Blackpool Teaching Hospitals NHS Foundation Trust Corporate Objectives 2012/13 Quality To provide Best in NHS Care for Our Patients. Advancing Quality Lean Improvement/Productive Ward NHS LA Level 3* Research & Development Quality Framework Nursing & Midwifery Strategy Information to Assist with Clinical Performance Privacy & Dignity Review Alert/Vision Patient Experience Revolution Quarterly report to the Board Healthcare Governance Committee Performance Monitoring Committee Adherence to AQ Pathways 95% compliance. MT 95% compliance/top 25%. Hospital Acquired Pressure Ulcers Privacy and Dignity (P&D) questions on Patient Survey Green Rating. Patient Experience/Local Inpatient Survey Green Rating. 30% reduction. Green rating. Green rating. Patient Safety Walkabouts Nursing Care Indicators All Divisions Green. All Divisions green. Health Care Associated Infections (HCAIs) MRSA below 3. C.Diff 51. MRSA below 3. C.Diff below 51 Medication Errors = 30% reduction. 30% reduction. Dementia improve diagnosis Safety Thermometer - monthly 90% of patients aged 75 and over screened on admission. 100% of Wards. End of Life Care reduction in patients dying in hospital. Nurse Staffing Levels 10 x 10 establishment. 10 x 10 establishment. Achievement NHSLA Level 3. NHSLA 3 compliant. CNST Level 2. CNST Level 2 compliant 1
People To realise the potential of our staff and be a great and safe place to work. Updated workforce strategy to reflect TOPP QuIPP workforce theme TOPPs post integration people plan Seven day working Roll out of Vision and staff support for all displaced staff HR Policies and Terms and Conditions Medical workforce review Provide Updated Clinical Skills Programme Staff Engagement The Blackpool Way refresh Mandatory Training Workforce Benchmarking Recruitment Process Improvement HR & OD Committee Number of staff in post Cost of Pay bill Number of Staff Re-deployed into new roles. Skill & Grade Mix Number of coaches/being coached Staff Survey/LMSQ Evaluation of Leadership Development programmes Reduce Number of Incidents Number of staff attending Mandatory Training Number of employee relations cases and formal concerns raised Medical workforce plan in each area Revised recruitment processes Reduced medical and nursing staff vacancies NG 31.3.13 Reduction in posts by value of up to 300 wte. Vision on track. Revised HR Policies in place. Appraisal rate above 90%. Re-launching of Blackpool Way 90% of staff compliant with Mandatory training None Trust driven turnover below 11% Trust vacancy rate below 5% Coaching and Mentoring Board Development Talent Management Clinical Leadership Development Customer Care The Blackpool Patient Revolution IIP Gold Action Plan Staff Survey Action Plan Health Care100 & Sunday Times participation Simulation Training Quarterly Staff Survey temperature stats HR & OD Committee Number of Coaches/Coachers Number of mentors/mentees Number of accredited leadership programmes Scores in Sunday Times Best Place to Work and Healthcare 100 Staff Survey Results Evaluation of Coaching impact In Patient Survey Staff Satisfaction Survey NG Coaching % mentoring available to all staff. Talent management leadership programme in place. IIP Gold retained. Staff Survey responses above 60%. Improving scores on key questions in study Staff Governor Involvement Health & Well Being Agenda Sickness Absence Targets Electronic Staff Records Benefits Realisation HR & OD Committee Patient Survey: Local & National NG Sickness rate below 3.2%. Fully compliant with Equality Act Equality and Diversity E-Rostering Corporate and social responsibility including work experience programme and apprenticeships Knowledge Management HR & OD Committee Complaints: Number % in < 25 days Sickness Absence Reduction in % of work related ill heath cases (MSK & Stress) Retention rates NG 18 work experience places offered Reduction below 10, 11/12 outturn 2
Safety To reduce avoidable harms to patients Care of the Critically Ill Care of the Acutely Ill Group Falls VTE Pressure Ulcers Medication Errors Cardiac Arrest Rate MOD 31.3.13 Target 0.38% of total inpatients in year Achieve Inpatient Falls target VTE Risk Assessment Achieve reduction in pressure ulcer target Achieve reduction in medication error target 30% reduction in inpatient falls in moderate/severe harm 90% compliant 30% reduction in pressure ulcers 50% reduction in medication errors by 2012/13 Safety Walkabouts Quarterly Safety Walkabout report to the Board Formal Patient Safety Walkabouts 6 ad hoc per week and 2 structured per month Health & Safety Executive Targets Evidence Centre Partnership Mortality Collaborative Nursing & Midwifery Strategy Transparency Project Global Trigger Tool Health & Safety Committee Achieve Health & Safety Targets Slips, Trips, Falls HSMR Global Trigger Tool (GTT) Patient Harms Deaths in hospital 5% reduction on previous year 5% reduction in avoidable incidents Reduce by 30% (2011/12 = target < 1542) HSMR: a) Within expected range for HSMR (Dr Foster) b) Within expected range for SHMI (new DH measure when announced) c) RAMI (CHKS) < 90 2011-12 target based on GTT harms/1000 bed days = 17.5% reduction = (17 mean) Readmission rates 5% reduction on previous year 30% reduction Infection Prevention Quarterly Infection Control report to the Board Hand Hygiene Audits >95% compliant SUSA/Talk Safe Observes Talksafe Observes Inverse in Talksafe Observes 3
Cost To achieve Best in NHS Care at the lowest cost. Vacancy Control Value for Money Better Care Better Value Energy/Waste Programme Job Planning Process QuIPP Project Review of on site/off site services Review Clinical/General waste QuIPP Programme Board Whole Time Equivalent (WTE) Better Care Better Value: Length of Stay (LoS) Did Not Attend (DNA) Readmission rates New to follow up ratio Energy Usages Finances EBITDA Sickness absence Bank expenditure Locum Expenditure TW 31.313 Achieve the following financial targets: Surplus of 3.1m (pre ToPPs) Cash Balance of?m QuIPP of 15.0m Financial Risk Rating of 3 4
Environment PHYSICAL Development of multi-storey car park and main entrance Regular Board Update Agreement for Preferred Contractor Finance from FTFF RB 2013 Sign agreement by June 2011 Strategy for Estate Board Paper Programme & Cost June 2012 Board paper to June Board Meeting Condition Review of all Community Services Properties ECONOMIC Rationalisation of estate & Support Services Risk Assurance Utilisation & Costs June 2012 Complete review by June 2011 PEAT Environment Food Privacy & Dignity March 2013 Board Update Reduction in properties & square metres RB March 2012 Monitored by site: Excellent>=96%; Good 75% - 95%; Acceptable 60%-74%; Poor 50%-59%; Unacceptable 0%-49% Reduce space by 5.% Integration of Community Estates Services Board Update Integrated Management Structure March 2012 Reduce variable costs Asset Management (Buildings & Equipment) Energy Strategy & deployment Board Update Improvement in Space utilisation Reduction in suppliers & costs Introduction of M.E.S. Board Update Use by major areas and processes Reduction in costs Reduce costs by 5.% Reduce supplies & costs by 5% Board paper to June Board meeting Reduction in energy by 5% Rating reviews Board Update Number of appeals and rebates Active rebates up to 100k SOCIAL Public Health, Healthy Transport & Green Agenda Board Update Schemes & initiatives implemented Reduction in Clinical Waste RB March 2013 N/A Reduce waste by 150 tonnes Waste reduction and recycling Carbon Management & Reduction Blackpool Council Schools Project Board Update Tonnes waste by category & % recycled March 2012 Increase recycling by 15% Progress on Carbon Management Plan Board Update Progress on Carbon Reduction Commitment Reduce carbon by 1000 tonnes Board Update Schemes Implemented N/A 5
Delivery To exceed all National and local standards of service delivery. A&E 4 hour 31.3.13 Access Targets Total time in A&E (95th Percentile) PO Development of Business Metrics Medeanalystics Time to initial assessment (95th Percentile) 4 hours 15 minutes CQC Targets Time to treatment decision (median) 60 minutes 7 Day Hospital Unplanned reattendance rate 5% Visual Management / Display Boards Control Rooms cancer targets Left without being seen 5% Scorecards 31 day subsequent treatment drugs 98% Own KPIs for their Services 31 day subsequent treatment surgery 94% CHKS 62 day urgent GP - Treatment 85% CQC Registration consultant screening service to treatment 90% consultant upgrade 85% (tbc) 2 week wait - all cancers 93% 2 week wait symptomatic breast (cancer not initially suspected) 93% 18/52 targets admitted (95th Percentile) admitted (median) admitted % treated <18weeks Non-admitted (95th Percentile) Non-admitted (median) <=23weeks <=11.1wks (tbc) >=90% <=18.3wks <=6.6wks (tbc) Non-admitted % treated <18weeks Open pathways %<18weeks <=95% >=92% LoS Based on CHKS Peer average Apr-Nov 2011 all admissions (exc day case) <=3.2 elective admissions (exc day case) <=3.3 Non-elective <=3.2 Cancelled Operations <=0.8% Theatre utilisation >=95% Number of beds: Ratio of beds to admissions Complaints: Number <=285 (tbc by MT) % in< 25 days 100% (tbc by MT) 6
% of Patients with Expected of Discharge (EDD) - variation against EDD Unsure if recorded to enable collection/monitoring Pre-op bed days Pre-op Bed Days - Number of patients admitted >1 day pre-op (based on National Standard Methodology) All Admissions Average per month (YTD April Dec11) 498 number of bed days - all admissions Dec11) 3891 Elective Pre-op Bed Days Number of patients admitted >1 day pre-op (based on National Standard Methodology) Dec11) 30 Number of Elective Bed Days Dec11) 276 Non - Elective Pre-op Bed Days Number of patients admitted >1 day pre-op (based on National Standard Methodology) Dec11) 468 Number of Non - Elective Bed Days Dec11) 3615 Readmission rates Readmissions Same Specialty - Readmissions following Daycase and Elective 75% reduction - Readmissions following Non-Elective 25% reduction - Readmissions following Non-Elective Non- Emergency Readmissions Different Specialty 25% reduction - Readmissions following Daycase and Elective 25% reduction - Readmissions following Non-Elective 25% reduction - Readmissions following Non- Elective Non-Emergency 25% reduction Patient Survey NCIs Smoking in Pregnancy Breastfeeding % Discharge summary < 24 hours. Performance measured against national average for 5 domains - the Trust received slightly worse than national average scores for 2 domains, overall the Trust was scored within the expected range. 7