BOARD OF DIRECTORS

PART I

This is to advise that there will be a meeting of the Board of Directors at 9.00 am on Wednesday 10 October 2012

in the Boardroom, Level 1, Yeovil Hospital NHS Foundation Trust

AGENDA

Welcome to Lesley Boucher, Governor appointed by South Somerset District Council - (A governor will attend each Board Meeting as an Observer)

Presenter 1. DECLARATIONS OF INTEREST Members of the Board are required to make known any interests relating

to items on the current agenda

2. APOLOGIES:

3. MINUTES OF THE PREVIOUS MEETING HELD ON 26 SEPTEMBER, 2012

PW Appendix 1

To APPROVE the Minutes of the Board of Directors’ meeting held on 26

September 2012

4. ACTION SHEET PW Appendix 2

5. MATTERS ARISING PW

6. CHIEF EXECUTIVE’S BRIEFING (20 mins) PM Oral To DISCUSS the key current issues affecting the Trust

7. PERFORMANCE, RISK & ASSURANCE 7.1 FINANCE & RISK REPORT PMo Appendix 4 To DISCUSS the Finance and Risk Report for August 2012 7.2 INTEGRATED PERFORMANCE REPORT – MONTH 5 –

AUGUST, 2012 JM Appendix 5

To DISCUSS the Integrated Performance Report for Month 5

8. REVALIDATION JHo Appendix 6 To receive an update on Revalidation

9. ITEMS FOR APPROVAL 10.1 There are no items for approval

2

10. ITEMS TO NOTE 10.1 MEDICAL DEVICES TRAINING HR Appendix 7 To note the progress achieved for Medical Devices Training 10.2 CHANGES TO CONSTITUTION

To NOTE the e mail approval of required changes to the constitution.

SC

Oral

11. ANY OTHER BUSINESS

12. EXCLUSION OF THE PUBLIC To resolve to exclude the public from the rest of the meeting by passing the following resolution: The Board of Directors resolves to exclude the public from the rest of the meeting because publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted or for other reasons arising from the nature of the business and the proceedings.

13. DATE AND TIME OF NEXT MEETING

There will be a meeting of the Board of Directors on Wednesday 14

November 2012 at 9.00 am to be held in the Boardroom, Level 1, Yeovil District Hospital.

1

APPENDIX BOARD OF DIRECTORS

2012

BOARD OF DIRECTORS

Minutes of a meeting of the Board of Directors held on Wednesday 26 September 2012 at Yeovil District Hospital

Present: Peter Wyman [PW] Chairman Paul Mears [PM] Chief Executive John Buckley [JB] Non-Executive Director Nick Cook [NC] Interim Director of Human Resources Maurice Dunster [MD] Non-Executive Director Julian Grazebrook [JG] Non-Executive Director Paul von der Heyde [PH] Non-Executive Director Jonathan Higman [JHig] Director of Operations Jonathan Howes [JHo] Medical Director Jeremy Martin [JM] Director of Planning & Performance Helen Ryan [HR] Interim Director of Nursing & Clinical Governance Mark Saxton [MS] Non-Executive Director Robert Steele [RS] Director of Facilities Gill Waldron [GW] Vice-Chairman In Attendance: Simon Chase [SC] Company Secretary Dean Stevens Assistant Director of Finance Sue McInnes Public Governor Nadia Manuelli Communications Consultant Rebecca Whittaker Matron for Outpatients – for item 162/12 Apologies: Pippa Moger [PMo] Acting Director of Finance

Action 157/12 DECLARATIONS OF INTEREST

The Chairman declared that he had been a partner in PwC until 30 June 2010 but that he no longer shares in their profits. No other interests were declared.

158/12 APOLOGIES AND WELCOME The Chairman welcomed Sue McInnes to the meeting and invited her to participate freely, but to respect the confidentiality of the meeting. He also welcomed Nadia Manuelli and Dean Stevens. Apologies had been received from Pippa Moger.

159/12 MINUTES OF THE PREVIOUS MEETING The Board APPROVED the minutes of the meetings held on 15 August 2012.

160/12 ACTION SHEET

The Board NOTED the action sheet.

Page 2

161/12 MATTERS ARISING There were no matters arising.

162/12 PATIENT STORY

Rebecca Whittaker joined the Board for this item. Helen Ryan and Matron Whittaker explained an incident that occurred in Outpatients recently. This had involved a failure to establish the correct identify of a patient. The Board asked a large number of questions and were reassured that rapid steps have been taken to reduce the likelihood of such an incident happening again. The organisation will also have the lessons learned circulated and a future ‘Big Gov’ meeting will feature this incident. The Chairman thanked Matron Whittaker for presenting the case so clearly and assured her of the Board’s full commitment to patient safety and high quality care.

163/12 CHIEF EXECUTIVE’S BRIEFING Paul Mears commented on his report. He particularly spent some time discussing Symphony, the collaborative care initiative, and the positive progress being made. He also highlighted Monitor's proposed licensing regime. Mr Mears also updated the Board on the unannounced inspection by the Care Quality Commission, which had taken place over the last two days. The informal feedback at the end of the visit has been extremely positive. The Board was very pleased to hear this positive result and expressed its thanks to the staff who supported the visit. There are some lessons to learn and follow-up actions will be taken to ensure these are embedded.

PERFORMANCE, RISK & ASSURANCE

164/12 PERFORMANCE REPORT Jeremy Martin outlined the key issues the Board needed to review. Jonathan Higman led the discussion on a number of matters. These included A&E performance and strengthening its leadership; RTT performance; and stroke performance and improvements, which the Board discussed thoroughly. Jonathan Higman agreed to circulate August performance figures as soon as they are available. The Board was informed of a very positive outcome to last week's cancer peer review, particularly in relation to oncology. The formal report should be available soon. The Board also discussed the extent to which the dashboard clearly indicated the key messages it needed to recognise and address. The Board agreed that the current arrangements needed to be revisited. Time will be given to reviewing the information the Board receives and how it can fully reflect the range of responsibilities it has.

JHig

PM

Page 3

The Board was informed that the Nursery provision is transferring from the Trust next week. The Board noted the high sickness rate in the Maternity Unit. Helen Ryan will investigate this.

HR

165/12 AUDIT COMMITTEE The Board NOTED the minutes of the meeting held on 4 September 2012. John Buckley highlighted the slow pace of implementing audit recommendations in some areas. This message was endorsed by Julian Grazebrook as this matter had arisen at the NCRAC meeting. It was agreed that the audit recommendations would be added to HMT agendas to ensure timely implementation and adequate management scrutiny.

SC

166/12 AUDIT COMMITTEE ANNUAL REPORT The Board NOTED the annual report.

167/12 CLINICAL GOVERNANCE ASSURANCE COMMITTEE The minutes of the meeting held on 5 September 2012 were NOTED.

168/12 NON-CLINICAL RISK ASSURANCE COMMITTEE The Board NOTED the minutes of the meeting held on 4 September 2012. Julian Grazebrook noted the opportunity the Trust has to revise its approach to policy management. Paul Mears confirmed that steps would be taken to improve the current arrangements.

169/12 FINANCE REPORT The Board NOTED the report and Dean Stevens provided an oral update on the August position. It was noted that there is an outstanding £500k gap in CIP plans and that there are also associated risks to current plans, placing a further £500k of savings in jeopardy. The Board expressed concern at this slippage. Paul Mears explained that yesterday HMT had reviewed each of the major plans and that further work would be carried out as a matter of urgency The Chairman stressed very clearly the fundamental importance of making the necessary savings as this is a prerequisite for the Trust's future. It was agreed that there would be a more focused discussion on CIP at October's meeting. The Board also noted that non-pay is further adrift than pay costs and that the position has worsened in August. Dean Stevens reported that the cash position is stronger than plan but is largely due to a slower pace of implementing capital schemes.

PM

Page 4

ITEMS FOR APPROVAL

170/12 HOSPITAL MANAGEMENT TEAM The Board APPROVED the revision of the status of the Hospital Management Team.

171/12 NEONATAL DESIGNATION MOBILISATION PLAN The Board NOTED the report and agreed that the approach to re-providing SCBU need to be revisited. Nevertheless, the Board AGREED to support the report's recommendations.

ITEMS TO NOTE

172/12 COUNCIL OF GOVERNORS’ MEETING The Board NOTED the minutes of the meeting held on 10 September 2012. On behalf of the Governors the Chairman highlighted the lack of pace in implementing changes and the importance of managing effectively the changes in personnel at Board level. The Board of Directors accepted both of these points and recognised their importance.

173/12 MONITOR Q1 REPORT The report from Monitor, previously circulated by email, was NOTED.

174/12 ANY OTHER BUSINESS

There was no other business.

175/12 EXCLUSION OF THE PUBLIC The Board RESOLVED to exclude the public from the rest of the meeting.

176/12

DATE OF NEXT MEETING The next meeting will be held on Wednesday 10 October 2012.

1

APPENDIX 2 BOARD OF DIRECTORS

10 OCTOBER, 2012

BOARD OF DIRECTORS – ACTION SHEET

10 October 2012

Minute Action Outcome Due By

98/12 Dementia Care – Provide a report on progress

An oral update will be given at the meeting

10 October 2012 HR

104/12 Night Discharge Arrangements – Provide a full report to a future meeting

An oral update will be given at the meeting

19 September

2012 HR

119/12 Medical Devices Annual Report – Provide a plan to improve levels of training

This is on today’s agenda to note

10 October 2012

HR +

RS

127/12

Clinical Governance – Report changes to endoscopy access through the Director of Operations’ section of the Performance Report

This will be included when the work has been

completed

10 October 2012 JHig

164/12 Performance Report – Figures will be circulated when available

The latest position is in the performance report

10 October 2012 JHig

164/12 Performance Report – Consider the key information the Board requires

The Directors have considered this and

NEDs will be consulted

From 26 Sept 2012 SC

164/12 Performance Report – Investigate high sickness rate in Maternity

An oral update will be provided at the meeting

10 October 2012 HR

165/12 Audit Committee – Incorporate review of audit recommendations into HMT business

This is being incorporated

From 26 Sept 2012 SC

169/12 Finance Report – Ensure a more focused discussion on CIP at the next Board meeting

This is on today’s Part 2 agenda under Transformation

10 October 2012 PMo

1

_____________________________________________________________________________ Report to: Board of Directors Report from: Interim Director of Finance Subject: Finance Report for Period Ending 31 August 2012 Date: 10 October 2012 Key Points

The income and expenditure position for August 2012 is a surplus of £797,000 which is £23,000 favourable from plan. The key financial risks for 2012/13 are: • Delivery of £4.6 million cost improvement programme. As at month 5 there is a gap of

£0.5 million. • Ability to achieve all of the performance metrics within the contract with

commissioners which if breached would invoke financial penalties. At the end of quarter 1 commissioners have invoked penalties of £181,000.

• Ability to manage bed capacity which will increase nursing costs. 1. Income and Expenditure

1.1 The income and expenditure position at the end of August 2012 is a surplus of

£797,000 which represents a favourable variance of £23,000 year to date and £46,000 favourable in month as detailed in Appendix 4b.

1.2 There is an overachievement of £11,000 on private patient income and an underachievement in other income of £9,000 in relation to post mortems.

1.3 Pay expenditure is £79,000 favourable in month, £75,000 favourable year to date. The nursing overspend has decreased to £35,000 and the medical staff overspend increased to £54,000 year to date. Other pay has underspent in month by £74,000 due to vacancies within admin and clerical and professional staff within pharmacy and radiology.

1.4 Activity related non-pay expenditure is £15,000 adverse in month due to additional expenditure in medical division and orthopaedics. Non activity related non-pay expenditure is £40,000 adverse in month due to high expenditure on printed forms and equipment repairs.

2. Clinical Contracted Income

2.1 As at the end of July the performance against the clinical income contracts with

commissioners is £26,000 adverse. The breakdown of this can be seen in the table below.

Income Budget YTD £’000

Actual YTD £’000

Variance £’000

Comments

Elective 8,084 8,419 176 Higher casemix of patients Emergency 14,120 14,252 132 Births are below plan and the

casemix for orthopaedic

APPENDIX 4 BOARD OF DIRECTORS

10 OCT 2012

2

emergencies is less that plan whilst general medicine is currently overperforming against plan

Outpatients 6,655 6,544 (111) Activity levels lower that plan in ophthalmology and oral surgery.

A&E 1,796 1,947 151 Activity higher than plan Other Non Tariff 9,377 9,390 13 SCBU overplan and high cost

drugs lower than plan. Total 40,032 40,552 520

2.2 The Trust did not met the performance metrics relating to referral to treatment times

in quarter 1 and as a result commissioners have invoked penalties of £181,000. There will be further penalties for quarter 2 as in July and August the metric was also not met.

2.3 In order to mitigate against these penalties there is a review of best practice tariff income and ensuring that all opportunites for these are maximised in 2012/13 as this is an area where the Trust can receive additional income above the contract value.

3. Divisional Risks

3.1 Family Health and Clinical Support: At the end of month 5 they are £19,000

underspent against budget and are forecasting to achieve all of the cost improvement savings. Key risks relate to the prescribing of drugs to cancer patients.

3.2 Surgery: At the end of month 5 they are £45,000 overspent against budget and have a recurrent gap within the cost improvement programme of £144,000 but are working on plans to close this gap. Key risks relate to consumable non-pay expenditure within orthopaedics and surgical specialties.

3.3 Medicine: At the end of month 5 they are £74,000 overspent against budget due to nursing across the medical wards and drugs expenditure and are forecasting a recurrent gap of £37,000 on the cost improvement programme but are working on plans to close this gap.

4. Cost Improvement Plan

4.1 The cost improvement programme (CIP) has a target of £4.6 million. Plans are in

place to achieve £4.1 million leaving a gap of £0.5 million. Further work is taking place to close this gap. At the end of August £1,355,000 has been achieved of which £1,286,000 is recurrent.

4.2 The following projects are currently red rated overall from a risk perspective, and this section highlights these risks together with the mitigating action being taken to address them.

4.3 Developing new models of care for Gynaecology and Obstetrics – Work is underway to commence a service review to identify alternative service delivery models that may be suitable and to create a project plan. This work also links closely with the beds and theatres workstreams. The project team are liasing with another Trust to consider if their model of care could be applied in Yeovil.

4.4 Bed Project – The plans for realeasing savings on utilisation of beds are being

3

reviewed by the Interim Director of Nursing and Director of Operations. Bed mapping will be undertaken to ensure all capacity is used in the most appropriate way.

4.5 Nursing – £40,000 of savings are still to be identified with a gap of £100,000 recurrently. The Interim Director of finance will be meeting with the nursing team to review the plans in place.

4.6 Outpatient dispensing review – the options appraisal being carried out by the Commercial Manager is almost complete. The provisional position is that the project is viable, with an earliest possible go live date of January 2013. This will be considered at the September meeting of the Commercial Strategy Group.

4.7 Theatres – this is a complex programme of work which saw some delay to the establishment of programme objectives and management support. These are now in place and there is a dedicated programme manager in place.

4.8 Commercial SHIS – Currently half of the £125,000 has been identified. The great majority of the budget is tied up in service contracts with systems suppliers and therefore there is not an opportunity to achieve any additional savings in 2012/13.

4.9 Pharmacy Drug Savings – Plans are being worked through to identify how the £100k will be achieved. The programme office is planning to attend the next meeting in October.

4.10 Surgery Division - £144,000 of recurrent savings are still to be identified but the division is working on plans to address this.

4.11 Facilities – £77,000 of in year savings are still to be identified. There are further schemes to be scoped and delievered as the year progresses.

5. Forecast

5.1 The forecast position for the financial year 2012/13 is to deliver a surplus of

£652,000 and achieve a risk rating of 3. Contingencies of £667,000 are being held and if all CIP is achieved and risks managed a surplus of above £1million could be delivered

5.2 There are a number of risks against this and further work is happening to understand these risks and develop action plans to mitigate them. The main risks being:

• Family Health Division – Increased drug costs within cancer • Surgery Division – Recruitment of medical staffing within Critical Care and

increased consumable costs within surgery and orthopaedics • Medical Division – Increased drug costs within Rheumatology and high

sickness levels within nursing • Commissioner levied fines for non-achievement of performance metrics • CIP – current gap £0.5 million

6. Cash Flow 6.1 The Trust has £7.5 million in the bank at the end of August which is £534,000 above

plan. The higher than planned cash balance is mainly attributable to a higher level of creditors than plan and capital expenditure being lower than planned.

4

6.2 As at 31 August 2012 the Trust’s cash investments were as follows:

Investment Value at 31 August 12

Interest Rate at 31 August 12

Access Terms

Government Banking Service Accounts

£1,268,992 0.25% Instant

Natwest Main Account £53,548 0.00% Instant Natwest Special

Interest £369,422 0.30% Instant

Natwest 95 day notice account

£3,000,000 1.35% 95 Day notice given 26 April 2012

Bank of Scotland £3,053,414 0.75% Instant Barclays £2,863

Plus Cash in Transit £(250,930) TOTAL £7,497,309

7. Capital

7.1 The capital programme for 2012/13 totals £4.3 million. Expenditure on the 2012/13

capital programme to the 31 August 2012 is £1.01 million against a plan to date of £1.56 million, this variance represents a timing issue for expenditure on projects and not an under spend.

7.2 Projects completed to date are CT Scanner, Women’s Hospital main entrance and birthing pool. Projects near completion are the Mosaiq chemotherapy e-prescribing and switch panel works.

7.3 Major on-going projects for 2012/13 are Women’s Hospital ground floor clinic works, Fire alarm replacement programme, Medical and Radiology equipment replacement programme and the Information Technology Electronic Health Record system.

8. Financial Risk

8.1 The financial risk rating at the end of August 2012 is 3.1 as shown in the following

table:

Metric Risk Rating Weighting Weighted Risk Rating

EBITDA achieved % of plan 4 0.10 0.40 EBTDA margin 3 0.25 0.75 Net Return after Financing 3 0.20 0.60 I&E surplus 3 0.20 0.60 Liquidity days 3 0.25 0.75 Total 3.1

5

List of Annexes

a. Executive Summary

b. Income and expenditure under current contract

c. Division budgetary performance

d. Cost improvement summary dashboard

e. Balance sheet

f. Cashflow statement

g. Capital expenditure

FINANCE REPORT FOR AUGUST 2012 Appendix 4a

EXECUTIVE SUMMARY

Budget Actual VarianceIncome 46,177 46,213 36 Cash Balance 7,499 Pay (30,286) (30,211) 75Non Pay (13,027) (13,148) (121) Cash less than Plan by 529EBITDA 2,864 2,854 (10)Other (2,090) (2,057) 33 Forecast - 12 Month Cash 6,479 Surplus 774 797 23

EBITDA % Plan 99.6%EBITDA Margin % 6.1%Surplus % Plan 103.0%Surplus % 1.7%

EBITDA % of plan 4 Capital YTD Spend 1,012EBITDA margin 3Return on Assets (Forecast) 3 Spend YTD less than Plan by 549I&E Surplus 3Liquidity 3 Annual Plan 4,295

Total Weighted FRR 3.1

CIP - Achieved YTD 1,355 Recurrent 1,286

Annual Target 4,615

COMMENTARYCIP

FINANCIAL RISK RATING

BUDGET PERFORMANCE SURPLUS PERFORMANCE

YTD

CASH

CAPITAL

Key issues Commentary .At Month 12 the year to date variance is £343,000 favourable against plan.

Key issues Commentary The variance in month is £46k favourable, and £23k favourable year to date. There is still a gap of £0.5 million within the CIP plan but current savings achieved in year are in line with plan.

0500000

100000015000002000000250000030000003500000400000045000005000000

1 2 3 4 5 6 7 8 9 10 11 12

£

Month

Cost Improvement Programme Cumulative Performance

Phased plan

Actual YTD

FYE YTD

-200

0

200

400

600

800

1000

1200Monthly Surplus Performance (£'000)

Surplus -Plan

Surplus -Actual

-80

-60

-40

-20

0

20

40YTD Surplus Variance (£'000)

Appendix 4b

FINANCE REPORT FOR AUGUST 2012INCOME AND EXPENDITURE UNDER CURRENT CONTRACT

Annual PlanAnnual Budget

Forecast Outturn

Forecast Variance

Favourable / (Adverse)

Budget Year to Date

Actual Year to Date

Variance YTD

Favourable / (Adverse)

Variance in Month

Favourable / (Adverse)

£'000 £000's £'000 £'000 £'000 £'000 £'000 £'000

IncomeNHS Clinical Income 95,500 95,862 95,862 0 40,032 40,035 3 0Non NHS Clinical Income 3,072 3,110 3,110 0 1,250 1,268 18 14Total Other Income 10,626 10,641 10,641 0 4,895 4,910 15 (9)Total Income 109,198 109,613 109,613 0 46,177 46,213 36 5ExpensesPay Expenditure (72,202) (71,924) (71,924) 0 (30,286) (30,211) 75 79Non Pay Expenditure (31,269) (30,728) (30,728) 0 (13,027) (13,148) (121) (46)Central Budgets 0 (4,284) (4,284) 0 0 0 0 0Contingency 0 0 0 0 0 0 0 0CIP 0 3,257 3,257 0 0 0 0 0Total Expenditure (103,471) (103,679) (103,679) 0 (43,313) (43,359) (46) 33Earnings Before Interest, Tax, Depreciation and Amortisation (EBITDA) 5,727 5,934 5,934 0 2,864 2,854 (10) 38Other Non-Operating Income 60 0 0 0 0 0 0 0Other Depreciation (3,224) (3,378) (3,378) 0 (1,309) (1,307) 2 2Donated Asset Depreciation (223) (215) (215) 0 (90) (90) 0 (1)PDC Dividend (1,747) (1,747) (1,747) 0 (716) (688) 28 6Total Interest Receivable 59 59 59 0 25 28 3 1Impairment 0 0 0 0 0 0 0 0Finance Expense - Unwinding of Discount on Provisions 0 0 0 0 0 0 0 0Net Surplus/(Deficit) 652 653 653 0 774 797 23 46EBITDA Margin 5.0% 5.2% 5.2% 6.1% 6.1%I&E Surplus Margin 0.6% 0.6% 0.6% 1.7% 1.7%Financial Risk Rating 3.0 3.2 3.1

Annual PlanAnnual Budget

Forecast Outturn

Forecast Variance

Favourable / (Adverse)

Budget Year to Date

Actual Year to Date

Variance YTD

Favourable / (Adverse)

Variance in Month

Favourable / (Adverse)

£'000 £000's £'000 £'000 £'000 £'000 £'000 £'000

NHS Clinical Income 95,500 95,862 95,512 0 40,032 40,552 520 546Net Surplus/(Deficit) 652 652 95,512 94,860 774 1,314 540 590

PbR Contract

Key Variances - Month 12 Pay Nursing is £26k adverse in month due to overspends in Medicine, Critical Care & Orthopaedics. Medical staff is £210k favourable in month due to underspends in Medicine & Surgery. Non Pay Drugs is £92k adverse in month due to overspends in Child Health, Medicine & Pathology. Activity Related Non Pay is £178k adverse in month. £50k of this relates to year end stock adjustments. The largest overspends are in Critical Care, Surgery & Orthopaedics.

Key Variances Month 5 Clinical Income Clinical income is breakeven in August. Private Patients Overachieved in month due to higher PP and amenity occupancy than planned. Other Operating Income There is an adverse variance in month of £9k due to the under achievement of mortuary income. Pay Nursing Underspend in month of £9k is due to favourable variances in Critical Care, Child Health, Medicine & Maternity. Medical Staff Overspend in month of £4k is due to an adverse variance in Orthopaedics due to locum cover. Other Other pay is underspent predominantly against Admin and Clerical & Professions Allied to Medicine staff groups. Non Pay Drugs Underspend of £9k is relating to favourable variances in Medicine & Pharmacy. Activity Related Expenditure Overspend in month of £15k relates to high expenditure on consumables in Medicine, Facilities & Orthopaedics Other Non Pay Expenditure Overspend in month of £40k relates to high expenditure on office expenses and medical equipment lease & maintenance.

Key Variances Month 5 Elective Income - favourable variance of £335k (in month £158k favourable) Emergency Income – favourable variance of £132k (in month £284k favourable) Outpatient Income - adverse variance of £111k (in month £58k favourable) A&E Income - favourable variance of £151k (in month £48k favourable) Non Tariff Income - favourable variance of £13k (in month £2k adverse)

Appendix 4c

FINANCE REPORT FOR AUGUST 2012DIVISIONAL BUDGETARY PERFORMANCE Medicine Surgical

Family Health & Clinical Support Corporate Total

Favourable / (Adverse)

Favourable / (Adverse)

Favourable / (Adverse)

Favourable / (Adverse)

Favourable / (Adverse)

£'000 £'000 £'000 £'000 £'000

YTD VariancePbR Income 392 55 73 (0) 520

Income (16) 4 31 17 36Pay (25) 4 24 73 75Non Pay (33) (53) (35) 0 (121)Earnings Before Interest, Tax, Depreciation and Amortisation (EBITDA) (74) (45) 19 90 (10)

Appendix 4dCost Improvement Summary Dashboard 2012/13

Project Name Project Status

Target 2012/2013

£'000

Actioned 2012/13 at

Month 5 £'000

Actioned recurrently

£'000

Forecast gap Non-Recurrent

£'000

Forecast gap Recurrent

£'000

Clinical PathwaysQuality Strategy G 20 - - - -

QUIPP - End of Life G 5 - - - -

CID, Cardiology, CCU A 15 - - - -

Gynae and Obs - new model of care R 50 - - 50- 50- Bed Project R 300 - -

Sub Total 390 - - 50- 50-

Community ServicesSouth Petherton G 250 104 104 - - Pharmacy - Somerset G 20 20 - - 20-

Sub Total 270 124 104 - 20-

Ways we WorkModern Support Services A 50 - - - -

Smoking Project G 3 - - 1 1

Modern Administration Services G 50 - - - -

Ophthalmology Services A 20 - - 20- 20-

Relocation of OMF A 6 - - 6- 6-

Setting the record straight G 10 - - - - Paperless Board Meetings G 4 - - - -

Sub Total 143 - - 26- 26-

Workforce StrategiesNursing Savings R 100 - - 40- 100-

Corporate Savings G 150 121 115 - - Salary Sacrifice Schemes G 50 37 39 - -

Sub Total 300 159 154 40- 100-

Commercial Reduce MRSA Screening A 25 - - - -

Private Physio G 5 - - - -

Inflation Management - Excluding Procurement G 700 291 291 - -

PPU G 90 28 28 - -

Pharmacy Drugs R 100 - - - -

Procurement - Excluding Divisions A 700 8 12 250- 250-

Commercial SHIS R 125 60 60 65- 65-

Inflation Management - Procurement A 100 70 70 - -

Outpatient Dispensing R 20 - - - -

Mental Health Clinical Trials A 20 - - - -

Transport Services G 50 - - - -

Somerset Pathology G 100 89 104 - - Other Commercial Projects A 100 - - - -

Sub Total 2,135 546 565 315- 315-

DivisionalMedical A 100 33 19 - 37-

Family Health G 200 138 178 - -

Surgical R 337 121 94 25- 144-

Facilities R 300 85 46 77- Other Divisional G 56 46 16

Sub Total 993 422 353 102- 181-

Other Schemes - To be identified G 385 104 110

Total target 2012/13 4,615 1,355 1,286 533- 692-

Appendix 4e

2012/13 2012/13 2012/13 2012/13Previous Mth Current Mth Movement Opening Closing

Aug-12 Aug-12 in Month Actual Forecast Movement£'000 £'000 £'000 £'000 £'000 £'000

Fixed AssetsIntangible Fixed Assets 204 220 16 286 204 0Tangible Fixed Assets 51,880 51,684 (196) 52,141 52,408 346Total Fixed Assets 52,084 51,904 (180) 52,427 52,612 346

Current AssetsStock 1,694 1,664 (30) 1,629 1,677 (16)Debtors 4,916 4,786 (130) 3,510 3,003 (393)Non Current Assets Held for Sale 184 184 0 184 0 (184)Cash in Hand and at Bank 7,267 7499 232 6,118 6,389 1,072Total current assets 14,061 14,133 72 11,441 11,069 479

Current liabilities (9,110) (9,319) (209) (7,774) (7,214) 77Net Current Assets 4,951 4,814 (137) 3,667 3,855 556Long Term Debtors 910 941 31 784 910 126Total Assets less Current Liabilities 57,945 57,659 (286) 56,878 57,377 499Creditors payable over one year 0 0 0 0 0 0Borrowings > 1 yr (191) (191) 0 (191) (63) 128Provision for liabilities and charges (834) (834) 0 (852) (828) 24Total Net Assets (Liabilities) 56,920 56,634 (286) 55,835 56,486 651

Financed by:Income and Expenditure Reserve Current year 1,085 799 (286) 0 653 653Public Dividend Capital 40,625 40,625 0 40,625 40,625 0Income & Expenditure Reserve previous year 5,841 5,841 0 5,839 5,839 0Revaluation Reserve 9,369 9,369 0 9,371 9,369 (2)Donation Reserve 0 0 0 0 0 0Total Financed 56,920 56,634 (286) 55,835 56,486 651

Year to Date AnalysisIn Month AnalysisFINANCE REPORT FOR AUGUST 2012BALANCE SHEET

Key Variances

Current Assets Stock has reduced by £30k in month. This is mainly attributable to a reduction in stock held for audiology. NHS Debtors have reduced in month by £74k. This is primarily due to the phasing of the Somerset PCT contract following an increase in the contract value. Non NHS debtors have reduced in line with the phasing of prepaid contracts. Current Liabilities Overall creditors and accruals have increased by £219k in month. £130k is for the Pathology Service charge.

Appendix 4f

Year end Plan Actual Variance Plan Actual Variance Forecast

Aug-12 Aug-12 Aug-12 Aug-12 Aug-12 Aug-12 Mar-13£'000 £'000 £'000 £'000 £'000 £'000 £'000

Opening Balance 7,267 7,267 0 6,118 6,118 0 6,118EBITDA 116 114 (2) 2,853 2,853 0 5,934

Excluding Non cash I&E items 0 6 6 79 115 36 70

Movement in working capital:Stocks & Work in Progress (Increase)/decrease (65) 30 95 (130) (35) 95 (48)Total Debtors (Increase)/decrease 385 131 (254) (1,021) (1,275) (254) 507Total Creditors Increase/(decrease) (466) 203 669 709 1,378 669 (126)Provisions & Liabilities (3) 0 3 (21) (18) 3 (24)

Capital Additions (162) (105) 57 (1,036) (1,012) 24 (3,924)Capital Creditors (107) (122) (15) (481) (496) (15) (434)Cash receipts from asset sales 260

Movement in LT debtors (Increase)/decrease (31) (31) (126) (157) (31) (126)Movement in LT Creditors Increase)/decrease 0 0 0 0 0 0 0

Drawdown of loans and leases 0 0 0 0 0 0 0Repayment of loans and leases 0 0 0 0 0 0 (128)

Movement in Other grants/Capital received 0 0 0 0 0 0 0Dividends paid 0 0 0 0 0 0 (1,748)

(302) 226 528 826 1,353 527 213

Interest (paid)/ received on cash balance 5 6 1 26 28 2 58

Net Cash Inflow/(Outflow) (297) 232 529 852 1,381 529 271

Closing Balance 2 7,499 7,497 6,970 7,499 529 6,389

Invested Cash 0 0

Floating Balance 7,499 7,499

Forecast cash position as at July 2013 6,479

Year to Date Analysis

Movement before interest received/ (paid) & PDC dividend on cash balances

In Month AnalysisFINANCE REPORT FOR AUGUST 2012 CASHFLOW STATEMENT

Key Variances Key Variances EBITDA, in month, is £32k below plan. Working Capital Stocks are lower than plan due to the reduction of audiology stocks. Non NHS Debtors are above due to an increase in funding from Somerset PCT. Creditors are above plan due mainly to a number of outstanding NHS invoices and a Pathology service charge accrual. Cash is currently held in GBS, NatWest and Bank of Scotland accounts. £3m is held in a 95 Day account earning 1.35%. The spread and location of deposits is continually reviewed to ensure competitive rates of return are achieved whilst managing investment risk in line with the Treasury Management policy.

Appendix 4g

Plan Actual VarianceRevised

Plan Outturn VarianceAug-12 Aug-12 Aug-12 Aug-12 Mar-13£'000 £'000 £'000 £'000 £'000 £'000

Capital Funding 2012/13 0 0 0 4,295 4,295 0

Capital ProgrammeBacklog Maintenance 164 74 90 370 370 (0)Medical Equipment 320 38 282 788 788 0Radiology Equipment 425 544 (119) 850 850 (0)Health & Safety 167 11 156 266 266 (0)IT Replacement 13 77 (64) 562 242 320Enhancing the Environment 10 23 (13) 91 91 0Development Funding 129 10 120 121 121 0Estates Strategy - Other 183 130 52 397 397 (0)Technical Reserve 0 0 0 245 245 0

0Women's Hospital - Estates Strategy 100 68 32 324 324 (0)

0Women's Hospital - Donated 40 36 4 180 180Donated Assets In Year 10 0 10 100 100 0

0 0Capital Program for 2012/13 1,561 1,012 549 4,295 3,975 320-Surplus/Deficit in year (0) (320) 320

FINANCE REPORT FOR AUGUST 2012CAPITAL EXPENDITURE

Year to Date Analysis Annual Forecast Key Issues: Backlog Maintenance The major projects planned for 2012/13 include Power Supply upgrade works, Electrical switchroom B cabling and Theatre ventilation plant works. Medical Equipment Replacement programme include an Laparoscopy stack, a Flexilog system, Accident & Emergency patient trolleys and Scopes. Radiology Equipment The CT scanner has been installed and is fully operational. A Digital Mammography unit is planned to be purchased this year. Information Technology The procurement process has recently been halted due to the unsuitability of the original process. The Trust is exploring the possibility of entering into a consortium to procure the necessary IT solutions which may include access to external funding. This will have the result of delaying the project but may also reduce the demand on Trust capital funding. At the moment the financial impact of the potential slippage is unknown and under investigation. Women's Hospital Works on the main entrance and birthing pool are complete. The ground floor clinics works have started and due for completion by February 2013m

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_____________________________________________________________________________ Report to: Board of Directors Report from: Director of Planning & Performance Subject: Integrated Performance Report Date: 10 October 2012 _____________________________________________________________________________

1. Introduction

1.1 This report sets out an overview of the performance of the Trust during the month of August 2012. It provides a summary of performance in key areas, and highlights the main risks and issues.

1.2 This report is structured as follows:

• Performance overview and key points from the corporate dashboard • Separate sections setting out more detail on performance in the four key

areas of: quality and patient experience; service delivery; human resources; estates and facilities.

2. Performance Overview

2.1 This section highlights the key points within the performance report for the Board’s attention:

• The rolling 12-month Hospital Standardised Mortality Ratio (HSMR) had fallen to 88.5, but increased to 95.8 in June.

• There was one post 72 hour C difficile case in August, and no MRSA cases.

• The two week symptomatic breast cancer and 62 day consultant upgrade targets were narrowly missed in August.

• Performance against the aim to reduce falls by 10% year on year is behind plan.

• Performance against the target for high risk TIA treatment was only 33.3% in August.

• Slot availability through the Choose and Book system for outpatient appointments was at 7.9% for August – the lowest yet, but still above the 4% target.

• One admitted and one non-admitted speciality did not achieve the 18 week waiting time target, which is in breach of our contract.

• Financial performance was £23,000 above plan.

3. Corporate Dashboard (Annex 1)

3.1 The main tool by which the Board receives assurance on the Trust’s performance is the Trust’s dashboard. This contains the key targets which the Trust is required to meet by the Department of Health or its commissioners.

3.2 This section highlights key risks or issues within the corporate dashboard:

APPENDIX 5 BOARD OF DIRECTORS

10 OCTOBER 2012

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Personal, high quality and safe care

• Objective: Reduce HSMR year on year by 2.5%: Dr Foster carried out the annual rebasing of their HSMR figures in September with the result that the rolling 12 month HSMR increased to 117.5. This had fallen back to 88.5 in May, but increased again to 95.8 in June, which is below the Trust’s expected rate of 100. The reduction is the result of a comprehensive programme of work led by the Dr.Foster Steering Group, chaired by the Medical Director.

• Objective: Maintain low infection rates: There were two cases of C. difficile (pre-hospital acquired) with one post 72hrs, but no MRSA cases in August.

• Objective: Reduce falls by 10%: Performance remains significantly above target.

• Objective: High quality stroke service: The 80% of patients spending 90% of their stay on a stroke ward was not achieved in August.

• Objective: High quality patient pathway: The readmission indicator remains red. There is a transformation project focussing on readmissions to determine if there are any clinical or data quality issues. This has commenced with an audit of a sample of readmissions conducted jointly with Somerset PCT and the Trust is awating the outcome report.

• Objective: High quality patient pathway: The Choose and Book availability indicator is amber, highlighting that just under 8% of patients who tried to book an appointment were unable to do so.

Strong, sustainable services, meeting local needs

• Objective: Waiting times: All three of the new waiting time indicators were achieved at Trust level in August; however, not all specialities achieved the targets. Breaches in oral surgery for admitted patients and in orthopaedics for non-admitted patients during August will mean the Trust incurs a fine and 50% of CQUIN income will be lost.

• Objective: A&E waits: Performance in August was 95.1%, narrowly achieving the target.

• Objective: Cancer waits: The 62 day consultant upgrade and 2 week symptomatic breast cancer wait targets were not achieved in August.

Our staff are our greatest strength

• Performance in August was consistent with previous months. Appraisal and mandatory training rates are static at around 72% and 79% respectively, although this is an improved position compared to the start of the year. A revised action plan is now being implemented following approval by the Board of Directors.

A valued partner in the local health service

• GP referrals were significantly above plan in August (3.7%), and 1.9% up in the year to date.

To manage our money wisely

• Objective: Achieve a financial risk rating of 3: 92% of CIP plans are in place, and work continues to identify the remainder through the Transformation Programme. Savings in the year to date are on plan. The income and expenditure position improved to £23,000 above plan at the end of August.

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Infrastructure to support delivery

• The Trust has formally joined a consortium with Gloucester and North Devon hospitals to procure an electronic health record.

4. Monitor Compliance Framework

4.1 There was only one risk in August surrounding Monitor’s Compliance Framework – the 2 week symptomatic breast cancer target - but performance is expected to be on track across the quarter.

5. Contract Performance Indicators

5.1 The best practice tariff indicators continue to be in the same percentage range as previous months.

5.2 Fines will be incurred for August for the non achievement of the referral to treatment standards and the 2 week asymptomatic breast cancer standard. CQUIN income for the month will also be capped at 50% for non-achievement of the RTT standards in every speciality.

6. Clinical Quality and Patient Safety (Annex 2)

Key Points

• There were two pre-hospital acquired C difficile cases with one post 72hrs case, but no MRSA cases in August.

• The hospital’s Standardised Mortality Ratio (HSMR) continues to fall and has been below 100 for 12 months, although it increased from 88.5 to 95.8 in June

• Performance against the internal target to reduce falls was behind plan. Clinical Quality

6.1 There were no MRSA bloodstream infections, either pre-hospital or post admission and as of the 17th September it was 258 days since the last Hospital acquired MRSA bloodstream infection.

6.2 There were two pre-hospital C. difficile cases and one post 72hrs case in August.

6.3 The infection prevention and control key performance indicators, which provide more detail, are attached at annex 2a.

6.4 The Hospital Standardised Mortality Ratio (HSMR) for the most recent rolling 12 months was 95.8, and the in-month figure for May was 67.9. The HSMR has been below 100 for 11 successive months.

6.5 The new Department of Health Summary Hospital-level Mortality Indicator (SHMI) is 105.63 (October 2010- September 2011), which is within expected limits for a trust this size.

6.6 The chart below shows the trend in the Trust’s HSMR over the last year.

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6.7 The target to ensure that 90% of patients are assessed for VTE risk and are recorded as such on PAS was achieved in July.

6.8 It should be noted that due to the lag in reporting of incidents, the data for incident reports is not always available at the time of writing the report. However, with the new web-based reporting system this has improved and therefore the most recent performance against the key patient safety targets for the year to the end of August is summarised below.

August data YTD data Full year target

Variance (%)

Patient safety incidents reported 216 1179

2668 (5% increase on 11/12 data)

On target

Patient Falls 77 429 770 Off target Rate per 1,000 bed days 8.86 9.91 7.5 Off target

Patients with dementia falling 15 157 None agreed N/A

Percentage falling more than once 19% 25% 25% On target

Hospital acquired pressure ulcers (grade 2 and above)

13 67 171 Off target

Rate per 1,000 bed days 1.5 1.78 1.5 On target

Patients with dementia with hospital acquired pressure ulcer

0 7 None agreed N/A

Root Cause Analysis investigations 9 39 74 (5%

reduction) Off target

VTE Risk assessment 91.1% 91% 90% On target

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(July data)

6.9 Nine new root cause analysis reviews were commissioned in August; two patients fell and sustained fractures, three patients developed grade 3 pressure ulcers, there was one failure to treat a patient with short term memory loss, one significant haematoma at the site of a cannula, one patient had the incorrect lens inserted during surgery which has been classified as a Never Event and there was a treatment delay for a lady with diabetic ketoacidosis.

6.10 A total of 16 remain open and under investigation, and the themes identified in these open reviews are as follows:

• 4 falls resulting in a fracture • 5 concerns about clinical treatment • 5 grade 3 pressure sore • 1 medication error • 1 unexplained broken toe • massive obstetric haemorrhage and unplanned hysterectomy

6.11 A number of actions have been taken as a result of completed investigations,

including:

• Purchase and introduction of additional 10 Falls Alarms • Request for a change to the pathology reporting system to ensure a

second patient identifier is available on all screens • Introduction of formal consent process for procedures in Outpatients • Development of checklist for surgical procedures in Outpatients

6.12 There were no new Patient Safety Alerts issued during August. The Trust has two that

remain open.

6.13 The Trust uses an early warning tool known as Swiss Cheese to detect early signs of potential patient safety issues within clinical areas. This tool has been adopted and validated across the South West region and is now known as QuESTT.

6.14 The indicators describe the most important conditions necessary for a well-functioning team. The tool prompts staff to make a judgement against the key indicators and then it automatically weights and scores them according to their importance. An overall score of more than 12 indicates that remedial action needs to be taken to prevent a later impact on the quality of care provided within that area. Each clinical area’s assessment is reviewed by peers from another area to ensure consistency and a robust approach.

6.15 In August there was one area rated amber (scores between 9 and 11): All 26 areas have submitted their reports to date.

6.16 The Trust has continued with its systematic roll-out of the Patient Safety Thermometer in line with the new national CQUIN measure. By August a total of nine wards were included in the roll-out and the “harm-free care” results are attached as Annex A. This system expects all in-patients to be assessed for four specific “harms”; pressure ulcer, fall, catheter associated urinary tract infection (UTI) and Venous Thrombo-embolism (VTE). Data is captured from reviewing the patients’ records and physical assessment of the patients by clinical staff on the wards. This information is then transferred onto a spread-sheet which produces a percentage of harm free care.

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All data collection must be carried out on the same day and the clinical assessments are carried out by Associate Directors of Nursing, Matrons and Ward Managers, with data input being completed by the Clinical Governance team. The results are fed back to the staff at the end of the morning and eventually run charts will be provided for display on the productive ward boards. The roll-out plan is on track to ensure that by the end of the year every appropriate clinical area in the Trust is submitting data. The results are now incorporated into a spreadsheet and attached as Annex 2b.

Patient Experience

6.17 Patient complaints and concerns raised via the Patient Advice and Liaison Service continue to provide the Trust with valuable insight into the patient experience. This should be considered in conjunction with the data available from patient surveys, including national, Your Care and EXIT surveys. The following chart shows the trend data in respect of complaints, PALs enquiries and compliments.

6.18 The overview information in respect of in-house patient satisfaction surveys is outlined in the table below:

August data

YTD data Full year target Variance

Complaints received 12 103 215 (5% reduction) On target Rate per 1,000 bed days 1.38 2.33 2 Off target Response within agreed timescale 86% 86% 95% Off target

PALs enquiries received 56 269 554 (5% reduction) On target Rate per 1,000 bed days 6.44 6.21 5 Off target Complaints re-opened 2 6 21 (10% reduction) On target Conciliation meetings 1 2 25 N/A

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held Ombudsman referrals 0 0 2 N/A Compliments received 15 529 1144 (5% increase) On target Litigation claims 5 102 (open) N/A N/A

7. Service Delivery

Key Points

• All of the 18 week RTT standards were achieved at Trustwide level and in all specialities with the exception of admitted oral surgery (which was part of the Trust’s recovery plan) and non-admitted orthopaedics. The position for the Trust’s major commissioner, NHS Somerset, is reflective of the overall position.

• Underachievement in these specialities means that the Trust remains subject to contractual fines from Commissioners and a cap on the CQUIN monies available. This represents a financial risk to the Trust.

• The Trust under-achieved on two of the Cancer standards during August – the two week wait for asymptomatic breast patients and the 62 day target for consultant upgrades. Underachievement resulted from small numbers and patient choice; however, the Trust remains on-course to deliver the Cancer standards across the quarter.

• The Trust continued to achieve the Emergency Department 4-hour wait. • The significant improvement in slot availability performance has been

sustained and a further improvement has been made during August. • Performance against the 90% stay target remains variable and an action

plan to address this, together with the other Sentinal Stroke indicators, is being implemented.

Referral to Treatment (RTT) Waiting Time Targets

7.1 The Monitor compliance framework for 2012/13 includes the following RTT standards:

• A maximum 18 weeks from referral to treatment in aggregate for patients on admitted pathways (target 90%)

• A maximum 18 weeks from referral to treatment in aggregate for patients on non-admitted pathways (target 95%)

• A maximum 18 weeks from referral to treatment in aggregate for patients on incomplete pathways (target 92%)

7.2 In addition, the national NHS contract stipulates that these targets should now be

delivered each month, in all specialities, for each Commissioner. For Quarter 1 the Trust agreed with NHS Somerset a plan and associated trajectory to deliver in all admitted specialties apart from orthopaedics and oral maxillofacial surgery. Delivery in these two specialities was to be achieved from July onwards.

7.3 The contract also contains a new standard that, from 1 April, no more than 1% of patients should wait longer than 6 weeks for a diagnostic test.

7.4 Performance against these standards for the financial year to August 2012 can be summarised as follows:

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Target Q1 Jul-12 Aug-12 Q2 To Date

MONITOR/DoH Admitted RTT Performance 90% 91.7% 94.2% 94.0% 94.1%

DoH Admitted specialties not achieving 18 weeks

2 for Q1 (T&O, OMF) 0 from Q2

1 (OMF)

1 (OMF)

MONITOR/DoH Non-admitted RTT Performance 95% 97.0% 96.4% 97.5% 96.9%

DoH Non-admitted specialties not achieving 18 weeks 0

2 (OMF, Neuro)

1 (Ortho)

MONITOR/DoH Patients on incomplete pathway waiting 18 weeks or less

92% 95.5% 93.6% 95.7% 94.6%

DoH Proportion of patients waiting longer than six weeks for a diagnostic test

1% 0.3% 0.1% 0.1% 0.2%

7.5 At a Trust-wide level, during August 2012, both the admitted and non-admitted

standards continued to be achieved at aggregate and in all specialties with the exception of admitted oral maxillofacial surgery and non-admitted orthopaedics.

7.6 The underachievement in admitted oral maxillofacial surgery was planned as part of the recovery plan in this speciality and dates for treatment have now been offered to all the remaining long waiting patients during September and October. The non-admitted standard in this specialty was achieved during August for the first time since October 2011, demonstating that progress against the recovery plan is being made.

7.7 The Trust has been working with the service provider (Taunton and Somerset NHS Foundation Trust) to deliver the necessary capacity in this service. As a result, appointments have been made into the vacant posts, putting the service in a much stronger position moving forward.

7.8 The underachievement in orthopaedics was a result of delays in the diagnostic pathway. This is under investigation.

7.9 The position for the Trust’s major commissioner, NHS Somerset, is reflective of the overall Trustwide position. The impact of the underachievement in these specialties is that the Trust will continue to be subject to contractual fines and a cap on the funds available via CQUIN.

Choose and Book - Slot Availability

7.10 The Trust’s slot availability performance in August was 7.9%. This represents a significant and continued improvement in performance from, the end of May 2012

The graph below shows the Trust’s historic performance against this standard which contains a 4% target within the Trust’s contract. The Trust is now nearing delivery of this Contractual

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standard:

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

%ag

e of

Slo

t Una

vaila

bilit

y Ep

isod

es to

Suc

cess

ful D

irect

Boo

king

s

Somerset and West Dorset Choose and BookSlot Unavailability Performance

Yeovil District Hospital NHS Foundation Trust -UBRNsmodified after 3 working days.Target trajectory to meet 4%

From 24/10/10 Percentage figures based only on the UBRNs modified by the RMC, not those booked by the provider.

7.11 As a result of the recommendations resulting from a review by the national Choose and Book implementation team in May 2012, a meeting took place with the NHS Somerset, NHS Dorset and the Somerset Referral Management Centre in early September. This resulted in agreement to a series of additional actions which are now being progressed across the health community. One key action is a proposal to change the referral process for orthopaedics, to increase utilisation of the Choose and Book system in this speciality. This proposal is under consideration by the Somerset Clinical Commissioning Group.

7.12 The Trust is also rolling out the ‘advice and guidance’ facility in neurology and urology. In addition, in urology are piloting a process that supports Consultants to review referrals on-line. This has proved very successful and it is planned to extend this across the Surgical Division.

7.13 Discussion with NHS Somerset and NHS Dorset has identified a number of different methodologies for reporting of slot availability performance at local and national level. A review is underway to agree the definitive reporting methodology from April 2013.

Cancer Waiting Times

7.14 Data for the cancer targets are sourced from the Somerset Cancer Register and continue to be fully validated one month in arrears. August data is, therefore, draft at this time and will be fully confirmed in mid-October.

7.15 Areas of note are as follows:

• The Trust under-achieved on two of the Cancer standards during August 2012 – the two week wait for asymptomatic breast patients and the 62 day target for consultant upgrades.

• Compliance against the breast standard was 90.9% against a target of 93%. This was a result of an unusually low number of referrals during August and two patients choosing to wait for treatment outside the 14 day standard. At the

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time of writing September performance was above the standard which would mean that the Monitor target for the quarter would be achieved.

• There was one breach of the 62 day consultant upgrade standard during the month against 9 referrals. This resulted in compliance of 88.9% against the 90% target. This breach has been investigated and was a result of an extended diagnostic phase as a result of multiple patient cancellations. Despite this breach the Trust remains on track to achieve this standard across the quarter.

• From a Monitor perspective a risk remains relating to the 62 day national screening target as a result of 1 breach during July. There have been no further treatments in August and at the time of writing their were no treatments on the system for September. This would put the Trust below the Monitor de-minimus level of 5 treatments across the quarter but there remains a risk if further treatments are identified before the end of September.

• The Trust underwent an external Peer Revew of the chemotherapy and acute oncology services on 18th and 19th September 2012. The formal report is awaited but verbal feedback provided by the review team was extremely positive, noting the quality of the service provide to patients, despite the ongoing issues with oncology cover and the dedication and commitment of staff.

• Cancer performance for the year to August 2012 can be summarised as follows:

Breaches Referrals Compliance Breaches Referrals Compliance Breaches Referrals Compliance Breaches Referrals Compliance

2WW for all urgent cancers 88 1300 93.2% 25 415 94.0% 30 446 93.3% 55 861 93.6% 93%

2WW for Asymptomatic Breast Patients 7 129 94.6% 2 36 94.4% 2 22 90.9% 4 58 93.1% 93%

31 DAY TARGET 1st treatment 1 187 99.5% 1 61 98.4% 1 63 98.4% 2 124 98.4% 96%

31 DAY TARGET for subsequent treatments - DRUGS 0 44 100.0% 0 18 100.0% 0 8 100.0% 0 26 100.0% 98%

31 DAY TARGET for subsequent treatments - SURGERY 0 49 100.0% 1 19 94.7% 0 15 100.0% 1 34 97.1% 94%

62DAY TARGET for 2WW referrals 17.5 126 86.1% 4.5 39 88.5% 4 45 91.1% 8.5 84 89.9% 85%

62DAY TARGET for national screening 1 10.5 90.5% 1 4.5 77.8% 0 0 N/A 1 4.5 77.8% 90%

62DAY TARGET for consultant upgrades 0 29.5 100.0% 0 5 100.0% 1 9 88.9% 1 14 92.9% 90%

TargetAug-12 Q2 To Date

Verified Open Exeter Draft

Jul-12Q1 Total

Emergency Pathways

7.16 For 2012/13 the effectiveness of the Trust’s emergency pathway will continue to be monitored against the four hour standard. This is defined as a maximum waiting time of 4 hours in the Trust’s Emergency Department, measured from the time of arrival to the time that the patient is either admitted, transferred or discharged from the department.

7.17 In addition, the Trust’s contract includes a target to reduce the number of patients arriving by ambulance that wait over 30 minutes to be handed over to the Emergency Department team. The Trust is subject to a contractual penalty for any over 30 minute handover delays.

7.18 Performance against these two standards is summarised below:

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Target Standard Q1 Total Jul-12 Aug-12 Q2 to

Date

MONITOR/ DoH

Percentage of patients spending four hours or less in the Emergency Department

95.00% 95.79% 95.61% 95.10% 95.36%

DoH % of Ambulance Handovers completed within 30 minutes

98% 93.9% 94.8% 94.2% 94.5%

7.19 The 4-hour standard continued to be achieved during August with performance of 95.1%.

7.20 The Trust has set an internal standard of a minimum of 98% of ambulance handovers being complete within 30 minutes. Performance against this standard is also reported in the table above.

7.21 The Trust continues with the implementation of its PRIDE programme which aims to transform its emergency care pathways. This programme consists of the following five work streams:

• Ambulatory emergency care • Improving the discharge process • Surgical emergency admissions pathway • Emergency Admissions Unit systems and practices • Emergency Department patient flow and workforce redesign

7.22 In addition to the work of the PRIDE programme a number of other changes which aim

to improve performance in the short term were instigated during August. The key changes put in place during the last month or planned for the near future are as follows:

• New consultant appointments in Acute medicine and Acute surgery are underway

• The Trust is advertising for a full time Clinical Director for Emergency Medicine and Urgent care to provide consistent leadership to the Emergency Department (ED) and Emergency Admissions Unit (EAU)

• A new operational manager for EAU is in post • The ED workforce plan is now in place and the Emergency Nurse practitioner

rota continues to be extended and strengthened • Ambulatory emergency care is planned to commence on EAU for cellulitus

and pulmonary embolism from 1 October 2012. This has been facilitated by the conversion of two side rooms.

• The ED escalation plan is under reviewand a set of internal professional standards has been agreed.

• A discharge awareness week is planned for the week commencing 24th September, this launches the Trust’s ‘Home for Lunch’ initiaitive

• A new system for actively reviewing all long stay patients has been instigated. This is being led by the Matrons and will feed a regular review process being established with Adult Social Care and the provider of community services.

7.23 Weekly performance against the 4-hour standard across the year can be summarised

as follows:

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85.0%

86.0%

87.0%

88.0%

89.0%

90.0%

91.0%

92.0%

93.0%

94.0%

95.0%

96.0%

97.0%

98.0%

99.0%

100.0%

YEOVIL DISTRICT HOSPITAL NHS FOUNDATION TRUSTWeekly Percentage of Patients Attending A&E Admitted, Transferred or Discharged within 4 Hours

1st April - 31st March 2011/12 and 2012/13

2011/12 Weekly 2012/13 Weekly Target

Stroke Care

1. Patients Spending 90% of their time on the Stroke Unit – (Target 80%)

7.24 A key indicator of the quality of stroke care delivered by the Trust is the percentage of patients spending 90% or more of their stay on the Stroke Unit.

7.25 Interim August performance suggests that the standard was achieved performance of 82.4%. This will be finalised when all patients admitted in the month have been discharged.

7.26 The Trust has agreed a series of service improvements which aim to sustainably deliver the 90% standard, together with the other key sentinel audit indicators. As part of this beds have now been ring-fenced on the acute Stroke Unit on Ward 9A, which from 14 September has reduced from 30 to 24 beds to enable the bed-to-nursing-and-therapy-staff-ratio to be increased. This change has been supported by new admissions criteria for Ward 9A that aim to facilitate the early transfer of all suspected Stroke patients to the ward.

7.27 Performance for the year to date can be summarised as follows:

90% Stay on Stroke Unit (Admissions) Apr-12 May-12 Jun-12 Jul-12 Aug-12

Yes 11 23 15 13 14 No 7 13 3 8 3 Total 18 36 18 21 17 % 61.1% 63.9% 83.3% 61.9% 82.4%

Note: There is a variation between this data and that presented in the table below. This results from a difference in the methodology of data capture. The data presented above represents stroke patients admitted in the reporting month, while that below represents stroke patients discharged in the reporting month

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2. TIA Clinic – High risk Transient Ischaemic Attacks (TIAs) receive treatment with 24 hours of referral (Target 60%)

7.28 This standard was underachieved during August 2012 with 33.3% of patients being seen and treated within 24 hours. There are two themes that resulted in this underachievement – delays in referrals from the Emergency Department and the lack of a weekend service.

High Risk TIAs Seen and Treated within 24hrs Apr-12 May-12 Jun-12 Jul-12 Aug-12

Yes 4 5 1 5 2 No 2 5 2 4 Total 6 10 1 7 6

% 66.7% 50.0% 100.0% 71.4% 33.3%

7.29 The Trust has agreed the principle of providing a seven-day high risk TIA service in

partnership with Taunton and Somerset NHS Foundation Trust. This is reliant on the successful recruitment of 3 additional Stroke Physicians across the two Trusts, for which recruitment is underway. The pathway is under development with the aim of extending the service to cover 7-days from November 2012.

3. Action plan to improve performance against the sentinel audit indicators for Stroke

7.30 Improving performance against the range of sentinel audit indicators that reflect the quality of the Trust’s Stroke service is a strategic priority for the Trust. The Trust’s performance is currently in line with other Trusts in the Region.

7.31 A action plan has been developed by the Stroke team which was shared with the Board of Directors at its August meeting. Performance against the key indicators for the period to the end of August is presented below. The Board will note that while there was a marked improvement during July, August performance was disappointing. The key issue relates to the clinical identification and diagnosis of stroke patients. The changes to the bed configuaration and admissions criteria for Ward 9A aims to address this. These changes were made during September.

Outcome Measure Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12>90% care in a Stroke Unit (%) 96% 81% 88% 67% 52% 84% 88% 64% 54% 73% 85% 68%Network Average 83% 80% 83% 80% 77% 79% 78% 72% 72% 71% 71%Network Aim 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80%

% patients admitted directly to an acute stroke unit within 4 hours of hospital arrival 46% 57% 84% 71% 40% 68% 75% 44% 29% 59% 75% 52%Network Average 51% 49% 47% 60% 47% 42% 43% 47% 42% 48% 48%Network Aim 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%

Patients scanned within one hour of hospital arrival (%) 17% 29% 24% 19% 12% 16% 13% 24% 14% 14% 15% 17%Network Average 22% 28% 23% 24% 28% 28% 26% 28% 31% 31% 28%Network Aim 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%

% high risk TIA patients investigated and treated within 24hours of first contact with a health professional 83% 89% 78% 60% 50% 71% 89% 67% 50% 100% 71% 33%Network Average 65% 63% 69% 58% 63% 67% 72% 70% 72% 55% 65%Network Aim 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60%

% of ischaemic stroke patients thrombolysed 8% 10% 12% 29% 16% 21% 13% 16% 4% 5% 25% 15%Network Average 12% 13% 7% 10% 14% 11% 6% 11% 9% 12% 13%Network Aim 10% 10% 10% 10% 10% 10% 10% 10% 10% 10% 10% 10%

On Aspirin <48 hours (%) 96% 91% 86% 91% 78% 90% 94% 100% 69% 86% 82% 86%Swallow Screening < 24 hours (%) 83% 91% 96% 91% 93% 100% 89% 95% 38% 73% 33% 59%CT < 24 hours (%) 83% 81% 93% 78% 86% 90% 89% 95% 81% 91% 85% 87%Physio < 72 hours (%) 91% 95% 93% 96% 100% 100% 100% 100% 84% 91% 83% 100%OT < 4 days (%) 91% 100% 96% 96% 96% 100% 100% 100% 88% 95% 83% 100%Weight recorded (%) 70% 95% 79% 96% 78% 86% 78% 95% 94% 86% 83% 95%Mood assessed (%) 96% 100% 100% 96% 89% 95% 94% 100% 81% 82% 100% 100%Rehab goals agreed by the team (%) 91% 100% 100% 96% 89% 86% 94% 100% 78% 68% 89% 91%Rehab goals agreed by the team < 5 days (%) 91% 95% 93% 83% 64% 57% 94% 95% 59% 59% 61% 70%Swallow assessment < 72 hours (%) 62% 89% 91% 92% 67% 89% 100% 49% 73% 33% 59%Patient initially admitted to a stroke unit (%) 52% 57% 79% 74% 61% 67% 79% 71% 72% 77% 80% 70%Diagnosis discussed with patient (%) 81% 82% 96% 100% 100% 100% 100% 100% 100% 96% 100%

Patients receiving 12 Sentinel key indicators* (%) 29% 43% 30% 21% 24% 39% 52% 28% 32% 18% 32%Network Average 36% 37% 41% 41% 31% 29% 33% 32% 31% 34% 29%Network Aim 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80%

Reporting Month

14

8. Human Resources (Annex 3)

Key points

• seven out of eight HR indicators were either green or amber this month (see appendix 3a).

• the pay budget overspend has now turned into a £74k underspend • sickness absence increased marginally to 3.4% • mandatory training and appraisal remained static at 72% and 79%

respectively.

Staff in post against vacancies

8.1 The vacancy position increased from 37 to 60 but is still green. There are particular issues in nursing for which Irish recruitment is underway. We have around 40 staff nurses coming in between the start of September and end of October this year.

Pay Budget Spend

8.2 The pay budget was underspent in the fifth month of this financial year by £74k. Theatre pay spend will increase in future months as agency spend kicks in, to cover sickness and leave. This is the first time agency staff have been used in this area for 18 months.

8.3 The clinical excellence awards for medical staff were launched in May following the national decision that they continue in 2012, and will be determined in October.

8.4 Clinical on-call arrangements for staff within the Agenda for Change pay bands are due for review, but due to staffing shortages in the HR team this project has been delayed. This project is now commencing as a high priority.

Sickness Absence Management

8.5 The sickness absence percentage end-of-year position was 3.6%, which is 0.4% up on the previous twelve months. In July the level was 3.4%.

Mandatory Training

8.6 Mandatory training was static at 72%. An action plan has now been agreed by the Board, and implementation is underway addressing a wide range of issues. This should significantly improve performance in due course.

8.7 The Health and Safety reporting position has now improved dramatically to 94%, due to a large number of reports being received recently.

Appraisals

8.8 The appraisals rate was static at 79%. An action plan has now been approved by the Trust Board, and implementation is underway. This should significantly improve performance in due course.

15

Employee Relations

8.9 Local employee relations case management has fallen to red, but this is on a very small sample size.

8.10 The nursery tender has been fully resolved and the TUPE transfer will take place on 1st October.

Workforce planning

8.11 Workforce planning for staff aged 55 and over is green.

8.12 Job planning for consultant medical staff is still underway. A steering group of the Medical Director, Divisional Directors and Director of Human Resources has been set up to drive these projects over the next year and beyond. Electronic records are being examined and improved, and this will help the Medical Director manage job planning far more easily

8.13 Professional heads, the academy lead, the Director of Nursing and the Director of Human Resources were asked for their workforce projections for the high level workforce plan the Trust provides to the SHA annually. This is to give a forward view of workforce mix for the next 5 years and help inform education and training commissioning plans.

8.14 The Academy lead and HR Managers intend to use this workforce baseline further, with the workforce toolkit, to help the Divisional teams refine their workforce assumptions to ensure these are reflected in their business plans and take account of any transformation work which has workforce implications.

9. Estates and Facilities (Annex 4)

Key points

• An external review is in progress via the Birch Foundation with two main work streams (catering and maintenance) to identify opportunities for service improvement.

Capital Projects

9.1 Women’s Hospital:

Clinic Rooms (Ground Floor): The project is on programme and within budget with no quality issues or concerns.

Special Care Baby Unit (SCBU): A meeting has been arranged for Friday 21 September to review the available options with the wider project team although further discussions are required to review all options in the context of the Women’s Hospital reconfiguration.

Offices (Ground Floor): Budget costs and the outline specification are being drawn up to include additional ultrasound room and relocation of first trimester screening. The works are planned for 2013-14.

9.2 Electrical Infrastructure: Thr upgrade works to the Women’s Hospital switchboard are planned for completion in September and October 2012 due to additional asbestos removal. The replacement of the switch-room ’B’ main electrical panel is programmed for April 2013.

16

9.3 Fire Alarm System Upgrade: Asbestos removal in level two is progressing. Further asbestos debris has been identified in service ducts at other locations of the hospital which will have an impact on the overall programme.

9.4 Theatre 2 Ventilation Plant Replacement: Work has been planned for the theatre shut-down period during October 2012.

9.5 Convamore Offices: Phase one works are complete and partially occupied with phase two planned for completion in November 2012.

Cleanliness

9.6 Good cleanliness scores have been maintained for all areas. A review of cleaning rotas is in hand as part of CIP. The consultation process for the restructuring of the housekeeping and domestic supervisors has started. The proposed structure will improve supervision of staff, and improve performance, whilst delivering savings.

Medical Electronics

9.7 The team is analysing scheduled services as part of an on-going process to look at smoothing out peaks in completion figures. There was a high level of leave for the period of August.

Maintenance

9.8 The maintenance team continues to work with the Birch Foundation to improve our data capture and process efficiency. The service improvement project is part-way through a 20 week programme to transform the service provided to the Trust. The aim of the project is to provide a more responsive and efficient customer service by changing the way resources are allocated and by developing better methods of communication within the team and with the users.

Minor Works

9.9 All orders were raised within the agreed timescale, with no feedback forms returned to EFM during August. A business case has been produced for a proposed in-house Minor Works Team which has the potential to reduce costs and improve service delivery.

Portering

10.10 The move to the new integrated portering team trial has been completed, and it has been agreed that this model will continue permanently. The rotas will be revised again in October to match staff resource to workload. Further improvements will be achieved by the implementation of a helpdesk at nights to streamline the service.

Residences

9.11 Cheverton Tower and Cheverton House have now closed. Occupancy levels are good in Convamore due to reduced accommodation availability. The occupancy continues to improve for the new accommodation at St Georges Avenue, and further open days were arranged in September to fill the remaining rooms. The feedback from tenants is very positive.

Switchboard

9.12 Switchboard has maintained performance.

17

Catering

9.13 The Birch Foundation continuous improvement project is progressing well. Patient meal time observations are being carried out by a representative from the Patients and Public Involvement group. The team are concentrating on quality improvements, service delivery and identifying food waste. The next stage will be looking at the future state of patients’ mealtimes in conjunction with the nursing staff and a patient representative across six workstreams: breakfast, lunch, supper, menus, retail and data. The first four workstreams are involving nursing and housekeeping staff to help to redesign the processes to reduce waste and provide a better service to our patients.

Financial Control

9.14 Month 5 showed an underspend of 3.48%.

Statutory Compliance

9.15 There was no change from August 2012.

10. Recommendation

10.1 The Board of Directors is asked to DISCUSS the performance risks.

18

List of Annexes

1. Corporate Dashboard – August 2012

2. Quality:

a. Infection prevention and control: key performance indicators

b. Safety Thermometer consolidated results

3. Human Resources:

a. HR Performance Dashboard

4: Estates and Facilities:

a. EFM Performance dashboard August 2012

PERFORMANCE DASHBOARD 2012/2013

STRATEGIC OBJECTIVE MEASURE LEAD DIRECTOR TARGET THRESHOLDS 1112 YTD Apr-12 May-12 Jun-12 Jul-12 Aug-12 1213 YTD

Personal, high quality and safe care

To reduce HSMR year on year by 2.5% Rolling 12 month HSMR Medical Director 90%<= 100 - Green>100 but lower confidence limit below 100 - AmberLower confidence limit above 100 - Red

97.2 92.9 88.5 95.8 Data only available up to June 2012

Percentage of patients who need it receiving appropriate VTE prophylaxis

Director of Nursing & Clinical Governance 95%

>=95% = Green85 - <95% = Amber<85% = Red

N/A 84% 98% 100% 99% 100% 96%

Percentage of patients with completed VTE risk assessment - PAS data submitted to Unify

Director of Nursing & Clinical Governance 90% >=90% = Green

<90% = Red 76.5% 90.0% 91.4% 91.9% 91.1% 91.1% Updated a month in lieu

Number of 48 hour + MRSA Bacteraemias cases (Rate per 1000 beddays)

Director of Nursing & Clinical Governance 1 per year 1 = Green

>1 = Red 2 0 0 0 0 0 0

Number of 72 hour + Clostridium Difficile cases Director of Nursing & Clinical Governance 28 per year

0 - <=2 per month = Green3 = Amber>=4 per month = Red

23 0 1 1 0 1 3

Percentage handwashing compliance Director of Nursing & Clinical Governance 95%

>=95% = Green85 - <95% = Amber<85% = Red

90.5% 90% 89% 90% 94% 89% 90%

Continue to reduce falls by 10% on 11/12 outturn

Number of falls(Rate per 1000 bed days)

Director of Nursing & Clinical Governance

737 (10% decrease on previous year)

<=64 = Green>64 = Red 780(8.4) 85 (9.7) 97 (11.0) 76 (9.39) 92 (10.3) 77 (8.9) 427(9.9)

To ensure that stroke patients receive quick, high quality interventions and appropriate care

Percentage of stroke patients spending 90% of time on stroke ward

Director of Nursing & Clinical Governance 80%

>=80% = Green60 - <80% = Amber<60% = Red

74.7% 61.1% 63.9% 83.3% 72.2% 77.8% 70.3%

Percentage of high risk TIAs treated within 24 hours Director of Nursing & Clinical Governance 60%

>=60% = Green50 - <60% = Amber<50% = Red

74.4% 66.7% 50.0% 100.0% 71.4% 33.3% 56.7%

30day readmission rate -Total readmissions Director of Operations <10% <10% = Green>=10% = Red 14.0% 13.5% 13.1% 13.9% 15.6% 14.6% 14.2%

Delayed transfers of care Director of Nursing <=3.5% <3.5% = Green3.5 - 5.0% = Amber>5.0% = Red

1.4% 1.4% 1.7% 4.5% 3.7% 2.5% 2.8%

Diagnostic waiting times of 6 weeks Director of Operations 99% >=99% = Green<99% = Red 99.9% 99.3% 99.9% 99.9% 99.9% 99.9% 99.8%

Cancelled Ops - Breaches of <28day readmission guarantee Director of Operations 5%

<=5% = Green5 - 15% = Amber>15% = Red

0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Cancelled Ops - Breaches <=5 calendar day offer of new date Director of Operations 0% <=0% = Green

>0% = Red N/A 42.9% 0.0% 0.0% 0.0% 0.0% 8.0%

CAB SLOT Unavailability - Number of slots unavailable to book via Choose and Book Director of Operations 4%

<=4% = Green<4 - 12% = Amber>12% = Red

17.0% 22.4% 24.3% 8.0% 12.1% 7.9% 14.4%

Achieve SW level 2 standards Director of Nursing & Clinical Governance On plan

On plan = GreenWithin one month = AmberNot within plan = Red

N/A Data not yet available

'Your Care' Patient Experience Question TBC Director of Nursing & Clinical Governance TBC TBC Data not yet confirmed

Percentage of patients rating their care as 'very good' or 'excellent' on the YOUR CARE questionnaire (ADULTS INPATIENT WARDS ONLY)

Director of Nursing & Clinical Governance

95%>=95% = Green85%-<95% = Amber<85% = Red

94% 94% 96% 92% 90% 93% 94%

Strong, sustainable services, meeting local needs

To achieve 18 weeks consistently in all specialties

18 week wait - Admitted Pathways -% achievement (Number of Specialties achieving target) Director of Operations 90% >=90% = Green

<90% = Red 22.1wks (92.1%)

91.9% (16/18)

91.2% (15/17)

92.2% (16/17)

94.2% (16/17)

94.0% (14/15)

92.6% (18/20)

18 week wait - Non-admitted Pathways -% achievement (Number of Specialties achieving target)

Director of Operations 95% >=95% = Green <95% = Red

17.4wks (96.0%)

97.5% (20/22)

96.8% (20/22)

96.7% (19/21)

96.4% (20/22)

97.5% (20/21)

96.9% (20/22)

18 week wait - Incomplete Pathways - % achievement (Number of Specialties achieving target) Director of Operations 92% >=92% = Green <92%

= Red 24.5wks (84.2%)

95.2% (18/22)

97.5% (19/22)

95.6% (18/21)

93.7% (16/22)

95.7% (20/22)

95.7% (19/22)

4 hour performance (Trust only) Director of Operations 95%>=95% = Green94%-<95% = Amber<94% = Red

95.9% 95.0% 96.5% 95.9% 95.6% 95.1% 95.6%

Ambulance Handover >30mins Breaches Director of Operations 98%>=98% = Green95-<98% = Amber <95 = Red

92.6% 96.0% 93.1% 94.8% 93.8% 94.0%

To ensure that cancer patients receive quick diagnosis and treatment

2 weeks from urgent suspect cancer GP referral to first outpatient appointment Director of Operations 93%

>=93% = Green88 - <93% = Amber<88% = Red

93.5% 93.1% 93.6% 93.1% 94.0% 93.3% 93.4%

2 weeks from Urgent GP referral to first outpatient appointment (Symptomatic Breast Patients) Director of Operations 93%

>=93% = Green88 - <93% = Amber<88% = Red

95.8% 93.8% 94.9% 95.1% 94.4% 90.9% 94.1%

31 days from decision to treat to start of 1st treatment extended to all cancers Director of Operations 96%

>=96% = Green91 - <96% = Amber<91% = Red

98.7% 100.0% 98.4% 100.0% 98.4% 98.4% 99.0%

31 days from decision to treat to start of treatment for subsequent DRUG treatment Director of Operations 98%

>=98% = Green93 - <98% = Amber<93% = Red

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

31 days from decision to treat to start of treatment for subsequent SURGICAL treatment Director of Operations 94%

>=94% = Green90 - <94% = Amber<90% = Red

98.2% 100.0% 100.0% 100.0% 94.7% 100.0% 98.8%

62 days from all referrals to treatment for all cancers Director of Operations 85%>=85% = Green80 - <85% = Amber<80% = Red

91.0% 78.7% 91.7% 87.4% 88.5% 91.1% 87.6%

62 days from Consultant Screening to treatment for all cancers Director of Operations 90%

>=90% = Green85 - <90% = Amber<85% = Red

87.9% 81.8% 100.0% 100.0% 77.8% N/A 86.7%

62 days from Consultant Upgrade to treatment for all cancers Director of Operations 90%

>=90% = Green85 - <90% = Amber<85% = Red

98.2% 100.0% 100.0% 100.0% 100.0% 88.9% 97.7%

To maintain our infection rates at the level of the best 25% of Trusts

To ensure that the risk of VTE is minimised

To provide a high quality pathway through the hospital for emergency and elective patients

To ensure that privacy and dignity for all patients improves, with an emphasis on the needs of patients with dementia

To ensure that patients are seen in a timely way in A&E

To ensure that patients are satisfied or very satisfied with their experience of the hospital

PERFORMANCE DASHBOARD 2012/2013

STRATEGIC OBJECTIVE MEASURE LEAD DIRECTOR TARGET THRESHOLDS 1112 YTD Apr-12 May-12 Jun-12 Jul-12 Aug-12 1213 YTD

Our staff are our greatest strength

To provide excellent support and development for our staff

Percentage of staff appraised within last 12 months (rolling year)

Director of Human Resources 80%

>80% = Green65 - 80% = Amber<65% = Red

73% 72% 72% 79% 79% 79% 79%

Percentage of staff attending mandatory training within last 12 months (rolling year)

Director of Human Resources 85%

>85% = Green70 - 85% = Amber<70% = Red

67% 68% 69% 72% 72% 72% 72%

To provide management development in those in leadership positions Number of Human Resources indicators achieved Director of Human

Resources7

>4 = Green3 - 4 = Amber<3 = Red

4 3 4 3 2 3 3

To develop a strategic workforce plan and succession planning process linked to business plans

Vacancy rate Director of Human Resources 5% (+/-)

< 5% Green5-9% Amber> 9% Red

3.8% 4.0% 3.6% 3.3% 2.2% 3.5% 3.5%

Total pay costs (Cumulative) Director of Human Resources £72.2M TBC £71.5M £6.1M £12.1M £18.0M £24.1M £30.2M £30.2M

Temporary staff cost (Cumulative) Director of Human Resources TBC TBC £1,967k £237k £454k £612k £796k £971k £971k

A valued partner in the local health service

To maintain overall market share GP Referrals Total numbers (% against plan) Director of Operations 0%0 - <5% from plan = Green5 - 10% away from plan = Amber>10% from plan = Red

28676 (-3.2%)

2285 (-2.3%)

2754 (17%)

2301 (-10.7%)

2523 (2.9%)

2295 (3.7%)

12158 (1.9%)

To increase market share in targetted S.Petherton GP practices GP Referrals for targetted Practices Director of Operations 5%

> 5% increase on 2011 = Green0 - 5% increase on 2011 = Amber<0% increase on 2011 = Red

0.3% 3.1% 4.6% 1.9% Data available a month in Lieu

To develop an effective Commercial Strategy Annual income earned from new sources Director of Finance £40.6K £41.4K £41.4K £44.4k £46.1k

Managing our money wisely

To increase the efficiency of our services by delivering a cost improvement programme of £4.6 million

% of CIP plans in place Director of Finance 100%0 - <5% from plan = Green5 - 10% away from plan = Amber>10% from plan = Red

100.0% 75% 91% 92% 92% 92% 92%

Achieve a financial risk rating of 3 CIP Total Savings(non-recurrent %)

Director of Finance 100%0 - 5% > plan = Green5 -10% away from plan = Amber10% <from plan = Red

100% (12%) 113% (21%) 105%

(11%)104% (16%)

105% (96%)

108% (103%)

108% (103%)

Financial risk rating Director of Finance 3> 3 = Green2.5 - 3 = Amber<2.5 = Red

3.2 2.6 3.3 3.8 3.3 3.1 3.1

Net Return after Financing Director of Finance 0.6%>=0.0% = Green0.5 - 0.0% = Amber<-0.5% = Red

0.0% 0.1% 0.2% 0.6% 0.7% 0.7%

Liquidity Ratio Director of Finance 23.1>20 = Green15-20 = Amber<15 = Red

22.4 22.6 21.7 23.1 24.7 24.0 24.0

PbR Income performance (£) YTD Director of Finance 0>0 = Green-£150,000k - 0 = Amber<-£150,000k = Red

-£170,000 -£360,000 £378,000 -£135,000 -£26,000 £520,000 £520,000

To deliver a surplus of £0.5M for investment in our buildings

I&E Surplus (YTD) Director of Finance 0.6%>1% = Green0.0 - 1.0% = Amber<0.0% = Red

0.7% -1.4% 2.3% 2.0% 2.9% 1.7% 1.7%

I&E position - variance from plan (YTD) Director of Finance On plan £343,000 -£67,000 -£28,000 -£30,000 -£21,000 £23,000 £23,000

EBITDA (% of Plan Achieved) Director of Finance 100%>100% from plan = Green85 - 99% = Amber<85% = Red

115.6% 81.8% 97.7% 98.1% 98.3% 99.6% 99.6%

EBITDA margin % Director of Finance 5.0%>5.9% = Green5.0 - 5.8% = Amber<5.0% = Red

5.5% 3.3% 6.9% 6.4% 7.3% 6.1% 6.1%

Infrastructure that supports delivery

Women's Hospital Development Strategy Project progress against plan and budget Director of Estates &

Facilities

On plan = GreenWithin one month = AmberNot within plan = Red

IT Procurement Strategy Project progress against plan and budget Director of Planning and Performance

On plan = GreenWithin one month = AmberNot within plan = Red

Health Campus Development Strategy Project progress against plan and budget Director of Estates & Facilities

On plan = GreenWithin one month = AmberNot within plan = Red

MONITOR DASHBOARD 2012/2013

Thresholds Monitoring Period Apr-12 Figures

Apr-12 Score

May-12 Figures

May-12 Score

Jun-12 Figures

Jun-12 Score

Q1 Figures Q1 Score Jul-12 Figures

Jul-12 Score

Aug-12 Figures

Aug-12 Score

Q2 Figures

Q2 Score YTD Figures

YTD Score

Targets - weighted 1.0

1 C.Diff year on year reduction(DH target - Post 72hrs only)

28 PA Quarter 0 0 1 0 1 0 2 0 0 0 0 0 0 0 2 0 Quarterly Target based on cumulative YTD

2 MRSA year-on-year reduction (de-minimus limit = 6)All cases

1 PA Quarter 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

3a Max waiting time of 31 days for subsequent DRUG treatments for all cancers 98% Quarter 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

3b Max waiting time of 31 days for subsequent SURGICAL treatments for all cancers 94% Quarter 100.0% 100.0% 100.0% 100.0% 94.7% 100.0% 97.1% 98.8%

4a Max waiting time of 62 days from urgent GP referral to first treatment for all cancers 85% Quarter 78.7% 88.9% 87.4% 86.4% 88.5% 91.1% 89.9% 87.6%

4b Max waiting time of 62 days from consultant screening service referral for all cancers 90% Quarter 81.8% 100.0% 100.0% 92.3% 77.8% N/A 77.8% 86.7%

5 18 week RTT admitted wait - All specialties 90% Monthly 91.9% 0 91.2% 0 92.2% 0 91.7% 0 94.2% 0 94.0% 0 94.1% 0 92.6% 0

6 18 week RTT non-admitted wait - All specialties 95% Monthly 97.5% 0 96.8% 0 96.7% 0 97.0% 0 96.4% 0 97.5% 0 96.9% 0 96.9% 0

7 18 week RTT Incomplete pathways - All Specialties 92% Monthly 95.2% 0 97.5% 0 95.6% 0 97.1% 0 93.7% 0 95.7% 0 95.6% 0 95.7% 0

8 A&E Clinical Quality: Total time of 4 hours in A&E 95% Monthly 95.0% 0 96.5% 0 95.9% 0 95.8% 0 95.6% 0 95.1% 0 95.4% 0 95.6% 0

MONITOR SCORE 1 0 0 0 1 0 1 1

Targets - weighted 0.5

9a Max waiting time of 2 weeks from urgent suspect cancer GP referral to first outpatient appointment 93% Quarter 93.1% 93.6% 93.1% 93.3% 94.0% 93.3% 93.6% 93.4%

9b Max waiting time of 2 weeks for symptomatic breast patients (cancer not initially suspected) 93% Quarter 93.8% 95.0% 95.1% 94.7% 94.4% 90.9% 93.1% 94.1%

10 Max waiting time of 31 days from diagnosis to first treatment for all cancers 96% Quarter 100.0% 0 98.4% 0 100.0% 0 99.5% 0 98.4% 0 98.4% 0 98.4% 0 99.0% 0

11 Access to health care for people with a learning disability N/A Quarter

MONITOR SCORE 0 0 1 0 0

TOTAL MONITOR SCORE 1 0 0 0 1 1 1 1

INDIVIDUAL TARGET SCORE TOTAL MONITOR SCORE

0 GREEN GREEN 0.0 - 0.9

0.5 or 1 RED GREEN/AMBER

1 .0 - 1.9

AMBER/RED

2.0 - 2.9

RED 3 or above

0

0

1

MONITOR - National Core Target thresholds and monitoring periods 2012-2013

0 0 0

0

11

10

0

0

00

0

1

0

0

0

0 0

0 0

BPT, PENALTIES AND CQUIN DASHBOARD 2012/2013

BPTs, PENALTIES and CQUINs MEASURE LEAD DIRECTOR TARGET THRESHOLDS Apr-12 May-12 Jun-12 Jul-12 Aug-12 1213 YTD

BEST PRACTICE TARIFFS (£1.4 Million)

Direct admission and 90% of spell spent in an acute stroke unit (% activity claimed) Director of Operations 73%

>=73% = Green55 - <73% = Amber<55% = Red

13% 15% 13% 10% 8% 8%

Rapid brain imaging (% activity claimed) Director of Operations 78%>=78% = Green58 - <78% = Amber<58% = Red

4% 6% 6% 4% 3% 3%

Assessed for thrombolysis and thrombolysed with Alteplase (% activity claimed) Director of Operations TBC

>=75% = Green50 - <75% = Amber<50% = Red

17% 10% 7% 11% 10% 10%

Same Day Emergency Care12 diagnoses that can be managed in an Ambulatory care manner, e.g. Asthma, COPD (% activity claimed)

Director of Operations 66%>=49% = Green33% - <49% = Amber<33% = Red

27% 30% 31% 32% 30% 30%

Fragility HIP Fracture Based on meeting the criteria provided in PBR Guidance 2012/13 (% activity claimed) Director of Operations 29%

>=21% = Green14 - <21% = Amber<14% = Red

0% 0% 0% 0% 0% 0%

Paediatric Diabetes pathwaysAnnual payments based on the criteria provided in PBR Guidance 2012/13. (% activity claimed)

Director of Operations 75%>=75% = Green50 - <75% = Amber<50% = Red

0% 0% 0% 0% 0% 0%

Incentivising procedures in outpatients Cystoscopies, Hysteroscopies and Hysteroscopic sterilisation performed in Outpatient Setting (% activity claimed)

Director of Operations 68%>=51% = Green34 - <51% = Amber<34% = Red

37% 42% 39% 37% 37% 37%

Transient Ischaemic Attack (TIA) Based on meeting the criteria provided in PBR Guidance 2012/13 (% activity claimed) Director of Operations TBC

>=75% = Green50 - <75% = Amber<50% = Red

0% 0% 0% 0% 0% 0%

Incentivising Daycases Performing specified types of procedures as daycases. (% activity claimed) Director of Operations 74%

>=56% = Green37 - <56% = Amber<37% = Red

53% 49% 47% 46% 47% 47%

Primary HIP and KNEE replacements Based on meeting the criteria provided in PBR Guidance 2012/13 (% activity claimed) Director of Operations TBC

>=75% = Green50 - <75% = Amber<50% = Red

100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Cataract pathwaysAnnual payments based on the criteria provided in PBR Guidance 2012/13. (% activity claimed)

Director of Operations TBC>=75% = Green50 - <75% = Amber<50% = Red

0% 0% 0% 0% 0% 0%

CONTRACT PENALTIES

Mixed Sex Accomodation Breaches Breach = £250 per patient per night Director of Nursing & Clinical Governance Budget = £0

No Breaches - GREEN 1 Breach - AMBER >1 Breach - RED

0 0 0 0 1 1

C.Diff cases above target Between £46K (1 case) and £915K (6 cases) Director of Nursing & Clinical Governance Budget = £0

No Breaches - GREEN 1 Breach - AMBER >1 Breach - RED

0 0 0 0 0 0

Ambulance Handover Breaches 30-60mins - £10, 60-90mins - £115, 90-120mins - £570, 120+mins - £2,200 Director of Operations Budget = £14K

(£20K max)

Within Budget = GreenWithin Stretch Budget = Amber Outside Stretch Budget = Red

-£3.0K -£1.4K -£2.0K -£1.0K -£1.1K -£8.6K

A&E 4hr wait breaches above 95% Maximum of £84K per annum Director of Operations Budget = £0KNo Breaches - GREEN 1 Breach - AMBER >1 Breach - RED

0 0 0 0 0 0

18 week RTT by specialty breaches above 90% for ADMITTEDpathways Director of Operations

No Breaches - GREEN 1 Breach - AMBER >1 Breach - RED

2 2 1 1 1 2 Oral surgery in Aug

18 week RTT by specialty breaches above 95% for NON-ADMITTED pathways

Director of OperationsNo Breaches - GREEN 1 Breach - AMBER >1 Breach - RED

1 2 2 2 1 2 Trauma and Orthopaedics

Readmissions above agreed contract levels On Plan Director of Operations <=£87K

Within Plan = GreenWithin 10% of Plan = Amber >10% over Plan = Red

1.1% 2.2% 0.9% 1.8% 0.3% 0.3%

All Cancer wait breaches over targets £47K per annum per target breached Director of Operations Budget = £0KNo Breaches - GREEN 1 Breach - AMBER >1 Breach - RED

2 0 0 1 1 4 August breach - 2 week symptomatic breast referrals

All Diagnostic wait breaches above 99% £50K per annum Director of Operations Budget = £0KNo Breaches - GREEN 1 Breach - AMBER >1 Breach - RED

0 0 0 0 0 0

CQUIN MEASURES (£2.3 Million)

Maintain levels of VTE Assessment Percentage of patients with completed VTE risk assessment - PAS data submitted to Unify

Director of Nursing & Clinical Governance 90%

>=90% = Green>=85% = Amber<85% = Red

90.0% 91.4% 91.9% 91.1% 91.1% Updated a month in lieu

To ensure that 95% of patients are satisfied or very satisfied with their experience of the hospital

Percentage of patients rating their care as 'very good' or 'excellent' on the YOUR CARE questionnaire (ADULTS INPATIENT WARDS ONLY)

Director of Nursing & Clinical Governance 95%

>=95% = Green85%-<95% = Amber<85% = Red

94% 96% 92% 90% 93% 93%

To improve awareness of diagnosis of Dementia - 90% of relevent patients assessed.

Relevent patients assessed using Dementia screening Question.

Director of Nursing & Clinical Governance 90%

>=90% = Green90 - <85% = Amber<85% = Red

Data not yet availalble

To improve quality of care of Dementia patients Obtain Level 2 Standard of care Director of Nursing &

Clinical Governance Level 2On plan = GreenWithin one month = AmberNot within plan = Red

Data not yet availalble

NHS Safety Thermometer Implement agreed NHS Somerset plan to submit NHS safety Thermometer monthly

Director of Nursing & Clinical Governance On Plan

On plan = GreenWithin one month = AmberNot within plan = Red

Nutrional support and managementPercentage of patients screened within 24hrs (Based on an audit of 5 patients per ward per month)

Director of Nursing & Clinical Governance 90%

>=90% = Green>=85% = Amber<85% = Red

52% 50% 82% 89% 70%

Antipyschotic medication usage Evidence of good practice Director of Nursing & Clinical Governance On Plan

On plan = GreenWithin one month = AmberNot within plan = Red

Improved planning for end of life care Implement plan to provide end-of-life training to all relevent staff

Director of Nursing & Clinical Governance On Plan

On plan = GreenWithin one month = AmberNot within plan = Red

Data not yet availalble

Use of Oesophageal Doppler monitoringto reduce Face to Face contact

Director of Nursing & Clinical Governance On Plan

On plan = GreenWithin one month = AmberNot within plan = Red

Data not yet availalble

Use of Telehealth to reduce Face to Face contact

Director of Nursing & Clinical Governance TBC

On plan = GreenWithin one month = AmberNot within plan = Red

Data not yet availalble

Reducing Face to Face contact by alternative means

Director of Nursing & Clinical Governance TBC

On plan = GreenWithin one month = AmberNot within plan = Red

Data not yet availalble

Acute Stroke Care

Up to £150K per month (de minimus = 20 patients) Budget = £0K

High impact innovations

Infection Prevention and Control Monthly Metrics Table

04/10/2012 Page 1 of 1

Date of Report Aug-12

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Annual Target

0 2 1 1 20 1 1 0 1 28 post

100% 100% 100% 100%93% 95% 91% 92%100% 100% 100% 100% 100%100% 100% 100% 100% 100%

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Annual Target0 0 0 0 0 11 0 0 0 0 -2 0 2 3 1

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Annual Target92% 100% 100% 96% 100% 100%90% 89% 90% 94% 89% 95%-100%

Dr Nurse Other Compliance scoreWard 10 55% 100% 71% 67%9A 100% 75% 100% 90%9B 87% 100% 92% 91%8A 79% 97% 83% 87%CCU 100% 100% 50% 92%7A 85% 100% 90% 92%PAC 75% 100% 80%6B 75% 95% 80% 89%Main TH 86% 100% 92%ICU 100% 100% 75% 91%KW 100% 100% 60% 85%ED 29% 86% 100% 65%Xray 100% 100% 60% 84%Freya 71% 83% 83% 79%

C. difficile total casesC. difficile Actual (Post 72 Hours)

ComplianceMRSA elective screening - Trust wide Compliance

Infection Prevention and ControlKey Performance Indicators 12/13

Numbers

Hand Hygiene - Trust Wide Compliance with auditHand Hygiene - Trust Wide average of scores submitted

MRSA Emergency Screening - Trust Wide ComplianceMRSA Long Stay Screening - Trust wide complianceSide Room isolation -Trust Wide Compliance

E Coli BSI HCAI Total Cases

Areas where hand hygiene score was below 95%:

NoneAreas of non-compliance with undertaking hand hygiene

NumbersMRSA BSI - Actual - Total Cases HCAIMSSA BSI HCAI Total Cases

Numbers

0

0.5

1

1.5

2

2.5

Apr-12 May-12

Jun-12 Jul-12 Aug-12Sep-12 Oct-12 Nov-12Dec-12Jan-13 Feb-13Mar-13

Clostridium Difficile Cases

C. difficile total cases C. difficile Actual (Post 72 Hours)

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13

Hand Hygiene - Trust Wide Compliance with audit

Hand Hygiene - Trust Wide average of scores submitted

0

1

2

3

Apr-12 May-12

Jun-12 Jul-12 Aug-12

Sep-12

Oct-12 Nov-12

Dec-12

Jan-13 Feb-13

Mar-13

MRSA BSI - Actual - Total Cases HCAI

MRSA BSI - Actual - Total Cases HCAI

Clinical Governance Delivery Committee Item 5.2 Annex D

May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13Ward 10 (inpt )9A 65.52% 66.67% 88.89% 92.59%9B 86.21% 76.67% 73.08% 66.67%8A 88.89% 96.55%6BCCU 85.71% 66.67% 100%EAU 89.29%6A8B 100% 95.45%ICU 77.78% 87.50% 62.50%Jasmine/GynaecologyFreya 7A 82.76%Kingston WingTrust-wide score 75.86% 77.33% 86.44% 86.81%

SAFETY THERMOMETER HARM FREE CARE SCORES 2012/13

Yeovil District Hospital NHS Foundation Trust August 2012

Key: YTD change - Better than previous month

HR Performance Dashboard ~ Trust level - Worse than previous month

= - Same as previous month

Metric / Indicator Description Threshold Measure YTD11/12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 YTD

12/13YTD

change

Variance between staff in post and budgeted FTE

% Variance(FTE Variance) 5% (+/-)

< 5% or "More for Less" Green5-9% Amber> 9% Red

-4%(65.4 fte)

-4%(69.6 fte)

-4%(62.9 fte)

-3%(56.3 fte)

-2%(37.5 fte)

-4%(59.9 fte)

-4%(59.9 fte)

Expenditure against pay budget (Year to Date)

£ Variance (negative indicates overspend)% Variance

Within budget

Underspend GreenOverspend =<1% & <£100k AmberOverspend >1% or >£100k Red

£498.9k1%

-£36.4k1%

-£37.2k0%

-£7.8k0%

-£4.2k0%

£74.7k0%

£74.7k0%

Sickness Absence % Monthly Rate 3.0%< 3.0% Green3.0-4.0% Amber> 4.0% Red

3.6% 2.7% 3.5% 3.3% 3.4% 3.5% =

Mandatory Training(Fire, Infection Control, Manual Handling, Child Protection plus Resuscitation for clinical staff)

% attendance within last 12 months (rolling year)

85%> 85% Green70-85% Amber< 70% Red

67% 68% 69% 72% 72% 72% 72% =

Appraisals(includes Staff Passport & Medical Devices competence assessment)

% appraised within last 12 months (rolling year)

80%> 80% Green65-80% Amber< 65% Red

73% 72% 72% 79% 79% 79% 79% =

Employee Relations Management(Grievance, Disciplinary, Capability & Harassment)

% managed within agreed timeframe (Total No. of Cases)

90%> 90% or "No Cases" Green60-90% Amber< 60% Red

100% (3) 100% (1) 100% (3) 100% (5) 75% (4) 50% (2) 50% (2)

Workforce Planning for staff aged 55 and over

% with plan known (total no. over 55yrs) 75%

> 75% Green50-75% Amber< 50% Red

96%(344)

97%(344)

98%(348)

96%(348)

96%(345)

96%(345)

96%(345) =

Health & Safety AuditAnnual return completed

% returns received within last 12 months (Total No. Required)

100%100% Green70-99% Amber< 70% Red

83%(52)

81%(52)

88%(52)

92%(52)

63%(52)

94%(52)

94%(52)

NB: Staff Variance "More for Less" - over-establishment and pay underspend

Division and Directorate Performance Indicators - Year to Date August 2012 Yeovil District Hospital NHS Foundation Trust

Division / Directorate Head-count

Variance between staff

in post & budgeted FTE

Expenditure against pay

budget (Year to Date)

Sickness Absence %

Jul YTD

Mandatory Training Appraisals

Employee Relations

Management

Workforce Planning for staff aged 55

and over

H&S Audit Qrtrly Returns

HR Indicators Achieved

(No. of Green indicators)

Emergency Department 93 2% (1.9 fte) -£1.8k, 0% 6.1% 62% 61% No Cases 100% (12) 100% (1) 4

Medicine Directorate 352 5% (15.4 fte) -£49.0k, 1% 4.4% 70% 70% 0% (1) 95% (60) 100% (8) 2

Pharmacy 55 1% (0.3 fte) £25.7k, 4% 1.9% 78% 49% No Cases 100% (5) 0% (1) 5

MEP Division Score 500 4% (17.0 fte) -£25.0k, 0% 4.4% 69% 67% 0% (1) 96% (77) 90% (10) 2

Critical Care Directorate 244 -5% (10.7 fte) £38.3k, 1% 4.0% 77% 81% No Cases 100% (43) 100% (6) 5

Orthopaedic Directorate 114 -3% (3.2 fte) -£50.5k, 3% 2.7% 73% 80% 100% (1) 93% (15) 100% (3) 5

Surgical Directorate 163 -9% (12.3 fte) £14.1k, 0% 2.1% 71% 88% No Cases 100% (27) 100% (5) 6

Therapists 79 4% (2.5 fte) £1.6k, 0% 1.0% 78% 71% No Cases 100% (7) 100% (1) 6

OSCC Division Score 600 -5% (23.7 fte) £3.5k, 0% 2.9% 75% 82% 100% (1) 99% (92) 100% (15) 6

Cancer Services Directorate 29 11% (2.3 fte) £10.7k, 3% 2.2% 62% 50% No Cases 80% (10) 0% (1) 5

Child Health Directorate 93 2% (1.1 fte) £2.4k, 0% 3.6% 80% 89% No Cases 92% (12) 100% (3) 6

Gynaecology Directorate 61 -4% (2.2 fte) £4.8k, 0% 3.3% 77% 61% No Cases 100% (14) 100% (2) 5

Maternity Unit 107 8% (5.8 fte) -£11.6k, 1% 7.6% 78% 83% No Cases 86% (14) 100% (2) 4

Operations Directorate 97 -0% (0.1 fte) £1.9k, 0% 2.1% 79% 72% No Cases 95% (22) 100% (2) 6

Pathology Services 13 -5% (0.6 fte) £3.9k, 1% 1.3% 75% 92% No Cases 67% (3) 0% (1) 4

Radiology Directorate 72 2% (1.1 fte) £9.4k, 1% 3.0% 65% 96% No Cases 94% (18) 100% (1) 6

F&D Division Score 472 1% (5.2 fte) £21.5k, 0% 3.7% 75% 79% No Cases 91% (93) 83% (12) 4

Estates & Facilities Management 187 -13% (24.2 fte) -£3.5k, 0% 3.7% 54% 93% No Cases 96% (48) 100% (7) 4

Finance & Other Services 47 2% (0.6 fte) £5.8k, 1% 4.2% 82% 82% No Cases 100% (5) 100% (2) 6

Management Services 99 0% (0.0 fte) £36.5k, 2% 1.9% 73% 70% No Cases 79% (24) 100% (4) 6

Nurse Administration 46 -5% (2.1 fte) £11.8k, 2% 1.4% 76% 98% No Cases 100% (4) 100% (1) 6

Yeovil Academy 27 -5% (1.3 fte) £21.9k, 6% 0.4% 90% 92% No Cases 100% (2) 100% (1) 7

Corporate Svcs Score 406 -6% (24.5 fte) £72.5k, 1% 2.8% 67% 88% No Cases 92% (83) 100% (15) 6

Trust Score 1978 -4% (59.9 fte) £74.7k, 0% 3.5% 72% 79% 50% (2) 96% (345) 94% (52) 3

Review of Pay Budget Variance 2009/10, 2010/11, 2011/12 & 2012/13 - Negative value indicates overspend

% Variance

DirectorateYr End Mar10

YTD Jun10

YTD Sep10

YTD Dec10

Yr End Mar11

YTD Jun11

YTD Jul11

YTD Aug11

YTD Sep11

YTD Dec11

Yr End Mar12

YTD Jun12

YTD Jul12

YTD Aug12

Emergency Department -7% -1% 0% 0% -3% -3% -2% -2% -1% -1% -3% -1% 0% 0%Medicine Directorate -5% 0% 0% 0% 1% -1% -1% -1% -1% -1% 0% -1% -1% -1%Pharmacy 4% 0% 0% 0% 0% 0% 1% 1% 1% 1% 2% 3% 3% 4%Critical Care Directorate -2% 0% 0% -1% -2% 0% 0% -1% 0% 0% 0% 0% 1% 1%Orthopaedic Directorate -4% 1% 0% 1% 1% 0% 0% 0% 0% 0% 1% -2% -2% -3%Surgical Directorate -3% -1% 0% -1% -1% 1% 1% 1% 1% 1% 2% 0% 0% 0%Therapists 2% 1% 1% 0% 0% 0% 0% 0% 0% 0% 1% 0% 0% 0%Cancer Services Directorate -1% 2% -3% 0% 0% 4% 3% 3% 2% 3% 3% 3% 3% 3%Child Health Directorate -1% 0% 0% 0% 0% 0% 1% 1% 1% 1% 1% 0% 0% 0%Gynaecology Directorate 0% 1% 1% 3% 2% 0% 0% -1% -1% -1% -1% 1% 1% 0%Maternity Unit -3% 0% 0% -1% 0% 0% 0% 0% 1% 1% 1% -1% -1% -1%Operations Directorate -3% -4% -3% 0% 0% 1% 1% 1% 1% 1% 1% 1% 0% 0%Pathology Services -1% 1% 2% 1% 0% 2% 4% 5% 5% 5% 4% 0% 1% 1%Radiology Directorate 0% 0% 0% 0% 1% 0% 0% 1% 1% 2% 2% -1% 0% 1%Facilities Management -1% -1% 0% 0% 0% 0% 0% -1% -1% -1% -1% -1% -1% 0%Finance & Other Services 4% 1% 2% 4% 5% 2% 1% 1% 1% 2% 5% 3% 2% 1%Management Services 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 2% 2% 2%Nurse Administration 0% -25% -11% -4% 0% -3% 0% -1% -2% 0% 0% 1% 2% 2%Yeovil Academy 2% 1% 1% 2% 2% 5% 5% 6% 5% 7% 8% 6% 6% 6%Trust Total -2% 0% 0% 0% 0% 0% 0% 0% 0% 0% 1% 0% 0% 0%

£ Variance

DirectorateYr End Mar10

YTD Jun10

YTD Sep10

YTD Dec10

Yr End Mar11

YTD Jun11

YTD Jul11

YTD Aug11

YTD Sep11

YTD Dec11

Yr End Mar12

YTD Jun12

YTD Jul12

YTD Aug12

Emergency Department -£259,270 -£10,733 £1,638 -£1,658 -£114,380 -£29,573 -£29,968 -£28,576 -£29,514 -£23,276 -£126,932 -£6,201 -£5,213 -£1,772Medicine Directorate -£603,812 £4,584 £4,961 £14,632 £106,072 -£44,829 -£53,916 -£76,614 -£71,643 -£54,749 -£41,199 -£26,218 -£54,491 -£48,995Pharmacy £43,529 £628 £2,790 £1,702 £3,427 -£93 £4,675 £5,953 £6,751 £11,973 £27,295 £13,320 £14,208 £25,720Critical Care Directorate -£151,743 £4,535 -£6,390 -£112,426 -£182,758 -£3,049 -£12,075 -£20,769 -£17,393 -£9,812 -£3,590 £11,857 £22,216 £38,348Orthopaedic Directorate -£177,176 £9,702 £650 £26,531 £33,176 £5,252 £200 -£1,919 £803 £5,326 £34,130 -£26,898 -£34,071 -£50,470Surgical Directorate -£185,261 -£13,974 -£11,910 -£36,166 -£42,288 £9,503 £12,201 £19,323 £21,971 £52,053 £123,958 -£3,182 £2,856 £14,077Therapists £41,437 £4,744 £11,464 £6,213 -£2,451 £142 £950 £1,657 £1,712 £5,680 £12,328 -£961 -£973 £1,579Cancer Services Directorate -£4,119 £2,576 -£9,383 -£1,201 -£1,207 £9,244 £10,187 £10,173 £9,977 £18,134 £27,961 £7,261 £8,365 £10,714Child Health Directorate -£35,690 £846 -£6,240 -£10,989 -£8,903 -£269 £6,713 £11,653 £9,168 £22,293 £33,939 -£111 -£628 £2,399Gynaecology Directorate £3,516 £4,772 £17,729 £60,215 £61,717 -£2,626 -£2,690 -£8,472 -£10,405 -£12,133 -£23,360 £5,068 £6,759 £4,753Maternity Unit -£98,465 -£741 £4,544 -£12,787 £14,543 £778 £1,052 £4,563 £8,827 £17,473 £30,468 -£5,356 -£15,212 -£11,603Operations Directorate -£48,111 -£17,677 -£28,818 -£2,862 £2,731 £3,815 £7,755 £7,137 £10,860 £18,841 £16,017 £4,207 £2,510 £1,947Pathology Services -£16,747 £6,330 £18,766 £24,872 £10,741 £12,159 £33,077 £47,468 £55,766 £84,535 £97,127 £1,714 £3,953 £3,870Radiology Directorate £12,389 -£287 £372 £9,313 £41,706 -£1,791 £419 £8,935 £17,347 £36,540 £48,276 -£11,210 £2,064 £9,403Facilities Management -£33,848 -£8,111 -£6 -£65 -£15,804 -£4,247 -£5,713 -£20,466 -£15,916 -£21,580 -£34,120 -£16,392 -£17,307 -£3,528Finance & Other Services £63,185 £2,819 £11,456 £35,787 £54,430 £5,212 £5,533 £4,575 £8,758 £14,032 £48,383 £5,489 £5,416 £5,828Management Services £49,985 £8,216 £15,267 £20,165 £36,042 £7,252 £11,854 £19,719 £24,408 £26,990 £36,004 £20,297 £26,838 £36,499Nurse Administration -£5,899 -£75,177 -£72,221 -£38,931 -£5,828 -£11,215 -£219 -£8,956 -£13,757 £3,789 £6,757 £5,229 £8,852 £11,790Yeovil Academy £35,951 £8,692 £10,414 £25,362 £36,249 £12,585 £17,845 £22,544 £29,114 £51,468 £74,695 £13,497 £18,093 £21,925Trust Total -£1,256,931 -£68,413 -£35,015 £7,575 £26,923 -£31,645 £7,985 £18,033 £66,939 £267,577 £498,885 -£7,832 -£4,225 £74,730

2009/10 2010/11 2011/12 2012/13

2009/10 2010/11 2011/12 2012/13

Yeovil District Hospital NHS Foundation Trust August 2012

Trust, Division, Directorate and Staff Group Summary

Appraisal Monitoring against eligible (active) assignments - Table 1(i.e. excludes maternity leave and career breaks plus active assignments identified as ineligible for the reasons shown in Table 2)

Table 1 - No. of eligible assignments, appraisals completed and resulting compliance % Table 2 - Summary of ineligible assignments as at August 2012

Appraisal Summary Aug-12 Sep11-Aug12 Aug-12

Medicine, Emergency and Pharmacy Division Eligible Assignments

Appraisals Completed Compliance % Reason No Yes Total

Emergency Department 67 41 61% GP 1 1 2Medicine Directorate 274 193 70% Internal Move < 6 months 22 8 30Pharmacy 37 18 49% Internal move 6 to 12 Months 5 3 8Division Total 378 252 67% MF - Dept Restructure 2 1 3

MF - Ext Secondment 4 1 5

Appraisal Summary Aug-12 Sep11-Aug12 Aug-12 MF - FTC 2 4 6

Orthopaedics, Surgery and Critical Care Division

Eligible Assignments

Appraisals Completed Compliance % MF - HR / OH Issue 2 2

Critical Care Directorate 210 171 81% MF - Retirement / Leaver 3 3Orthopaedic Directorate 92 74 80% MF - Sickness 5 1 6Surgical Directorate 133 117 88% N/A, Based at Exeter 1 1Therapists 62 44 71% New Starter < 6 months 116 8 124Division Total 497 406 82% New Starter 6 to 12 months 72 36 108

Sickness > 1 Month 10 9 19

Appraisal Summary Aug-12 Sep11-Aug12 Aug-12 Training Drs 85 85

Family and Diagnostics Division Eligible Assignments

Appraisals Completed Compliance % Total 330 72 402

Cancer Services Directorate 20 10 50%Child Health Directorate 70 62 89% MF = Manager FeedbackGynaecology Directorate 51 31 61%Maternity Unit 81 67 83%Operations Directorate 79 57 72%Pathology Services 12 11 92%Radiology Directorate 67 64 96%Division Total 380 302 79%

Appraisal Summary Aug-12 Sep11-Aug12 Aug-12

Corporate Services Eligible Assignments

Appraisals Completed Compliance %

Estates & Facilities Management 164 153 93%Finance & Other Services 34 28 82%Management Services 74 52 70%Nurse Administration 41 40 98%Yeovil Academy 24 22 92%Corporate Services Total 337 295 88%

Trust Total 1592 1255 79%

Appraisal Summary Aug-12 Sep11-Aug12 Aug-12

ESR Staff Groups Eligible Assignments

Appraisals Completed Compliance %

Add Prof Scientific and Technic 39 23 59%Additional Clinical Services 249 186 75%Administrative and Clerical 402 331 82%Allied Health Professionals 78 65 83%Estates and Ancillary 170 150 88%Healthcare Scientists 6 6 100%Medical and Dental 120 107 89%Nursing and Midwifery Registered 528 387 73%

Valid Appraisal as at August 2012

Ineligible for appraisal monitoring

Count of ineligible assignments

Average estimated cost of sickness per person - 2012/13 and 2011/12

Medicine, Emergency and Pharmacy Division

Jul12 Sickness

Costs

Jul12 No. of sick staff

Av. Sick Costs per

person

YTD Sickness

Costs

YTD No. of sick staff

YTD Av. Sick Costs per

person

Medicine, Emergency and Pharmacy Division

YTD Jul11 Sickness

Costs

YTD Jul11 No. of sick

staff

YTD Jul11 Av. Sick

Costs per person

Emergency Department 12,557 8 1,570 70,556 35 2,016 Emergency Department 39,813 35 1,138Medicine Directorate 20,966 56 374 78,019 137 569 Medicine Directorate 109,848 145 758Pharmacy 2,063 9 229 5,584 22 254 Pharmacy 3,690 9 410Division Total 35,586 73 487 154,159 194 795 Division Total 153,351 189 811

Orthopaedics, Surgery and Critical Care Division

Jul12 Sickness

Costs

Jul12 No. of sick staff

Av. Sick Costs per

person

YTD Sickness

Costs

YTD No. of sick staff

YTD Av. Sick Costs per

person

Orthopaedics, Surgery and Critical Care Division

YTD Jul11 Sickness

Costs

YTD Jul11 No. of sick

staff

YTD Jul11 Av. Sick

Costs per person

Critical Care Directorate 27,515 36 764 93,075 99 940 Critical Care Directorate 91,495 95 963Orthopaedic Directorate 6,934 22 315 24,205 51 475 Orthopaedic Directorate 37,255 49 760Surgical Directorate 5,191 19 273 28,404 46 617 Surgical Directorate 39,394 35 1,126Therapists 1,962 10 196 6,872 21 327 Therapists 9,364 23 407Division Total 41,602 87 478 152,557 217 703 Division Total 177,508 202 879

Family and Diagnostics DivisionJul12

Sickness Costs

Jul12 No. of sick staff

Av. Sick Costs per

person

YTD Sickness

Costs

YTD No. of sick staff

YTD Av. Sick Costs per

personFamily and Diagnostics Division

YTD Jul11 Sickness

Costs

YTD Jul11 No. of sick

staff

YTD Jul11 Av. Sick

Costs per person

Cancer Services Directorate 4,038 2 2,019 5,059 5 1,012 Cancer Services Directorate 2,918 9 324Child Health Directorate 5,780 19 304 27,737 43 645 Child Health Directorate 29,804 36 828Gynaecology Directorate 957 8 120 12,020 25 481 Gynaecology Directorate 17,391 16 1,087Maternity Unit 15,065 22 685 62,010 51 1,216 Maternity Unit 24,822 45 552Operations Directorate 4,277 7 611 13,769 29 475 Operations Directorate 17,914 26 689Pathology Services 546 2 273 2,827 12 236 Pathology Services 8,583 13 660Radiology Directorate 3,337 11 303 19,286 23 839 Radiology Directorate 34,454 26 1,325Division Total 33,999 71 479 142,708 188 759 Division Total 135,887 171 795

Corporate ServicesJul12

Sickness Costs

Jul12 No. of sick staff

Av. Sick Costs per

person

YTD Sickness

Costs

YTD No. of sick staff

YTD Av. Sick Costs per

personCorporate Services

YTD Jul11 Sickness

Costs

YTD Jul11 No. of sick

staff

YTD Jul11 Av. Sick

Costs per person

Estates & Facilities Management 10,158 26 391 34,138 76 449 Estates & Facilities Management 43,536 67 650Finance & Other Services 2,401 7 343 22,163 21 1,055 Finance & Other Services 11,945 22 543Management Services 2,106 8 263 17,274 23 751 Management Services 36,719 30 1,224Nurse Administration 127 2 63 3,181 15 212 Nurse Administration 2,480 5 496Yeovil Academy 0 0 0 823 5 165 Yeovil Academy 641 5 128Corporate Services Total 14,792 43 344 77,579 140 554 Corporate Services Total 95,320 129 739

Trust Total 125,979 274 460 527,003 739 713 Trust Total 562,065 691 813

2012/13 2011/12

REF PERFORMANCE MEASURES TARGET MEASURE APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MARYTD

AVERAGE

YEAR 11-

12BY

B

B2 Audit pass rate 90%>90% Green

80-89% Amber

<80% Red99.0% 98.2% 97.7% 98.1% 97.7% 98.1% 98.2% PW

C

C2

Percentage of scheduled service related work

requests for YDH NHS FT that have been

completed by their required by date85%

>85% Green

65-84% Amber

<64% Red73.0% 91.0% 77.0% 97.0% 74.0% 82.4% 87.3% BP

C3

Total of MHRA Medical Device Alerts that the

actions have not been completed by the

published Action Completion date.

0<0 Green

1-2 Amber

>3 Red

1 1 0 1 0 1 0.2 BP

D

D1Pre-planned Maintenance (PPM) tasks are

completed on time95%

> 95% Green

80-95% Amber

< 80% Red89.9% 90.0% 87.8% 85.0% 88.0% 88.1% 85.70% DS

D4Reactive maintenance calls are responded to

within agreed priority time.90%

> 90% Green

75-90% Amber

< 75% Red80.8% 75.0% 73.7% 79.7% 76.8% 77.2% 85.1% DS

D6Number of incomplete jobs that have exceeded

their target completion time" (set by priority)100

<100 Green

101-250 Amber

>250 Red

233 191 276 343 223 253 225.0 DS

D7Total number of emergency call-outs (out of

hours)40

<40 Green

41-65 Amber

>65 Red87 87 77 57 84 78 65.0 DS

E

E1Percentage of feedback forms giving positive

comments.75%

> 75% Green

50-75% Amber

< 50% Red

50.0% 100.0% 100.0% N/A N/A 83.3% 92.60% SHu

E2Orders are placed within 8 weeks of receipt of

request.90%

> 90% Green

85-90% Amber

< 85% Red

83.0% 83.0% 100.0% 100.0% 100.0% 93.2% 93.40% SHu

F

F1Portering requests completed within agreed

timeframe90%

> 90% Green

80-89% Amber

< 80% Red

94.0% 92.5% 95.0% 91.0% 90.0% 92.5% 92.00% JH

G

G1 Maintain occupancy levels 80%>80% Green

70-79% Amber

<70% Red

70.7% 71.2% 70.8% N/A 81.0% 73.4% 72.50% JR

G2 New residences occupancy levels 100%100% Green

98-99% Amber

<97% Red

30.0% 41.6% 48.5% 66.6% 75.0% 52.3% N/A JR

H

H1 Answer all calls within 21 seconds 80%>80% Green

75-89% Amber

<75% Red

79.9% 81.3% 80.8% 79.6% 80.8% 80.5% 81.60% JR

L

L1 Variance from budget in month 0.0%<0% Green

0-2% Amber

>2% Red

-0.12% 1.68% -0.68% 0.13% -3.48% -0.51% 0.18% NB

M

M1 Compliance with Statutory Requirements 70%>70% Green

50-69% Amber

<50% Red

69.0% 72.8% 74.6% 74.6% 74.6% 73.1% 69.0% NB

Cleanlinesss

Portering

Medical Electronics

Maintenance

Minor Works

EFM Performance Management Dashboard

August 2012

Statutory Compliance

Switchboard

Financial Control

YTD POSITION

YTD POSITION

Residences

1

_____________________________________________________________________ Report to: Board of Directors Report from: Medical Director Subject: Medical Revalidation Date: 10 October 2012 1. PURPOSE 1.1 The purpose of this paper is to brief HMT on medical revalidation and the actions being

taken to ensure the Trust is prepared for its introduction. Medical revalidation is the process by which all doctors with a licence to practice in the UK will need to satisfy the General Medical Council (GMC), at regular intervals, that they remain fit to practice and should retain that licence. Subject to a final assessment of readiness, the regulations that will make revalidation a legal requirement are due to come into force in late 2012.

2. BACKGROUND 2.1 Plans for periodic revalidation of doctors in the UK have been under discussion for

some years. A formal system of revalidation was first proposed by the GMC in 2001, but its introduction was delayed while the Shipman Inquiry reached its conclusions. This Inquiry concluded that the NHS and GMC did not have the systems or culture in place that would have allowed conduct such as that of Shipman to be detected, and that current appraisal processes were of variable quality and effectiveness.

2.2 Following extensive consultation, proposals for the reform of medical regulation were

outlined in the 2006 DH White Paper “Trust, Assurance and Safety” and thereafter in a 2008 report by the Chief Medical Officer entitled “Medical Revalidation - Principles and Next Steps”. In 2011, following an extensive pilot phase, these proposals were reviewed by the Health Select Committee and are now being taken forward through a series of legislative and non-legislative initiatives, subject to a final assessment of readiness in late 2012.

2.3 The principal aim of revalidation is to assure patients and the public, employers,

healthcare providers and other healthcare professionals that licensed doctors are up to date and practising to the appropriate professional standards. In so doing, revalidation will:

• Provide support for organisations in the continuous improvement of the quality and

safety of healthcare for patients; • Help doctors meet their professional commitment to keep up to date and improve

their practice through meeting specialty standards and identifying development needs where appropriate;

• Assist employing organisations in identifying issues early and put in place appropriate processes to support doctors.

APPENDIX 6 BOARD OF DIRECTORS

10 OCTOBER 2012

2

2.4 When initially proposed, revalidation appeared to be a mechanism for uncovering badly performing or potentially dangerous doctors. Revalidation, as now understood, however, is intended to be a positive affirmation that a doctor is up to date and practising to appropriate prescribed professional standards. Although the GMC is charged with overseeing the revalidation process, the Medical Royal Colleges and Faculties are responsible for defining the specialist requirements for revalidation expected of a doctor practising in a particular specialty.

3. HOW MEDICAL REVALIDATION WILL WORK 3.1 All doctors will be required to have a ‘prescribed connection’ to one particular

organisation (referred to as a doctor’s ‘designated body’) that will provide them with a regular appraisal and help them with the process of revalidation. Doctors will need to have an annual appraisal based on the core guidance for the medical profession, as outlined in the GMC’s ‘Good Medical Practice Framework’.

3.2 At appraisal, doctors must provide a portfolio of supporting information drawn from their

practice, which demonstrates how they are continuing to meet the principles and values set out in Good Medical Practice. Whilst individuals will be expected to collate most of this information themselves, some will need to come from the organisation that is supporting them with revalidation. Specifically, there are six types of information required for the purposes of revalidation, namely:

• Continuing professional development (CPD); • Quality improvement activity; • Significant events; • Feedback from colleagues; • Feedback from patients; • Review of complaints and compliments.

3.3 Every organisation that employs medical staff is required by law to appoint a

Responsible Officer (RO) and provide appropriate resources. The role of the RO, usually the Medical Director of the designated body, is to make a recommendation to the GMC, for each doctor, every five years. This recommendation will confirm that the doctor is up to date and fit to practice, and therefore should be revalidated. The RO will make their recommendation with reference to an individual’s appraisals over the last five years and other information drawn from their organisation’s clinical governance systems. Based upon this recommendation, the GMC will re-issue the doctor’s licence to practice and the doctor will be able to continue to practice in the UK. Where a doctor has provided insufficient evidence for revalidation, the RO may choose to request that revalidation is deferred, or that the individual is referred for further investigation by the GMC.

3.4 Full and specific arrangements for the implementation of revalidation have recently

been confirmed, and GMC guidance indicates that approximately 20% of doctors should be revalidated in ‘Year One’ (December 2012 to March 2014) and will need to be identified by September 2012. The criteria by which these doctors will be identified has been decided, following GMC and SHA guidance, with the majority of doctors to revalidate within the first cohort (by end March 2014) selected at random by GMC number, and subsequent cohorts in the following 2 years (April 2014 – end March 2015 / April 2015 – end march 2016) being wholly randomly selected, also by GMC number.

3

4. CURRENT LOCAL PREPAREDNESS

Responsible Officer 4.1 The Medical Director has been designated as the Trust’s RO and has attended the

designated RO mandatory training. Should a conflict of interest arise between the RO and a particular doctor(s) for whom the RO is responsible, then arrangements will need to be made for a deputy RO to stand in. The GMC has issued guidance on how this process should be undertaken should the need arise.

Number of Doctors to be Revalidated

4.2 Based upon the number of existing medical staff currently in employment, the Trust will be the designated body for approximately 140 doctors for the year 2012, for the purposes of revalidation. In July 2012 the GMC provided designated bodies with a list of those doctors who they believe have a prescribed connection with them. We are currently reconciling our data with those provided by the GMC. For the majority of doctors this is a relatively straight forward process, however there are a significant number of doctors (fixed term contract holders/trust locums and others) for whom there is still a lack of clarity about where their prescribed connection lies. However, it would appear that if they have a contract of employment with YDH (however short) then we will be their ‘employer’ and therefore designated body (unless they have been employed through a locum agency, with whom their primary contract exists). This group of doctors will be very transient; will affect our figures in terms of compliance with revalidation requirements and appraisal numbers; will be difficult to manage within our proposed revalidation process/PrEP system but, more importantly, will prove difficult to confidently recommend for revalidation if their allocated revalidation date comes up when they are in our employment.

4.3 The position with respect to doctors in training is to be clarified, but it is expected that

this role will sit with the Deaneries or Local Education & Training Boards, who presently hold responsibility for the Annual Review of Competence Progression (ARCP) process. However it is clear that Trusts & the RO will play a key role in providing clinical governance, CPD & performance data on trainees for the revalidation process. A pilot is currently being undertaken by the Severn Deanery to understand how this will run. Deaneries will operate as part of the newly formed Local Education and Training Boards (LETBs) when they are launched in April 2013.

Appraisal Infrastructure and Status

4.3 Central to the revalidation process is a doctor’s record of annual appraisal over the five-

year revalidation period. Participation in annual appraisal has been a requirement for some time (and, indeed, is a condition of eligibility for pay progression and consideration for excellence awards), but is now set to become even more important. Through appraisal, doctors will need to demonstrate they are practising in accordance with the Good Medical Practice Framework and the associated college-defined specialty standards. During the revalidation cycle, a doctor will be expected to provide sufficient supporting information, in all six domains, at appraisal to allow their appraiser to assess the quality of professional practice, and ultimately for the RO to feel confident in recommending them for revalidation. Quality assuring this is a key part of the revalidation process.

4.4 The Trust has a medical appraisal policy and process, which reflects the provisions of

the Good Medical Practice Framework. This was endorsed by HMT & Local Negotiating

4

Committee (LNC) earlier this year. It is however recognised that the revalidation process continues to evolve and this policy will, as a result, need to be updated in the future.

4.5 The appraisal process has previously been predominantly paper-based and was reliant

upon doctors collating and presenting a portfolio of necessary information for assessment by their appraiser. In June 2012 the Trust procured a web based IT Revalidation Management System (RMS) that will allow doctors to effectively gather and store relevant supporting information in order to meet the requirements of the Medical Appraisal Guidance (MAG) and Revalidation. The system, called PrEP (Premier IT E-Portfolio), will also allow the allocated appraiser access to supporting information submitted by the appraisee, as well as the appropriate appraisal sign off form. The Responsible Officer will be able to see the appraisal portfolios of all doctors within the trust, collate & monitor any performance concerns and record recommendations for revalidation. The system is web based so that doctors can access it from anywhere, at any time. It also provides a dashboard for the RO to assess progress at Divisional, Directorate & Individual level in terms of progress towards revalidation.

4.6 Currently, there are 38 recognised medical appraisers within the Trust, all of whom

have attended recognised appraiser training. A key requirement for Revalidation is not only to ensure adequate numbers of appraisers, but also to ensure enough time is available for appraisers & appraisees to undertake the process, that appraisee feedback is sought and that audit is undertake to ensure the quality of the outputs from appraisal. Although our appraisers are all medical staff, recent guidance has confirmed that this is not a mandatory requirement for revalidation.

4.7 The appraisal rate amongst all medical staff is currently 92%. As a consequence of

revalidation awareness-raising within the medical workforce, this has increased steadily over the past six months. Further improvement is required, particularly in supporting non-consultant grade doctors through the appraisal process which, to many, is a new and significantly more robust process than that with which they have previously been familiar.

4.8 As part of readiness for Revalidation we have been required to complete a number of

Organisation Readiness Self Assessments(ORSA’s) for the DoH via the Revalidation Support Team(RST) in addition to the SHA’s own monthly progress reports. The latest (from June) has been collated with all those from the South of England SHA. We have currently been rated as green on a RAG score and as such are considered to be ‘on track’. A gap analysis has been undertaken. NCRAC has also recently undertaken an Audit with RSM Tenon with regard to our readiness for Revalidation. The findings are currently awaited.

Multi-Source Feedback (MSF) Support

4.9 A key requirement for the supporting information to be presented by individuals at their appraisal is feedback from colleagues & feedback from patients. The GMC have set out very particular standards required for this MSF. Current requirements are that doctors must undergo an MSF at least every three years. However, for the first revalidation cycle of revalidation (Dec 2012 onwards) an MSF is required. We therefore need to consider a tool to enable this to be available before Dec 2012 for the first cohort of doctors to be submitted to the revalidation process. The Trust is currently looking in to an appropriate MSF toolkit to use.

5

5.0 FURTHER ACTIONS 5.1 Notwithstanding the preparations that have been made in anticipation of the introduction

of medical revalidation in 2012, further actions need to be taken to ensure a comprehensive and robust system is established. These are summarised, as follows:

- Confirming with the GMC the doctors with whom we have a prescribed connection –

July 2012. This has been done, but there is a continual turnover of medical staff, including a number of Trust Locums, both short & long term around whom the process of revalidation is still unclear.

- Plan in place to ensure all doctors are appraised by March 2013. Progressing well,

raised internal awareness & educational sessions arranged. Monthly audit of appraisal status disseminated to RO, Appraisal Lead & DD’s. PrEP system introduced with training & support. Regular updates at Trust wide meetings and intranet page. Awareness that the requirement for revalidation lies with the individual doctor concerned.

- Revalidation of RO by March 2012. SHA plan to do this in Dec 2012. Work in

progress, requirement for MSF to have been done before then, appraisal of MD role by CEO, training undertaken, Trust ORSA/monthly updates and data from internal audit to be presented in addition to clinical data.

- Procure a MSF fit for purpose by end Sep 2012. - Quality Assurance of appraisal & revalidation process. Revalidation support group

to be established, feedback from appraisals to be reviewed including quality of appraisal documentation (PDP’s & summary of discussions) including review of supporting evidence as being on track.

- Time & Support for appraisers within current job plans. Review the possibility of

training non-medical staff within the Academy to undertake revalidation ready appraiser / appraisal training.

- Confirm with GMC by Sep 14th timescale for scheduling doctors for revalidation over

next three years. RO by Dec 2012 then 20/40/40 %. - Clarification of the process of revalidation for trust locums and liaising with

PCT/CCG with regard to agency locums. - Managing the revalidation system: Time/resource requirements for ongoing review

documentation & PrEP system to ensure doctors are on track to revalidate so there are no surprises when it comes to revalidation. The revalidation process itself.

- Review ‘Pre-Employment checks’ to capture details of: current RO & Designated

Body; Revalidation due date & date of last appraisal; Records of appraisal; relevant performance monitoring information; records of patient & colleague feedback; records of fitness to practice investigations, disciplinary procedures; potential

6

requirement for MD/RO to be responsible for language assessments of medical staff.

- Remediation process & policy, with resource to support doctors who are indentified

as failing.

- Work between Human Resources Dept., Clinical Governance Dept and RO to ensure that relevant capability / disciplinary information etc. pertaining to revalidating medical staff securely held in single, accessible location, to inform the RO when making recommendations for revalidation to the GMC.

6. SUMMARY 6.1 To date, the Trust has made good progress in preparing for the implementation of

medical revalidation, which is anticipated in late 2012. The requirements of revalidation place significant responsibilities upon the RO/MD, employers and doctors, alike. Awareness of these responsibilities within the medical workforce is increasing. Clearly, a central tenet of the revalidation process is the effective and efficient application of regular appraisal, submission & review of good quality, supporting information and the full participation of medical staff in its associated activities. The implementation of an electronic revalidation system will help improve the administration of the appraisal process and assist doctors in the collation, storage and presentation of supporting information and documentation. However, the burden of actually keeping track of and revalidating all the doctors in the organisation at the same time & quality assuring the process cannot be under-estimated.

7. RECOMMENDATION 7.1 The Board of Directors is asked to note the contents of this paper.

_________________________________________________________________________________________

8 App 7 Medical Devices Training Report BoD Part 1 10 Oct 2012 Page 1 of 2

Report to: Hospital Management Team / Board of Directors

Report from: Helen Ryan, Director of Nursing and Clinical Governance Robert Steele, Director of Estates and Facilities

Subject: Medical Devices Training Update

Date: 10 October 2012

1. Introduction

The purpose of this paper is to update the Board of Directors on the progress for Medical Devices training.

2. Background

The Annual Medical Devices report was presented to the Board of Directors on the 13 June 2012 with an action to improve medical devices training as this had not progressed as expected. Since then this has been followed up through the Academy, reported to NCRAC and the Medical Devices Committee.

The Director of Nursing as training lead has led the setting up a training plan and check list of commonly used devices. A time plan is now in place with stage one implemented and the second stage on-going. Specialist departments including main theatres conduct their own training needs analysis (TNA) and this has been used to develop a centralised approach with record keeping.

The Work Plan and Gap Analysis of Medical Devices Training/Competency arrangements were established by the Trusts Risk Management Facilitator/Medical Devices Training Co-ordinator to address the shortfalls and gaps.

3. Progress

Good progress has been achieved with the June target met including:

Safer use of medical devices awareness training is now part of day two corporate induction training since January this year.

The top ten commonly used ward medical devices have been identified. Training and competency and the Academy web site is being updated.

All competency assessments have been updated; local induction checklist has been drafted and is being trialled to ensure all training is documented as part of local induction.

Staff passports usage and compliance regarding medical devices is being addressed by Anna Tennant and seconded by Maddie Groves. The format of the staff passport is being reviewed by HR .

Maddie Groves has taken over the steering of medical devices training and the Medical devices Training Needs Assessment is being updated.

4. Ward Records / Reporting

All training records held at ward level will be reviewed by the 5 October 2012 and forwarded to the Academy to update central records. Records are also being checked for the Maternity Unit to check Maternity Assurance of Competence. Once this has been completed and uploaded onto the OLM training database a report will be produced to demonstrate progress.

APPENDIX 7 BOARD OF DIRECTORS

10 OCTOBER 2012

_________________________________________________________________________________________

8 App 7 Medical Devices Training Report BoD Part 1 10 Oct 2012 Page 2 of 2

5. E-Learning

The E-Learning system has been tested within the Academy however the content appears to be too generalistic at present and therefore will not be pursued.

6. Actions

Further actions which are on-going include:

Electronic reminders for individual mandatory training to be established linked to the staff training passport

E-Portfolio to be discussed with clinical teams with feedback at next meeting

Up to date OLM reports to be monitored at staff meetings

Assurance of competence to be obtained from the Therapy Manager and Radiology Manager

7. Recommendations / Actions

The Board of Directors is asked to NOTE the progress achieved for Medical Device Training.