the interim target of 80% by end March 2012. A review of AHP services in community hospitals has been undertaken and a training programme developed to facilitate patient flow from the Stroke Unit into the community. Work is ongoing to improve SSCA data collection. The Stroke pathways and protocols are being reviewed. The standard for brain scans, currently 80% to be undertaken on day of admission, may be redefined as within 24 hours. Update on progress to be prepared for the September meeting of the Improvement Committee. Action: C Goskirk 4 TOPIC: INTEGRATION ISSUES MEASURING AND MONITORING OF TARGETS Issues/Risks Assurance Actions The development of targets for Children s Services and Adult Services taking account of what can realistically be achieved within available resources. Need to set targets/standards for services in respect of transition from childhood to adulthood. NHS Highland and The Highland Council continue to work in partnership to put in place appropriate mechanisms to measure/monitor performance against targets and standards, including proposals for the development of a balanced scorecard for Children s Services and for Adult Services, and the enhancement of the Improvement Committee processes. Measures for both Adult and Children s Services to be finalised for inclusion in the final version of the Highland Partnership Agreement. Draft balanced scorecards to be submitted to the April meeting of the Improvement Committee. Action: K Oliver Work to be done to develop a comprehensive plan for dealing with children with complex needs moving into adulthood. Action: M Somerville 8
IMPROVEMENT COMMITTEE ASSURANCE REPORT Meeting on 5 March 2012 Issues relating to availability of data and data sharing between NHS Highland and The Highland Council to enable performance to be monitored Assurance that services will continue to improve following integration. Work is ongoing to identify key measures for both Services, and thereafter establish baselines and develop targets and trajectories for each measure. 5 TOPIC: SCOTTISH PATIENT SAFETY PROGRAMME Issues/Risks Assurance Actions Continuing spread of programme, ensuring it is locally embedded. NHS Highland is the first Scottish Board to achieve a score of 3.5 and is now working towards level 4. Raigmore: Very good progress made with implementation of the bundles. Need to look at adverse events and crude mortality. Progress report on implementation of the programme and its effectiveness in terms of outcomes for patient care and safety to come to the November 2012 meeting of the Improvement Committee. Action: General Managers North CHP: Slight increase noted in crude mortality rate and HSMR. North CHP: Further spread of bundles achieved within Caithness General Hospital, now being implemented within community hospitals and also the Scottish Ambulance Service. Training initiatives in place for use of global trigger tool and mortality reviews. Case note reviews are being undertaken. Argyll & Bute CHP: The programme is well embedded in Lorn & Isles Hospital, however it will be challenging to roll it out to the numerous small and re mote locations within the CHP area. 9
IMPROVEMENT COMMITTEE ASSURANCE REPORT Meeting on 5 March 2012 Mid CHP: Variable position with regard to consultant engagement. Mid CHP: Progress is being made with spread.. 6 TOPIC: SCREENING DATA FOR ARGYLL & BUTE RESIDENTS BEING SCREENED IN NHS GREATER GLASGOW & CLYDE Issues/Risks Assurance Actions NHS Greater Glasgow & Clyde provide screening or the organisation and monitoring of a number of screening programmes. Improvements require to be made to NHS GGC laboratory/data systems to facilitate extraction of relevant data. There is also an issue regarding availability of data from ISD for some of the screening programmes, as ISD continues to report on the old NHS Argyll & Clyde area. The CHP is continuing to liaise with NHS Greater Glasgow & Clyde regarding a solution to the systems issues identified. Ongoing input from public health staff and NHS Highland Screening Coordinators ensures availability of all the relevant data required to monitor performance against the targets. Noting that a generic solution had previously been found in respect of retinopathy screening, based on post codes, it was agreed to write to ISD recommending this as a way forward. Action: E Mead 7 TOPIC: SERVICE IMPROVEMENT GROUP The Committee received and noted the reports of the meetings held on 20 December 2011 and 30 January 2012. 8 TOPIC: RISK ASSESSMENT FOR NHS HIGHLAND JANUARY 2012 The Committee noted the risk matrix setting out the position in relation to performance against the HEAT targets as at January 2012. All areas were either green or amber with the exception of CAMHS (26 weeks from referral to treatment) which was showing red. The Committee noted it was unlikely that this target would be delivered. 10
IMPROVEMENT COMMITTEE ASSURANCE REPORT Meeting on 5 March 2012 9 TOPIC: IMPROVEMENT COMMITTEE ANNUAL REPORT 2011 2012 Kenny Oliver confirmed that the preparation of the Committee s annual report for 2011 2012, which requires to be submitted to the Board s Audit Committee in May 2012, was in hand. 10 FUTURE AGENDA ITEMS Meeting on 30 April 2011: Integration A&E Attendance Update Equality and Diversity Impact Assessment Process/Delivery Improvements CAMHS Update on long term conditions work, particularly in relation to anticipatory care and polypharmacy All Cancer Treatments Referral Patterns A&E Attendance Future Meetings: Integration (July 2012 meeting) Reduce Carbon Emissions/Energy Consumption (July 2012 meeting) Children s Fluoride Varnish/Childsmile Programme (July 2012 meeting) Highland Ethnicity Recording (July 2012 meeting) Chronic Pain Endoscopy Scottish Patient Safety Programme (November 2012 meeting) Patient Focussed Booking Change Fund New to Return Ratio EQIA Compliance Better Together Quality Outcomes Framework 11
IMPROVEMENT COMMITTEE ASSURANCE REPORT Meeting on 5 March 2012 11 SCHEDULE OF IMPROVEMENT COMMITTEE MEETINGS 2012 The Improvement Committee will meet on the following dates in 2012:- (Mondays, 13:30) 30 April 2 July 3 September 5 November 12