Balanced Score Card Report Review of February 2018 Data

Balanced Scorecard Patient Access Quality & Safety Patient and Service User Human Resource Management Finance

Patient Access Emergency Department

6 Hr PET @8:00am 4

2017/2018 30 Day Moving Average

Trolley Numbers Jan- Mar 2017 v Jan March 2018 (24/03/2018) 6

ED Attendances & Month & YTD All Attendances - All Ages

Total number of patients discharged Sat/Sun Weekend Discharges 140 Weekend (Sat + Sun) CUH Discharges 120 117 100 80 60 40 44 50 53 48 46 48 42 43 44 49 49 57 45 48 43 36 42 52 51 51 37 20 0 Weekend ending

Targeted >14 Day Occupancy

Project Flow Improving Patient s Hospital Experience Project Flow 2018

Patient Flow 2018 (PF18 ) - Objectives Achieve 50% reduction 30 day moving average No patient >75yrs wait >9 hours for a bed No patient PET (Acute Floor) >18 hours Non Admitted PET (Acute Floor) to 95 % Overall PET (Acute Floor) to 75% within 6 hours

PF18 Priorities contd... Bidirectional flow with Mallow protocol Audit weekend discharge process Enhance links with community services re: LTC, transitional care, home care packages Continue PDD audits National Patient Experience Survey = enhance discharge information provided to patients

Capacity SAFER Bundle Red2 Green Weekend Discharges >14 day or Stranded Patient >75yrs old Acute Floor D2A pathways Bidirectional Flow Step Down 24/7 AMU

Patient Access - Outpatient Waiting Lists

Total Medical Patients to be seen by 15 Month Target (151) (21/03/2018)

Total Surgical Patients to be seen by 15 Month Target (2995) (21/03/2018)

Patients Currently Waiting Longer Than 12 Months 21/03/2018 (5231)

Patient Access - Inpatient Waiting List

Inpatient and Day Case Waiting List (23/02/2018) Count of IDWait category wl type ACTIVE PREADMIT SUSPENSION Grand Total Adult 1266 250 29 1545 Child 116 27 1 144 GI Scope 110 165 8 283 Grand Tota 1492 442 38 1972

Patients waiting > 15 months 285

Quality & Safety

S. Aureus Bloodstream Infections G 23

Clostridium Difficile G

ALOS All Inpatients January 2018 R

ALOS Medicine January 2017 R

ALOS Surgery January 2017 R 27

HIPE Coverage November - % of cases entered into HIPE(A38) G

% of people waiting less than 13 weeks ( 13 weeks) for a routine colonoscopy G 29

Routine Colonoscopy December 2017 R 30

Elective Laparoscopic Cholecystectomy January 2018 R

Cancer KPI Breast-Lung-Prostate October 2017 February 2018

Rapid Access Clinic Review Symptomatic Breast Service Review the current pathway for this patient group to be progressed by the NCCP Test messaging service to send outpatient appointment reminders to patients to be discussed with ICT The requirement for an additional Consultant for the Breast Reconstruction service Audit of the input from the GP sessions to be completed Prostate Service Requirement for additional Registrar to facilitate return patient clinics Additional access for MRI Scans, Bone Scans and CT Staging Scans. Access to Robotics which would provide many benefits in relation to patient treatment options

Thoracic Lung Service Rapid Access Clinic Review The SSWHG have funded an additional 5 CT slots for RALC to allow all patient to have their CT prior to first clinic visit CNS and consultant conduct a virtual nodule clinic and patients are either issued a clinic appointment or discharged over the phone by the CNS From February 2018 the RALC will change from Monday to Friday to allow for increased capacity Work has taken place to streamline the Cardio Thoracic MDM and it is anticipated that the MDM component of MOCIS will help further by allowing the meeting to be recorded electronically The ANP post funded by the NCCP is currently being progressed

Radiotherapy Patients In/Out of Target - February 2018 OUT OF TARGET, 52, 61% IN TARGET, 33, 39%

Consultants In/Out of Target February 2018 25 20 15 10 5 0 Dr Faisal Jamaluddin (Locum RO) Dr. Aileen Flavin (RO) Dr. Bolanle Ofi (Locum RO) Dr. Carol McGibney (RO) Dr. Frederik Vernimmen (RO) Dr. Paul Kelly (RO) Total 6 15 16 14 13 21 In Target 3 10 7 3 4 6 Out of Target 3 5 9 11 9 15

Reasons for Out of Target February 2018 40 35 30 25 20 15 10 5 0 Personal Medical Capacity Data Other choice Missing Total 4 8 40 0 0

Chemotherapy Patients In/Out of Target February 2017 Outside Target, 5, 10% In Target, 45, 90% 38

Consultants In/Out of Target February 2018 12 10 8 6 4 2 0 Dr Deirdre O'Mahony Dr Derek Power Dr Derville O'Shea Dr Dearbhaile Collins Dr Oonagh Gilligan Dr Vitaliy Mykytiv Dr Susan O'Shea Dr Richard Bambury Total 7 12 1 7 2 1 1 11 8 InTarget 6 10 1 7 2 1 1 9 8 Out of Target 1 2 0 0 0 0 0 2 0 Prof Seamus O'Reilly

Risk Management February KPI data Serious Reportable Events reported CUH 1 communicated in February Medication Safety Incidents reported - 57 Complaints 3 complaints raised in July with 0% closed within 30 day timeframe New claims notified to hospital 0 Risk Register Updated Risk Register submitted to SSWHG In March 1 new risk added (March) CUH 78 - Failure to rescue the Deteriorating Patient leading to preventable harm up to and including ICU admission/death.

CUH Quality Improvement Strategy - 2018-2020

6 Goals that will shape quality focus of the Hospital for the next 3 years.

Examples of Quality Initiatives PF18 unscheduled care Pressure Ulcer to Zero Collaborative Fall Prevention Group VTE Collaborative QI Close Links with National Office for Clinical Audit End PJ Paralysis Citizens Information Outreach for Patients and Families Improved Q-Pulse access Schwartz Rounds Started Sept 2017 5 held to-date Implementation of safety crosses

Development of Lean Innovation Centre

Lean Management Change Initiatives - Examples Orthopaedic trauma service Dialysis - At Home treatment service Maximising weekend discharges Radiology unscheduled care Radiotherapy Head and Neck service Cancer patient pathway Bed Management pathways Pathology services

Human Resource Management

WTE s CUH Sick Leave 2016 v 2017- CHANGE CUH Total % Sick Leave 2016 v 2017 v 2018 % 6 4 2 4.77 4.53 4.42 3.84 3.92 4.65 4.59 4.22 4.17 3.91 3.39 3.9 4.27 3.65 3.77 3.98 3.78 3.89 3.94 3.84 4.04 4.15 4.35 4.08 4.98 0 Jan Feb Mar April May June July August Sept Oct Nov Dec 2016% 2017% 2018% % Target 50 40 30 20 10 0 43.96 Jan-17 44.55 Feb-17 CUH Long Term Sick Leave WTE s 40.05 34.55 31.14 44.15 37.35 34.88 28.89 31.32 29.2 Nov-17 Oct-17 Sep-17 Aug-17 Jul-17 Jun-17 May-17 Apr-17 Mar-17 29.83 Dec-17 26.11 Jan-18

EWTD Compliance - October 2017 February 2018

Finance

Finance Position-February 2018 CUH Group (excl CUMH direct) Gross pay & non pay budget 61.12m Actual pay & non pay 63.23m Actual Deficit 2.12m (-3.5%) Less adjustments 1.17m Adjusted Deficit 0.95m (-1.7%)

Finance Report February 2018 Actual outturn ytd 2018 Pay & Nonpay (incl CUMH ) Gross pay & non pay budget 60.78m (2017 : 56.8m) Actual pay & non pay 62.95m (2017: 57.9m) Actual Deficit 2.17m (-4.0%) (2017 : 1.1m/-1.9%) Less adjustments 1.12m (2017 : 0.5m) Adjusted Deficit 1.05m (-1.7%) (2017 : 0.5m/-0.9%) Pay & Nonpay (excl CUMH ) Gross pay & non pay budget 54.13m Actual pay & non pay 56.0m Actual Deficit 1.87m (-3.5%) - Less adjustments Bad debts provision 665k - PCRS 457k Adjusted Deficit 747k (-1.4%) Direct Pay & Nonpay CUMH Gross Direct pay & non pay budget 6.65m Actual direct pay & non pay 6.96m Actual Deficit 302k (4.5%)

CUH Pay & Non pay Budget Surplus/(Deficit) %

CUH Nonpay-Budget v Actual ytd 2018 NON-PAY Budget Actual Variance C U M H A c t C U H / C U M H A c t 2017 Act Medicines 5,116 5,039 77 11 5,050 4,789 Medical & Surgical 4,421 4,680 -(259) 512 5,192 4,965 Blood 805 852 -(47) 1 853 820 Medical Gases 68 77 -(10) 0 77 78 Medical equipment 612 953 -(341) 76 1,029 804 Radiology 892 1,015 -(124) 1 1,016 931 Provisions 316 338 -(22) 16 354 338 Catering 76 77 -(1) 3 80 72 Cleaning/Waste 433 487 -(54) 236 723 637 Laundry 294 314 -(19) 0 314 304 Energy 498 539 -(41) 0 539 541 Bedding/ clothing 58 110 -(51) 15 125 66 Furniture 27 35 -(8) 9 44 30 Pathology 1,625 1,771 -(146) 33 1,804 1,788 Maintenance /Grounds 115 169 -(53) 7 176 179 Transport /staff travel 297 307 -(10) 18 325 310 Office expenses 309 376 -(66) 35 411 349 Telecommunications 74 78 -(4) 2 81 78 Computer 187 169 18 15 184 161 Administrative expenses 963 1,759 -(796) 141 1,900 1,782 Staff recruitment/training 112 139 -(27) 25 164 135 Miscellaneous 250 305 -(55) 35 340 224 TOTAL NON-PAY 17,549 19,590 -(2,041) 1,191 20,781 19,382 Less Bad debts -190-780 590-780 -588 NON-PAY excl Bad Debts 17,359 18,810 -(1,451) 1,191 20,001 18,795 53

CUH AGENCY WTE 2014-8 Jul-14 Sep-14 Dec-14 Jan-15 Jun-15 Sep-15 Dec-15 Jun-16 Sep16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Radiotherapist 9.40 4.00 4.87 2.78 0.9 Radiographer 0.09 0.05 0.06 Labs 12.04 13.40 11.0 12.19 Cardiac Techs 3.80 3.80 1.0 Physio 1.60 1.50 Pharmacy 2.00 1.00 Admin 23.40 9.08 9.36 14.1 Nursing 46.20 33.0 34.7 37.8 30.4 28.6 26.1 31.6 27.6 25.5 33.3 33.3 32.7 31.7 34.3 37.3 44.8 41.3 42.0 41.3 35.4 42.3 48.4 HCA 34.80 16.2 22.7 23.2 29.8 30.8 38.2 38.4 52.1 17.7 26.1 25.3 34.5 34.5 33.9 36.6 41.6 35.7 39.4 40.8 39.2 47.4 54.7 House-Keeping 10.40 0.16 Physics 4.30 2.6 1.6 1.09 0.75 0.66 0.46 0.83 0.83 0.83 0.83 0.83 0.23 Catering 3.00 8.5 2.0 2.7 6.9 3.9 0.9 1.2 Social Work 1.00 0.5 Occ Therapy 1.00 0.37 Dietician 0.50 0.3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Medical 11.00 5.27 4.77 4.4 5.86 7.97 15.73 Consult 0.25 0 0.6 0.34 2.9 3.94 0 1 0 0 0 NCHD 2.47 6.7 1.87 1.82 2.83 2.94 2.15 2.34 1.54 0.8 1.18 3.04 1.51 2.85 2.98 2.09 54 164.5 99.7 91.1 98.26 74.6 71.9 81.4 76.75 88.23 46.9 63.05 63.26 71.37 69.95 71.88 76.4 91.1 83.12 85.44 85.61 78.45 93.68 106.2

CUH AGENCY COSTS k 2016-2018

Acute Nursing Agency WTE 2016 to 2018 Acute HCA Agency WTE 2016 to 2018 56

CUH Average Nursing & HCA Agency WTE s per Week 2016-2018 CUH Average Specials /Other Nursing & HCA Agency WTE s per Week 2016-2018

CUH /CUMH Actual Non-pay expenditure k Jan 2018 v 2017

Patient Income 2016 2018

C U H / C U M H Ot her Inco me yt d 2 0 18 Inco me B ud g et k A ct ual k V ariance k R ent al inco me & Licence f ees 89 10 9 20 B eq uest s/ D o nat io ns 25 - ( 2 5) R esearch g rant s 49 33 - ( 16 ) C arp ark 3 74 430 55 D rug reb at es / PC R S 1,52 7 2,4 78 9 51 Insurance claims / M isc 8 2 - ( 6 ) 2,0 73 3,0 52 9 79 C U H / C U M H R eco up ment s and R ef und s yt d 2 0 18 Inco me B ud g et k A ct ual k V ariance k R eco up ment s Pay 14 8 12 2 - ( 2 6 ) R ef und s- Pay 28 - ( 2 8 ) R ef und s- Ot her 39 1 - ( 3 8 ) Po st ag e reb at e 47 47 U nclassif ied 33 15 - ( 18 ) 249 18 6 - ( 6 3 )

MGH - Finance Report February 2018 Mallow YTD 2018 outturn Gross pay & non pay budget 3.41m (2017: 3.26m) Actual pay & non pay 3.49m (2017: 3.33m) Actual deficit 80k (-2.3%) Less adjustment -Bad debts provision 12k Adjusted deficit 67k(-2%) (2017:- 73k (-2.2%)) Mallow Income outturn YTD 2018 Income budget 578k (2017: 578k) Actual Income 642k (2017: 799k) Actual surplus 64k (11%) (2017:Surplus 221k/38%)

BGH - Finance Report February 2018 Bantry ytd 2018 outturn Gross pay & non pay budget 3.58m (2017: 3.35m) Actual pay & non pay 3.75m (2017: 3.4m) Actual deficit 167k (-4.7%) Less Adjustments increase in Bad debts provision 35k MIsc 2k Adjusted deficit 130k (-3.6%) (2017: 51k (-1.5%) Bantry Income outturn Income budget 621k (2017: 584k) Actual Income 494k (2017: 581k ) Actual deficit 128k (-21%) (2017:- 3k (-0.5%)

Capital Projects

Paediatric Unit Project Capital Projects Status Phase 1 - build programme completed Phase 2 funding received proceed to Design Stage Radiation Oncology Unit Builder commenced on site on Monday 20 th February Education and Training Centre Blood Sciences Project Draft Statement of Need completed and discussion ongoing with UCC Meeting held with UCC Design Team appointed Infrastructural works are near completion 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 OPD & Day Care Tender documents ready to issue in January 18 Theatre Accommodation tender documents being prepared for early 18 Helipad Meeting held with the IAA Ground Level Helipad the agreed option

Radiation Oncology Centre

Engagement with The Christie Cancer Centre Development of clinical protocols Assistance with procurement and commissioning of equipment Training and education of staff Transfer of radiation protection protocols Advice on the design and build of facilities Advice on the effective use of existing technology

CUH Designated as a Major Trauma Centre 2018