Balanced Score Card Report Review of January 2018 Data

Balanced Score Card Report Review of January 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 January 2018 4

2017/2018 30 Day Moving Average 5

AMAU Activity AMAU Referrals January 2018 200 180 160 140 120 100 184 80 60 104 140 40 64 20 0 Admitted Patients Emergency Department General Practitioner Planned Repeat Admissions 13 Outpatients Department 5 Other Referrals

Non Admit PET January Comparison Annual Non Admit PET 2014-2017 80% 70% 60% 50% 40% 30% 62% 71% 73% 77% 74% 20% 10% 0% 2014 2015 2016 2017 2018

>24 Hour PET PET >24hrs 350 320 316 328 300 264 266 250 200 150 136 137 100 85 98 68 89 86 95 50 0 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 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

>75yrs Bed Wait >9hrs >75yrs Bed Wait >9 hrs (2017) 250 200 150 100 50 218 199 200 215 129 120 108 143 126 170 149 248 57 0 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

Full Year Non Admit PET 80% 70% 60% 50% 40% 67% 71% 73% 79% 30% 20% 10% 0% 2014 2015 2016 2017

Targeted >14 Day Occupancy 10000 >14 Day Patients and >14 Day Occupancy 180 9000 160 8000 140 7000 6000 5000 4000 3000 120 100 80 60 2000 40 1000 20 0 01/09/2017 01/10/2017 01/11/2017 01/12/2017 01/01/2018 01/02/2018 01/03/2018 0 Bed Days Patients

January Review 607 patients on trolleys compared with 719 in January 2017 (17% reduction) Decrease in Gen Medical Bed Stock Infection Control Measures were challenging 2 strains of flu and Norovirus Visiting restrictions difficult Only one day of surge of orthopaedic trauma

Project Flow Improving Patient s Hospital Experience Project Flow 2018

PF 18 Objectives Input Throughput Egress PET across acute floor non admit 95% overall 70-75% >75 years conversion rate 100% PDD documentation SAFER implementation Red to Green concept Bi-directional flow >14 days - >7days 14 day occupancy

PF18 Priorities Implementation of SAFER bundle: Senior review before 11am for all patients All patients must have PDDs Flow from assessment units to wards early Early discharges before 11am Review patients with extended lengths of stay Red2Green Increase communication to all staff

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

Patient Access - Outpatient Waiting Lists

Total Medical Patients to be seen by 15 Month Target (176) (14/02/2018)

Total Surgical Patients to be seen by 15 Month Target (3361) (14/02/2018)

Patients Currently Waiting Longer Than 12 Months (5081) (14/02/2018)

Ophthalmology Waiting List Validation 9253 patients - Summarised below Ophthalmology Return Waiting list validation Consultant E.O. G.O.Connor Connell S.Fenton A.Cullinane Z.Idrees Total Letters sent out 2583 1540 1168 2052 1910 9253 Yes to Stay on w/l 2014 1153 872 1550 1445 7034 Pt request removal 155 89 72 157 96 569 RIP 31 29 12 30 34 136 No response to validation but attended TCI 39 42 33 25 33 172 Query for service 1 1 Return Post, Trying to contact patient 0 Also attending Diabetic Screening -? Potential removals 74 72 46 102 108 402 Hospital Removed 15 9 11 14 15 64 Incorrect w/l entry 1 1 2 Removed through no response to validation 251 143 121 168 175 858 No response to date 26/02/2018, Still on w/l due to DNA,TCI 4 3 1 4 3 15 Total 2583 1540 1168 2052 1910 9253 Total removed through No response to validation 942 Total Re-instated after removal through No response 82

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 (17/01/2018)

Endoscopy Activity (Source: NQAIS) AAU Emergency Elective Total 2015 125 589 2076 2790 2016 121 612 2345 3078 2017* (Jan-Nov Inc.) 102 606 2266 2974 25

Quality & Safety

Clostridium Difficile G 27

S. Aureus bloodstream infection G 28

NEWS Full Implementation G 29

ALOS All Inpatients November 2017 R

ALOS Excluding LOS over 30 Days R 31

ALOS Medicine November 2017 R

ALOS Surgery November 2017 R 33

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

% of people waiting less than 13 weeks ( 13 weeks) for a routine colonoscopy G 35

Routine Colonoscopy December 2017 R 36

% day case rate for Elective Laparoscopic Cholecystectomy December 2018 (mean Jan Nov) 37

Cancer KPI Breast-Lung-Prostate October 2017 January 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 - January 2018 OUT OF TARGET, 60, 67% IN TARGET, 30, 33%

Consultants In/Out of Target January 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 16 22 17 16 5 14 InTarget 7 8 2 3 1 9 Out of Target 9 14 15 13 4 5

Reasons for Out of Target January 2018 30 25 20 15 10 5 0 Personal choice Medical Capacity Data Missing Other Total 2 14 26 16 2 43

Chemotherapy Patients In/Out of Target January 2017 Outside Target, 4, 9% In Target, 39, 91% 44

Consultants In/Out of Target January 2018 12 10 8 6 4 2 0 Dr Deirdre Dr Dearbhaile Dr Derek Dr Derville Dr Oonagh Dr Richard Prof Seamus O'Mahony Collins Power O'Shea Gilligan Bambury O'Reilly TOTAL 9 5 5 2 4 7 11 InTarget 7 5 5 2 3 6 11 Out of Target 2 0 0 0 1 1 0 45

Reasons for Out of Target January 2018 3 2.5 2 1.5 1 0.5 0 Personal Medicial Capacity Data Other Missing Total 1 3 0 0 0 46

Risk Management January KPI data Serious Reportable Events reported CUH 4 communicated in January which occurred in previous months (1 in July, 1 in August, 1 in November, 1 in December) 5 SRE s occurred in January (currently being submitted) Medication Safety Incidents reported - 20 Complaints 10 complaints raised in July with 10% closed within 30 day timeframe New claims notified to hospital 78 Risk Register Risk Register no new risks added

CPE Screening Current CUH CPE Screening protocol: All patients on admission to ICU/CITU and NICU and weekly thereafter All patients on admission to the haematology unit 2D and weekly thereafter All patients epidemiologically linked to a CPE carrier all patients admitted from another hospital with a current CPE problem. All international transfers/admissions (inc NI) As directed by the Infection Prevention and Control Team

Falls Prevention Trial of Falls Prevention non-slip socks on Ward 1A will finish at the end of January Trial to be done on Medical Short Stay Ward Ward 4C have been using the safety cross for 1 year and have seen a 15% reduction in falls. Falls Prevention group currently appraising different falls risk assessments and will be updating the CUH falls policy.

Rate of Falls per 1,000 Bed Days 50

Spread Across the CUH Campus 52

Rate of Pressure Ulcers reported per 1,000 bed days Jan Dec 2017 53

Human Resource Management

WTE s CUH Sick Leave 2016 v 2017- CHANGE CUH Total % Sick Leave 2016 v 2017 % 6 4 2 4.77 4.53 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 3.94 4.04 4.08 4.98 0 Jan Feb Mar April May June July August Sept Oct Nov Dec 2016% 2017% % Target 50 40 30 20 10 0 40.76 Aug-16 35.76 Sep-16 CUH Long Term Sick Leave WTE s 41.8 38.81 43.96 44.55 34.55 37.35 32.49 31.14 May-17 Apr-17 Mar-17 Feb-17 Jan-17 Dec-16 Nov-16 Oct-16 28.89 44.15 40.05 Aug-17 Jul-17 Jun-17

EWTD Compliance January - December 2017

Finance

Finance Report January 2018 CUH /CUMH Actual outturn FY 2017 PAY & NONPAY Gross pay & non pay budget 363.1m (2016 : 352.9m) Actual pay & non pay 371.3m (2016: 355m) Actual Deficit 8.2m (-2.3%) o Less Adjustments 3.8m o Bad debts provision 3.19m o PCRS Drugs 626k Adjusted Deficit 4.4m (-1.2%) ((2016 : 2.1m/-0.6%) Income Income budget 77.7m (2016 : 80.5m) Actual Income 76.0m (2016 : 79.9m) Actual Deficit 1.7m (-2.2%) (2016 : 0.6m/-0.7%) 58

Finance Report- January 2018 59

Finance Report -January 2018 Actual outturn Jan 2018 PAY & NONPAY (pre CUMH transfer) Gross pay & non pay budget 31.5m (2016 : 28.8m) Actual pay & non pay 33.1m (2016: 29.1m) Actual Deficit 1.6m (-4.9%) (2016 : 330k/-1.1%) PAY & NONPAY (excl CUMH ) Gross pay & non pay budget 28.1m Actual pay & non pay 29.7m Actual Deficit 1.6m (-5.6%) - Less adjustments Bad debts provision 0.9m - PCRS 45k Adjusted Deficit 0.6m (-2.2%) DIRECT PAY & NONPAY CUMH Gross Direct pay & non pay budget 3.44m Actual direct pay & non pay 3.43m Actual Surplus 13k (0.4%) 60

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

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 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 62 164.5 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 93.68 106.19

CUH AGENCY COSTS k 2016-2018

Acute Nursing Agency WTE 2016 to 2018 Acute HCA Agency WTE 2016 to 2018 64

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 Nonpay-Budget v Actual Jan 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 2,688 2,722 -(34) 6 2,727 2,494 Medical & Surgical 2,323 2,420 -(98) 238 2,658 2,474 Blood 423 445 -(22) 1 446 411 Medical Gases 36 38 -(3) 0 38 41 Medical equipment 322 472 -(150) 45 517 421 Radiology 468 545 -(76) 0 545 461 Provisions 166 179 -(13) 10 189 174 Catering 40 39 1 2 42 35 Cleaning/Waste 228 244 -(16) 118 362 336 Laundry 155 155 -(0) 0 155 152 Energy 262 257 4 0 257 269 Bedding/ clothing 31 46 -(16) 8 54 33 Furniture 14 21 -(7) 3 24 8 Pathology 854 902 -(48) 6 908 919 Maintenance /Grounds 61 68 -(7) 3 71 67 Transport /staff travel 156 176 -(20) 10 186 154 Office expenses 163 186 -(23) 19 205 207 Telecommunications 39 40 -(1) 1 41 37 Computer 98 93 5 3 96 68 Administrative expenses 506 1,491 -(985) 87 1,578 634 Staff recruitment/training 59 96 -(37) -24 72 60 Miscellaneous 131 185 -(53) 26 211 133 TOTAL NON-PAY 9,220 10,820 -(1,600) 561 11,382 9,588 Less Bad debts -100-991 891-991 -90 NON-PAY excl Bad Debts 9,121 9,830 -(709) 561 10,391 9,498 66

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

Patient Income 2016 2018

CUH Patient Income Budget Surplus/Deficit % 69

C U H Ot her Inco me Jan 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 47 66 19 B eq uest s/ D o nat io ns 13 - ( 13 ) R esearch g rant s 26 33 7 C arp ark 19 7 231 34 D rug reb at es / PC R S 802 8 50 48 Insurance claims / M isc 4 - ( 4 ) 1,0 8 9 1,18 0 91 C U H R eco up ment s and R ef und s Jan 2 0 18 Inco me B ud g et k A ct ual k V ariance k R eco up ment s Pay 78 78 - ( 0 ) R ef und s- Pay 15 - ( 15) R ef und s- Ot her 21 1 - ( 19 ) Po st ag e reb at e 47 47 U nclassif ied 17 15 - ( 2 ) 13 1 14 1 11

CUH Debtor Days Consultant Claims 2016-2018

MGH - Finance Report January 2018

Finance Report January 2018 73

BGH - Finance Report January 2018

BGH - Finance Report January 2018 75

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