Delivering our Vision How are we doing? August 2018 We will pursue perfection in the delivery of safe, high quality healthcare which puts the people of our community first
Safety & quality Patient Vision We will pursue perfection in the delivery of safe, high quality healthcare which puts the people of our community first Values One team Dignity & respect Compassion Strategic objectives Safe Effective Caring Responsive Well-led Annual priorities Reduce avoidable harm Improve discharge planning Create best environment for patients Timely access to services Staff health, well being and working lives Through integration and partnership we aim to become both a provider and employer of choice 2
August 2018 summary SAFE - People are protected from abuse and avoidable harm We declared three serious incidents in August 2018. Patient safety indicators continue to show expected levels of performance. There were no MRSA bloodstream infection cases and 4 Trust-apportioned Clostridium Difficile cases in August 2018. EFFECTIVE - People s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence. Mortality is lower than expected for our patient group when benchmarked against national comparators. Emergency readmissions within 7 days improved for the second month with performance of 3.5%. Serious Incidents 3 % HSMR (Mar 2018) 97.9 Safety Thermometer 98.3% Emergency readmissions within 7 days 3.5% CARING - service involves and treats people with compassion, kindness, dignity and respect. The Friends & Family Test continues to show good patient feedback for the Emergency department while Inpatient FFT performance dropped with 94.6% of patients recommending us to their friends and family (96.0% in July). % ED FFT 94.3% % Inpatient FFT 94.6% 3
August 2018 summary RESPONSIVE - services meet people s needs. The ED 4hr standard was not achieved in August 2018 with performance of 94.6% placing us in the top 20, Type 1 Departments, nationally for nonspecialist hospitals. SASH system LAEDB performance was 97.0% for August 2018 placing performance in the top 10, nationally for non-specialist hospitals We achieved the national cancer TWR standard with performance of 93.0%. 62 Day GP performance fell below the national standard with performance of c.80% (against a target of 85%) but to be confirmed as final pathology results are confirmed. We did not achieve the national RTT 92% standard with performance of 89.4% in August. The recovery plan continues to progress. ED 95% seen in 4 hours 94.6% WELL LED - leadership, management and governance of the organisation assures the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture % 62 Day GP TBC% RTT Incomplete 89.4% The SASH Star Awards nomination period closed at the end of August 161 nominations have been received across the 11 categories. The Awards evening is scheduled for 27 th November. We received the results of the culture assessment survey - which is measuring the impact of VMI across the five years of the partnership. The assessment has provided a useful benchmark which shows an overall positive continuous improvement across a range of different indicators from year 1 to year 3. A further assessment is due in year 5. Our SASH Leaders project, which aims to deliver robust succession planning and talent management processes, continues to be developed and we are moving to the next phase of the pilot in September, with the full scheme due to be launched from April 2019. The SASH Inclusion Steering Group terms of reference are being finalised. This group will oversee the delivery of the objectives approved by the Board in the SASH One Team Inclusion Strategy. Vacancy Rate 9.8% % Staff turnover 16.4% % 4
August 2018 summary FINANCE AND USE OF RESOURCES The Trust achieved a 1.5m [adjusted] surplus at the end of August, which was 1.6m favourable to the YTD plan. This position included 2.6m Provider Sustainability Funding (PSF) for delivery of financial plans and ED targets. Total agency spend in the first five months of 2018/19 was 8.0m. This was 1.9m higher than the 6.1m YTD agency ceiling specified by NHSi. The Trust had a cash balance of 9.2m at the end of August. The revolving working capital balance at the end of July was 6m, with plans to repay 3.0m of this in Sept 2018 and 3m in March 2019. The Trust s 2018/19 planned capital requirement for 2018/19 has risen to 19.5m. Until confirmed by NHSi the Trust is only able to spend 10.9m on capital in 2018/19. The Trust has requested 8.4m of additional CRL. The remaining 0.2m is anticipated from donation receipts. Action: The Board are asked to note and accept this report Outturn m Adjusted Surplus 16.1m Outturn m Savings 4.8m Legal: Regulation: Patient experience/ engagement: Risk & performance management NHS constitution; equality & diversity; communication. All aspects of care provision is covered by the Health and Social care Act, this paper provides assurance on safe high quality care (Including mortality). The Care Quality Commission (CQC) regulates patient safety and quality of care and the CQC register and therefore license care services under the Health and Social Care Act 2009 and associated regulations. This paper includes significant detail on both patient experience and access to services. This is the main Board assurance report for performance against quality and financial measures and is linked to risk management through the SRR. This report covers performance against access standards with the NHS Constitution. 5
Section 2 Are we safe? 6
Safe People are protected from abuse and avoidable harm Safety The Trust declared three serious incidents in August 2018. 2018/20641- Maternity incident A 40 year old woman attended for an early pregnancy scan and combined screening in June, the twins were identified in the scan however one twin had no heartbeat. Miscommunication about the deceased twin between sonographer and labs department meant that combined screening was undertaken in error, leading to an inaccurate risk score for the live twin in utero. Never Event 0 2018/20738 Fall: An 84 year old male patient had an un-witnessed fall following right knee surgery. He sustained a fracture to his right ankle, requiring surgery. Fracture was not identified until two weeks after the fall. 2018/21229 Treatment delay: An 83 year old female patient, being treated for macular degeneration with intravitreal injections, failed to receive a 12 week follow up appointment. She presented to department with reduced vision, approximately 6 months after her last appointment. Positive Safety Thermometer performance continued for the New Harm measure with performance of 98.3% in August 2018. Serious Incidents 3 Safety Thermometer 98.3% 7
Safe People are protected from abuse and avoidable harm Ward staffing Safer staffing - The Trust continues to monitor ward nursing numbers and skill mix on a daily basis and is assured that adequate staffing is in place. The Trust has delivered the planned vs actual staffing profile for August at organisational level. Nurse recruitment - Continues both locally and from overseas. Trainee Nursing Associates The next cohort of Trainee Nursing Associates have now been recruited to, with 12 students commencing their training in September. Retention The Trust continues to embed the various work streams outlined in the retention strategy. We have opted into retention support in partnership with NHS Improvement which will focus on role flexibility amongst other key retention goals. RN Fill Rate Day 94.5% RN Fill Rate Night 96.3% 8
Safe People are protected from abuse and avoidable harm Infection control MRSA There were no cases of MRSA in August 2018. Clostridium difficile There were 4 cases of Trust-apportioned Clostridium difficile in August 2018. None of the cases were due to cross infection. MRSA 0 So far this year, 7 cases have been reviewed by the CCG, and 2 cases have been viewed as lapses in care. One lapse was attributed to Meadvale ward for delay to isolation, and the other to Godstone ward, for antibiotic prescribing issues, delay to stool sample and isolation. RCA action plans are being monitored by the Division. C-Diff 4 9
Delivering our vision How are we improving? Safe Reduce avoidable harm Reduce falls In August 2018, the Trust falls rate was 4.14 falls per 1,000 bed days which is a reduction from last years (Aug-17) 5.25 falls per 1000 bed days. In the last 20 months our falls rate has consistently remained below the national average. In August we had no serious or moderate Incidents relating to falls. Total Falls 78 Falls / 000 Bed days 4.14 Reduce pressure damage Total Pressure Damage 7 Pressure Damage / 000 Bed days 0.37 In August, we reported 5 grade 2 and two grade 3 cases of pressure damage. Three of these cases related to medical devices. We are focusing on the top 10 wards with the highest incidences of pressure damage and providing clinical support in these areas. This month five of the cases occurred in these areas. The new national consensus statement has now been published which details changes to the current grading and reporting practices including moisture associated skin damage. We are familiarising the divisions with these changes, through ward based teaching sessions. We have launched new nursing documentation across the Trust which includes these new changes and a more concise daily SSKIN bundle. 10
Safe Scorecard Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Trend No of Never Events in month 0 0 0 0 0 1 0 0 0 0 0 1 0 Safety Serious Incidents - No declared in month 3 4 8 4 5 2 4 3 0 2 2 6 3 Serious Incidents - No per 1000 Bed Days 0.16 0.21 0.41 0.21 0.26 0.1 0.22 0.15 0 0.11 0.12 0.33 0.16 Patient Safety Incidents causing Severe harm or Death - Number in Month 1 4 3 2 4 2 2 2 0 2 1 3 0 Patient Safety Incidents causing Severe harm or Death - Percentage of all patient safety incidents 0.2% 0.7% 0.5% 0.3% 0.7% 0.3% 0.3% 0.4% 0.0% 0.5% 0.2% 0.5% 0.0% Safety Thermometer - % of patients with harm free care (new harm) 98.8% 98.8% 99.3% 98.7% 98.3% 99.6% 98.7% 99.3% 97.7% 98.7% 97.9% 99.4% 98.3% Percentage of patients who have a VTE risk assessment 96.9% 97.2% 97.2% 97.4% 97.1% 96.6% 97.0% 97.2% 98.0% 97.9% 97.6% 97.6% 97.4% Infection Control (Trust Aquired) MRSA BSI (incidences in month) 0 0 0 0 0 0 1 0 0 0 1 0 0 CDiff Incidences (in month) 6 4 3 2 2 2 1 5 1 2 2 5 4 MSSA Trust Incidence 1 0 1 1 0 0 1 0 1 0 1 0 1 Gram negative blood stream infections Trust Incidence 6 4 11 6 9 Ward Staffing Average fill rate registered nurses/midwives (%) - Day 93.4% 93.5% 95.4% 93.2% 91.8% 93.1% 92.6% 91.0% 94.5% 97.6% 96.1% 95.0% 94.5% Average fill rate care staff (%) - Day 92.3% 96.3% 94.4% 95.2% 93.8% 95.8% 94.7% 97.5% 99.3% 97.3% 100.2% 96.6% 95.5% Average fill rate registered nurses/midwives (%) - Night 96.7% 96.0% 95.8% 96.5% 95.5% 95.8% 94.5% 94.8% 95.9% 97.3% 96.6% 96.6% 96.3% Average fill rate care staff (%) - Night 95.4% 95.1% 94.3% 96.8% 95.7% 96.5% 96.2% 96.2% 96.8% 97.4% 95.8% 96.1% 95.1% Reduce Avoidable Harm Falls - Total in month 101 76 102 82 96 107 90 86 81 60 76 104 78 Falls per '000 Bed days 5.25 4.07 5.23 4.4 4.99 5.4 4.99 4.4 4.54 3.37 4.38 5.66 4.14 Pressure Damage (Hospital Aquired) - Total in Month 8 12 8 8 10 10 6 8 12 10 7 5 7 Pressure Damage per '000 Bed days 0.42 0.64 0.41 0.43 0.52 0.50 0.33 0.41 0.67 0.56 0.40 0.27 0.37 11
Section 3 Are we effective? 12
Effective People s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence Mortality and readmissions Work continues to resolve the issues around multiple Finished Consultant Episodes which is likely to be contributing to our rising HSMR. Clinical investigations continue into our alert around Acute, unspecified renal failure. The readmissions audit is nearing completion and will be presented to our Effectiveness Committee in October-18. However overall rates have now improved again. HSMR (March 2018) 97.9 SHMI (Mar-18) 0.95 Other effectiveness 7 day Readmission 3.5% 28 day Readmission (Jul-18) 7.9% The Committee received the Q1 Clinical Audit Report and noted some good assurance from completed audits particularly around using SASH+ improvement methodology and audit in response to recent never event in Maternity. The National Stroke Audit has seen the Trust improve to Band B Agreed the launch of guidance around seizure management at end of life, which was written in response to an issue flagged in a recent complaint. 13
Delivering our vision How are we improving? Effective Improve discharge planning Discharge Planning The executive sponsor and value stream sponsorship team have been established and are meeting regularly to oversee and progress the work within the value stream. High level metrics and targets which measure the progress and impact of the value stream have been agreed by the value stream sponsorship team and baseline data collection is underway These metrics will be re-measured and reported on a quarterly basis. The first 5 day rapid process improvement workshop for this value stream will took place the week commencing the 10th September. The focus of this workshop was on setting an EDD (Estimated date of discharge). The boundaries for the event are from when the patient has been clerked by the medical team to when their EDD has been set. The sponsor for this workshop was Dr Ben Mearns and the genba where the RPIW took place was AMU. Improvements during this first RPIW are detailed below:- Reduction in steps walked by consultant from 145 to 0 Reduction in lead time from completion of medical clerking to EDD being set and on cerner from 23.5 hours to 28 minutes 14
Effective Scorecard Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Trend Mortality and Readmissions HSMR (56 Monitored diagnoses - 12 Months) 95.4 96.5 96.6 96.2 95.5 94.3 95.9 97.6 97.3 97.9 SHMI 0.95 0.94 0.95 Emergency readmissions within 7 days 3.5% 3.7% 3.9% 4.1% 4.1% 3.7% 3.8% 3.7% 3.3% 3.8% 4.2% 3.6% 3.5% Emergency readmissions within 28 days 7.7% 8.0% 7.8% 8.4% 8.3% 7.6% 7.5% 7.4% 7.1% 7.8% 8.2% 7.9% Other Effectiveness Maternity - C Section Rate - Emergency 18.2% 15.2% 15.9% 21.2% 20.8% 17.7% 20.1% 19.6% 19.6% 20.2% 20.5% 21.9% 24.5% Discharge Planning YCM - Were you kept informed of your estimated date of discharge from hospital? 64 68 67 67 69 63 63 71 70 73 69 YCM - When you were ready to be discharged, were you satisfied with the plan that was put in place? 79 77 83 74 78 75 74 79 78 81 81 Average No of Stranded Patients - 21 Days 130 122 124 112 84 109 107 116 105 83 87 98 103 Average No of Stranded Patients - 14 Days 180 174 182 166 140 172 167 177 158 131 137 148 149 15
Section 4 Are we caring? 16
Caring service involves and treats people with compassion, kindness, dignity and respect Friends and family test Overall Our overall organisational FFT score is 93.3% for August with a response rate of 31.21%. Inpatients Inpatient FFT has fallen from 96.0% for July to 94.6% for August. The response rate sits at 29.3%. Daycase Daycase FFT stood at 96.0% in July and remains at 96.0% in August. The response rate is 12.0%. Emergency Department The ED FFT score is 94.3% with a combined response rate of 17.3% for adults, paediatrics and Clinical Decision Unit. Maternity The FFT score for the postnatal ward is 95.1%. The Delivery/birthing centre score for August is 95%, the response rate has dropped from 12.3% in July to 10.3% for August. The combined score for all maternity touch points is 94.6% and the response rate is 14.85%. Outpatients - The FFT score for outpatients has droppped slightly from 91.7% in July to 90.5% in August (1491 responses). ED FFT 94.3% Patient experience platform Responsiveness to feedback Automated actions generated by the Meridian system require key staff to make appropriate and continuing improvements in their areas. Areas with a low or decreasing FFT score are monitored and work streams arise from this feedback. The Patient Experience Committee (PEC) begin their meeting with a patient story which is discussed and focusses the committee. Focusing on priorities for improvement at ward/departmental level Priorities are consistently being raised to key staff through the alerts system on the reporting platform and by the monthly batch reports provided to the clinical areas by Meridian. The monthly PEC analyses data from Meridian. Performance maps which allow areas to understand their top priorities for patient experience are being used more widely. Using Tablets for Feedback Clinical areas have been issued with IPADs for clinical audit which also have easy access to the your care matters survey and FFT questions. Areas are now (with the support of volunteers) gathering feedback directly onto the IPAD and into our patient experience platform prior to patients discharge from our care. We are hoping to further embed this feedback mechanism over the coming months. Surveys and FFT in different languages We now provide patients with the option to complete the FFT question in 6 different languages with an aim to increase that number of additional languages in the coming weeks. We have finished designing a survey which is suitable to offer to patients with learning disabilities. Inpatient FFT 94.6% Outpatient FFT 90.5% 17
Caring service involves and treats people with compassion, kindness, dignity and respect Other Patient Experience Mixed Sex Breaches We continue to report zero mixed sex breaches in July. Complaints The Trust received 41 complaints in August which is within normal variation. The top two subjects of complaints raised in August were care implementation (11), then appointments (6). 6 complaints from previous months were reopened in August. 1 complaint was referred to the Ombudsman. Wayfinding & Signage Colourful zoning vinyl has been installed on both the ground and 1 st floors. Entrance way vinyl s have been installed on the ground floor to ensure the public know where services and wards are. The 1 st floor will have this signage installed over the coming weeks and decision boards are also being produced to display at key points to assist the public in knowing which way to turn when they reach a junction. Plans to improve the ED signage are underway with proofs being produced. Accessible Information standard With the functionality of the accessible information standard enabled on Cerner, staff are now identifying and recording the communication needs of patients with sensory disability. Outpatient letters continue to be offered in a variety of formats in line with the communication preferences. Additionally, work is underway to enable text message communication with patients in relation to outpatient bookings. This is expected to be available to service users within the next month. Complaints per 10,000 pt. contacts 9 Mixed Sex Breaches 0 Carers Raising awareness and supporting carers The carers steering group continues to meet regularly and the two carer support organisations are present within the trust to provide support and guidance for carers of patients and staff who are carers. Work is on going to promote the Carers Passport which raises the profile of carers and supports them when the person they care for is admitted. 18
Delivering our vision How are we improving? Caring Create best environment for patients Estate / Building Developments Major Schemes Building works for the new ward have now commenced and the modular units will be put in place at the end of September. Units for the new Dental and Gynaecology/Obstetric Outpatients (which forms part of the Neonatal project) will arrive in November and are scheduled for opening by June 2019. The current outpatient facilities for these services will be displaced by the expanded Neonatal unit. The Neonatal fit-out is then programmed to commence in July 2019, with an anticipated opening during December 2019. Other works Works are planned across a number of wards and clinical areas during 2018/19. Works planned are as follows: Planned Works Abinger Ward refurbishment starts 22 nd October AMU relatives room being spec d Bletchingley toliets complete Buckland Emergency Lighting refurb being spec d Burstow various inc new flooring Charlwood relatives room Endoscopy hygiene sheeting Fracture clinic painting Therapies hand therapy room P&D Holmwood/Chipstead flooring being tendered Leigh and Newdigate dementia friendly doors Meadvale overbed lighting Mortuary viewing room starts 1 st October OPD painting Outwood various painting underway Rusper toilets complete Planned Works Changing Places toilet Woodland beverage bay and flooring - end of september Tandridge overbed lights Holmwood new nurse call system Tilgate dementia doors, windows, overbed lighting Brickfield House OH kitchen to become clinic room Contact area break-out areas refurb Nursery Garden Signage works PGEC Reception tender in october Chamomile Courtyard furniture Redwood Annex minor works 19
Delivering Our Vision How are we doing? Caring Scorecard Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Trend Friends and Family Test Emergency Department FFT - % positive responses 93.7% 95.5% 96.7% 98.3% 96.5% 97.6% 96.1% 94.4% 95.1% 95.0% 94.5% 94.5% 94.3% Inpatient FFT - % positive responses 95.2% 95.7% 94.5% 93.8% 96.2% 94.5% 95.2% 93.2% 92.8% 96.8% 95.7% 96.0% 94.6% Day Case FFT - % positive responses 93.9% 96.1% 95.5% 95.4% 92.8% 97.3% 95.6% 93.5% 95.5% 96.4% 96.8% 96.0% 96.0% Outpatient FFT - % positive responses 90.5% 89.0% 88.8% 89.7% 88.3% 89.3% 90.3% 88.8% 90.5% 91.8% 91.0% 91.7% 90.5% Maternity FFT - Antenatal - % positive responses 96.8% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 0.0% 100.0% 100.0% 71.4% Maternity FFT - Delivery - % positive responses 100.0% 100.0% 80.0% 100.0% 83.3% 100.0% 100.0% 100.0% 88.9% 100.0% 93.3% 98.2% 95.0% Maternity FFT - Postnatal Ward - % positive responses 97.3% 95.6% 89.6% 96.8% 93.6% 97.5% 99.2% 96.7% 98.4% 96.2% 94.3% 96.7% 95.1% Maternity FFT - Postnatal Community Care - % positive responses 97.2% 100.0% 100.0% 96.6% 97.8% 95.9% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 95.5% Other Caring Mixed Sex Breaches 0 0 0 0 0 0 0 0 0 0 0 0 0 Complaints - Number received in month 41 37 51 36 33 49 53 60 47 45 53 58 41 Complaints - Rate per 10,000 patient contacts 9 8 10 7 7 10 12 12 10 9 11 12 9 20
Section 5 Are we responsive? 21
Responsive services meet people s needs Emergency department The ED 4hr standard was not achieved in August 2018 with performance of 94.6% placing us in the top 20, Type 1 Departments, nationally for non-specialist hospitals. SASH system LAEDB performance was 97.0% for August 2018 placing performance in the top 10, nationally for non-specialist hospitals. There were 3 breaches of the Ambulance Handover 1hr standard. Full investigations and RCA s are underway. RTT and diagnostics ED 4hr 94.6% Amb Handover over 60min 3 We did not achieve the national 92% standard with performance of 89.4% in August. The key driver of the adverse performance relates to patients awaiting their first outpatient appointments where planned reductions in waiting times have not been achieved, with a linked adverse financial impact. Specialty specific capacity issues (e.g. Cardiology, Neurology & Ophthalmology) as well as cancer referral volumes continue to be the root causes. Clinical divisions have re-forecasted recovery plans to recover both performance and activity variances. We have seen an increase in the number of patients waiting over 52 weeks at the end of August, with 16 long waiting patients still waiting for treatment (10 in July) and spanning a number of specialties but Neurology being the single largest cohort. Of these 16 patients, 9 have already either received treatment or been referred back to the care of their GP. The remaining 7 patients all have treatment plans in place to ensure that they move through their pathway as quickly as is clinically appropriate with 3 patients having treatment dates in September and the remaining 4 with planned treatments in October or relevant appointments for the next step in their pathway in place. No patient harm has been identified from RTT 52 week breaches and root cause analysis of the pathway is undertaken by clinical divisions. The 6 week diagnostic standard continued to be delivered with performance of 0.7% (against a target maximum of 1%) in August. 6 Week Diagnostic 0.7% RTT Incompletes 89.4% 22
Responsive services meet people s needs Cancer treatment Cancer performance has been challenging in August 2018 across a number of pathways. The TWR national standard was delivered with performance of 93.0%. The TWR breast symptomatic standard was delivered with performance of 93.6% (against a target of 93%). Performance against the 31 Day DTT to Treatment is to be confirmed but fell below the national standard. Breaches against this standard are related to the impact of a lack of Dermatology capacity throughout July & early August together with patient choice. 62 Day GP performance fell below the national standard with performance of c.80% but to be confirmed as final pathology results are confirmed. Breaches against this standard spanned a number of specialty's and reasons include diagnostic capacity, delays in Histology reporting and complex pathways. The impact of patient deferrals due to the holiday season continue to impact performance and are being managed closely by clinical teams. Close and proactive operational management of the 62 day pathway is in place via weekly Cancer PTL s, which feed into the executive led weekly Elective Care Board. 4 patients were treated in August beyond 104 Days - 1xSarcoma complex pathway with treatment at Royal Marsden, 2 x Upper GI with treatment at Royal Surrey and 1 x Head and Neck with treatment at SASH. RCAs are completed for all patients. The 62 day screening standard was achieved with performance of 91.6%. Two Week Wait 93.0% 62 Day GP TBC% 23
Delivering our vision How are we improving? Responsive Timely Access to Services Elective Productivity Programme The Elective Productivity Programme continues in 2018/19 with outpatients, endoscopy and theatres being the key focus in order to maximise the use of resources and support waiting time reductions. Outpatients and Endoscopy plans are in place, with on-going recruitment of booking staff being the key focus in outpatients. The theatres programme from 2017/18 continues and improvements are being seen in a number of specialties with reductions in late starts and cancellations. Outpatient Waiting Times Waits for first outpatient appointments were a challenge in 2017/18 and the improvement journey will continue into this year with the objective of first eliminating waits over 18 weeks before driving towards RTT target wait times for each specialty. Capacity was a challenge in August with the number of patients waiting over 18 weeks for their first OP appointment increasing by 92. Booking Services Access to booking services is a key focus for 2018/19 with extended daytime and weekend opening hours being put in place. New channels to manage bookings will also be rolled out in the year including further use of text messaging, email and self service through the national E-Referral system where usage is increasing week by week in conjunction with local GP practices which saw hard Paper Switch Off go live at the end of August. 24
Responsive Scorecard Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Trend Emergency Department ED 95% in 4 hours 94.4% 94.1% 93.2% 95.0% 92.3% 88.2% 87.6% 90.7% 95.5% 97.9% 97.1% 95.5% 94.6% Patients Waiting in ED for over 12 hours following DTA 0 0 0 0 0 0 0 0 0 0 0 0 0 Ambulance Turnaround - Number Over 30 mins 306 225 299 206 319 290 303 293 146 34 66 54 129 Ambulance Turnaround - Number Over 60 mins 47 40 38 38 73 87 89 56 26 0 1 5 3 Cancer Access Cancer - TWR 91.2% 91.6% 94.0% 94.6% 94.9% 93.2% 94.7% 94.6% 93.0% 93.1% 93.2% 94.1% 93.0% Cancer - TWR Breast Symptomatic 90.5% 85.7% 94.1% 83.9% 96.5% 96.1% 96.8% 97.6% 92.1% 93.1% 92.1% 91.5% 93.6% Cancer - 62 day Referral to Treatment Standard 86.4% 87.2% 92.3% 86.9% 80.0% 86.4% 83.1% 87.2% 84.0% 81.2% 80.8% 80.4% TBC Cancer - 62 Day Referral to Treatment Screening 83.3% 87.5% 75.0% 91.7% 86.7% 79.0% 83.3% 87.5% 76.9% 100.0% 92.9% 91.7% 91.6% Cancer - 31 Day Diagnosis to Treatment 95.5% 96.5% 97.2% 98.0% 96.6% 96.8% 96.2% 96.5% 97.3% 99.4% 98.7% 91.0% TBC Cancer - 31 Day Second or Subsequent Treatment (SURGERY) 95.5% 100.0% 100.0% 92.3% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Cancer - 31 Day Second or Subsequent Treatment (DRUG) 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% RTT Incomplete Pathways - % waiting less than 18 weeks 86.4% 86.1% 86.6% 87.9% 87.9% 88.8% 88.6% 89.4% 89.9% 90.7% 90.0% 90.0% 89.4% RTT RTT Patients over 52 weeks on incomplete pathways 23 20 22 19 17 17 14 19 16 15 8 10 16 Percentage of patients w aiting 6 weeks or more for diagnostic 0.7% 0.8% 1.19% 0.7% 0.3% 0.7% 1.10% 0.6% 0.2% 0.1% 0.4% 0.4% 0.7% No of operations cancelled on the day not treated within 28 days 5 11 19 8 15 22 13 22 0 1 5 2 0 25
Section 6 Are we well led 26
Well led leadership, management and governance of the organisation assures the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture Establishment Vacancy rates across all staff groups have decreased by 0.51% to 9.8%. For Nursing, vacancy rates have remained unchanged at 14.7%. Turnover for all staff groups has increased slightly by 0.19% and is now at 16.4%, whilst turnover for nursing staff has increased by 0.3% and also stands at 16.4%. The Trust had 160 new starters (including bank) in August and of these 16 were NMC registered band 5/6 nurses / midwives. Six international nurses commenced in August and there are a further 18 scheduled to started by the end of September. The resourcing team currently have 321 candidates in process (including bank and international). Vacancy Rate 9.8% Turnover Rate 16.4% Training and Achievement Review MAST Compliance 79.0% Achievement Review 48.1% MAST completion figures have increased to 79% for the end of August against a KPI of 80%. All clinical Divisions have a compliance rate of at least 76%, with both Cancer & Diagnostics and the Surgery Divisions achieving over 80% (against a green RAG rating KPI of 80%). Estates & Facilities have continued to surpass 70% and at the end of August this was at 70.86%. The Achievement Review (AR) completion rates as at the end of August was 48.1% - the target is 90% by the end of October. The HR Business Partners are working with Divisions to ensure that they have booked in ARs in line with the AR timetable. 27
Delivering our vision How are we improving? Well Led Staff health, well being and working lives Sickness Overall Sickness has reduced by 0.31% and was recorded as 3.6% for August. There has been a sharp drop in GI cases in August following the norovirus outbreak in July. Absence due to mental health issues were the highest reasons for sickness absence in month, however the level of these have remained broadly static over the past four months. There have been slight increases in August in absence due to MSK, but overall these have also remained at similar rates to the previous four months. There has been a slight increase in absences due to surgery. Absences due to seasonal conditions (i.e. colds, coughs, and flu ), continue on a downward trend. Sickness % 3.6% Health and Well being strategy The SASH 2018 Staff Well-being Day was held on 13 th September over 50 exhibitors had stalls showcasing a variety of ways staff can enhance their personal health and well-being. Over 800 staff attended the day making this the most successful health and well-being event we have held to date. The 2018 Flu Vaccination campaign commenced on 17 th September, and 300 vaccines were administered on the first two days of the campaign. The target is for 75% of frontline healthcare workers to be vaccinated by the end of the campaign The 2018 National Staff Survey will be launched on 8 th October and this will be open until 30 th November. The Chief Nurse and Director of OD & People met with colleagues in ED to discuss issues of abuse from patients / visitors towards staff. A number of actions were discussed and these are being reviewed at present. 28
Well Led Scorecard Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Trend Establishment and Training Total Establishment (WTE) 4006.2 4009.0 4027.2 4031.0 4030.8 4033.7 4033.7 4091.5 4081.0 4082.8 4089.9 4114.7 4118.6 Vacancy Rate (All Staff) 11.1% 11.6% 10.9% 10.0% 10.2% 9.5% 9.3% 10.2% 9.1% 9.4% 9.7% 10.3% 9.8% Staff Turnover rate 16.1% 16.5% 16.2% 16.4% 16.8% 16.1% 16.5% 16.1% 16.0% 16.2% 16.2% 16.2% 16.4% % of Staff who have had an Achievement Review YTD 48.9% 65.0% 84.0% 90.3% 92.0% 92.2% 92.6% 93.2% 2.9% 11.0% 19.0% 36.4% 48.1% %age of staff who have completed MAST training in the last 12 months 77.0% 76.6% 76.1% 76.0% 77.9% 77.0% 77.8% 78.1% 77.3% 77.0% 77.3% 78.4% 79.0% Staff health, well being and working lives Overall Sickness Rate 4.1% 3.8% 4.1% 4.5% 4.3% 4.7% 4.1% 4.2% 3.8% 3.6% 3.9% 3.9% 3.6% 29
Section 7 Do we use resources effectively 30
Effective use of resources Income and Expenditure Trust achieved a 1.5m [adjusted] surplus at the end of August, which was 1.6m favourable to the YTD plan. The planned forecast outturn remains as a 16.1m surplus This position included 2.6m Provider Sustainability Funding (PSF) for delivery of financial plans and ED targets. Total agency spend in the first four months of 2018/19 (was 8.0m which was 1.9m higher than the 6.1m YTD agency ceiling specified by NHSi. Outturn m Adjusted Surplus 16.1m Savings Plan Outturn Savings m M3 4.8m The 4.8m 2018/19 savings programme submitted to NHSi consists of: 2.2m Agency savings 0.5m Reduction in Additional Duty Hours 0.5m Get It Right First Time (GIRFT) 1.6m Supplies & Services 31
Effective use of resources Capital Plan The Trust s 2018/19 planned capital requirement for 2018/19 has risen to 19.5m. Until confirmed by NHSi the Trust is only able to spend 10.9m on capital in 2018/19. The Trust has requested 8.4m of additional CRL. The remaining 0.2m is anticipated from donation receipts. Cash Management Trust had a cash balance of 9.2m at the end of August. The revolving working capital balance at the end of August was 6.0m. A further repayment of 3m is being made in Sept 2018 and 3m in March 2019. Cumulatively the Trust paid 93% of its invoices within 30 day of receipt by value and 93% by volume. In month the Trust paid 97% of its invoices within 30 days of receipt by value and 96% by volume. 32
Resources Scorecard Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Trend Outturn m Surplus / (Deficit) - Plan 21.3 21.3 21.3 21.3 21.3 21.3 21.3 21.3 16.1 16.1 16.1 16.1 16.1 Outturn m Surplus / (Deficit) - Forecast 21.3 21.3 21.3 21.3 21.3 11.0 11.0 13.6 16.1 16.1 16.1 16.1 16.1 YTD m Surplus / (Deficit) - Plan 3.0 4.3 7.1 9.6 9.7 16.2 17.6 21.3 (1.9) (0.7) 0.2 1.2 (0.1) YTD m Surplus / (Deficit) - Actual 3.1 4.4 5.3 7.1 9.7 9.8 8.1 13.6 (1.0) 0.6 0.7 1.3 1.5 Annual Outturn UNDERLYING m Surplus / (Deficit) - Plan 12.0 12.5 12.5 12.5 12.5 12.5 12.5 12.5 6.9 6.9 6.9 6.9 6.9 Annual Outturn UNDERLYING m Surplus / (Deficit) - Actual 12.0 12.0 11.9 11.9 11.9 5.3 5.3 2.8 6.9 6.9 6.9 6.9 6.9 YTD Savings m - Actual 1.8 2.2 2.8 3.5 4.1 4.8 4.2 6.2 0.2 0.5 0.7 1.1 1.4 OT Risk m Surplus / (Deficit) - Assessment (16.3) (16.0) (16.0) (16.0) (16.0) (5.5) (5.5) 0.0 0.0 0.0 (13.9) (13.9) (13.9) Outturn Cash position m Fav / (Adv) - Forecast 2.7 2.7 2.7 2.7 2.7 2.7 2.7 2.7 5.0 5.0 5.0 5.0 5.0 YTD Cash position m Fav / (Adv) - Actual 5.4 5.1 6.0 4.7 4.9 3.3 4.8 5.3 4.2 7.6 4.5 11.3 9.2 YTD Liquid ratio - days (10.0) (9.0) (8.0) (6.0) 1.0 (3.0) (5.0) (2.0) 0 2.0 3.0 (4.0) (4.0) YTD BPPC (overall) volume m 86% 82% 74% 67% 70% 73% 75% 77% 97% 88% 91% 93% 93% YTD BPPC (overall) value m 87% 83% 78% 74% 75% 77% 78% 80% 94% 88% 91% 92% 93% Outturn Capital spend Fav / (Adv) - forecast 18.8 18.8 18.8 18.8 18.8 11.6 11.6 12.4 16.8 17.0 19.5 19.5 19.5 33