Board of Directors’ Meeting Report – 5th September 2017 ... · RTT Reporting Specialty Cardiology Ear, Nose & Throat (ENT) Gastroenterology General Medicine General Surgery Geriatric

Title Integrated Performance Board Report

Sponsoring Director Yvonne Blücher, Managing Director

Author(s)

Director of Operations, Information Team, Director of Nursing, Director of HR, Director of

Estates and Facilities, Medical Officer

Purpose

The purpose of the report is to provide an overview of the Organisation's performance for the

month of July 2017.

Previously

considered at By Executive Team on 21st August 2017.

Board of Directors’ Meeting Report – 5th September 2017

Agenda item 64/17

Executive Summary: This Integrated Performance Board Report is presented to the Trust Board as written assurance

on the current levels of activity and performance within the Trust together with a detailed analysis of Trust performance

against the key national targets and locally agreed measures. It further identifies areas of underperformance against

the standards and details of agreed remedial action plans to return the organisation to an acceptable level of

performance compliance.

Performance:

• 4Hr A&E standard of 95% - April's performance was 95.30% which exceeded the national standard. However, May

was 91.74%, June was 90.71%, and July was 91.66%, which were all below the national standard.

• Referral to Treatment incomplete pathway standard of 92% - The May and June performance against the standard

were 86.26% and 85.35%, these are below the recovery trajectories. The July position is 83.57% which below

trajectory. The areas of challenge are within Ophthalmology, MSK, ENT, and Respiratory – where demand is

outstripping capacity.

• In Sept additional capacity has been identified for ENT, out-sourcing continues with Ophthalmology, Respiratory have

recruited a locum to increase out-patient capacity. 4 Eyes analysis has identified areas of capacity opportunity in MSK,

ENT and general surgery which will be maximized in Sept/Oct

• The Trust has engaged with the CCG to develop a recovery plan. The total number of patients to be treated in the

affordable plan is 2703. This will contribute approximately 2% improvement to our overall performance which is

calculated at 87.4% against a trajectory of 92%

• Cancer 62 day standard of 85% - The performance in June was 63.5% which is below trajectory and the unvalidated

July position is 77.3% which is above the trajectory. The recovery trajectory to achieve compliance against the standard

is this October. Daily cancer meeting with AD and strict PTL management has contributed to the recovery. Pathways

have all been reviewed against best practice and changes implemented. Additional capacity created in theatres. 2

week rule appointments reduced to 7 day waiting. Work in progress to reduce diagnostic test waits with external

partners.

Quality:

• Complaints: 91 new contacts were received from people wishing to raise a complaint during July 2017, 57 of which

were managed as formal complaints. 24% of the concerns received were managed through the rapid response early

resolution process, following agreement with the complainant. The key themes raised in complaints were unchanged;

Clinical Treatment, Clinical Judgement, Outpatient Appointments/Delays and Communication.

• Friends & Family: The response rate increased for inpatients and maternity during July 17 whilst there was a slight

decrease in ED and outpatients.

• Falls: falls per thousand bed days remains below national average. 1 extreme severity fall and 3 moderate severity

falls in July 17 are currently being investigated.

• Pressure ulcers: In July 17 there were 2 avoidable pressure ulcers, 1 due to poor documentation and the other RCA

meeting is yet to be held.

Estates and Facilities:

• One statutory PPM was not signed off in the month. This was due to undergoing a tender to provide pest control

services.

• Domestic cleaning standards were generally met, eleven areas were identified as needing further cleaning and re-

audit. These are highlighted in the body of the report.

• Underperformance in switchboard targets for GP calls and external calls. This is due to waits experienced at

departmental level. Discussed at AD/Hons meeting and working with departments to achieve improvement.

Southend University Hospital NHS Foundation TrustPage 1 of 33

Date Reviewed by

SLT & JEG 24 August 2017

Excellent Patient Outcomes

Excellent Patient Experience

Engaged and Valued Staff

Financial and Operational Sustainability – Financial, Operational, Estate

Risk 1 – Failure to provide adequate patient safety and quality of care

Risk 2 – Poor patient experience

Risk 3 – Failure to meet operational performance targets

Risk 4 – Trust not being financially sustainable

Risk 5 – Inability to recruit and retain staff

Risk 6 – Unable to maintain estates and facilities to an adequate standard

Essex Success

Regime

Does this proposal have any implications for the other Trusts within the Essex Success

Regime (BTUH and MEHT) or for the Mid and South Essex health economy as a whole?

If so, please outline the anticipated impact (including positive and negative implications) and

the degree to which these have been discussed with and endorsed by the other Trusts and the

Success Regime Leadership Team?

Legal implications /

regulatory

requirements

Poor performance can affect all aspects of the organisation resulting in possible regulatory

sanctions and legal claims against the Trust.

Quality impact

assessment

The aim of the Integrated Performance Board Report is to ensure that patient, public, and

workforce safety is maintained to the highest standards.

Equality impact

assessment

As far as can be ascertained this paper has no detrimental impact for the 9 protected

characteristics under the Equality Act 2010.

Recommendation: The Board is asked to receive assurance from this report.

Related Trust

Objective

Related Risk

Workforce:

• The Trust continues to work on improving appraisal return rates. The compliance rate in July is 74%, an increase from

June at 72% and May at 70%.

• The vacancy rate has reduced from 12.59% in June to 12.14% in July (further to an increase earlier in the year due to

the more accurate reporting of establishments).

• Agency Spend as % of total pay bill has reduced from 8.99% in June ytd to 8.87% in July, continuing on the downward

trend.

• Sickness absence for the year to date in July is 3.84% a decrease from June at 3.88% and May at 3.96%.

• Staff Voluntary Turnover has increased from 13.07% in June to 13.49% in July and is on an increasing trend.

• Statutory and mandatory training continues to achieve the Trust target at 85%.

Southend University Hospital NHS Foundation TrustPage 2 of 33

Executive Summary:

SUHFT Integrated Performance Report

Operational SMART Objectives

RECOVERY TRAJECTORY

Southend University Hospital NHS Foundation Trust Page 3 of 33

Executive Summary:



A&E Graph: Weekly performance of A&E attendances July again proved to be a challenging month with high attendances through the ED and generally high acuity levels. Patients requiring longer stays in hospital reduced bed availability and as such at times flow was affected. As a result of this, performance again couldn’t compete with April’s 24 green days, however, equalled that of May and June with 11. The ED saw a number of changes in July, the most significant being a change in the front door model where GP SEEDS were replaced by Consultant and nurse led triage. This started on the 3rd and so far there has been no notable change in performance. The CDU successfully opened on the 3rd of July and has consistently been utilised; however, there is on-going work around process which should further improve the utilisation and efficiency of this new resource. Nurse staffing levels both in the ED and across the Trust remained extremely challenging throughout July (due to short term sickness, maternity leave, awaiting new starters and vacancies due to difficulties in recruiting), which at times impeded flow and affected the efficiency of the system; however, there is significant focus on this and by September it is expected that nursing staffing levels, particularly within the ED will be improved. Medical staffing levels across acute medicine have continued to cause on-going challenges and at times impacted flow through AMU. This was partially mitigated through the redeployment of medical resources where able, with job planning work underway, however, this is a long term fix and will require time.


Executive Summary:



Note: The '95th percentile Arrival to Initial Assessment' reports the time at or below which 95% of the patients waited for their initial assessment from arrival (this only applies to patients arriving by ambulance). The 'Median Arrival to Treatment' is the midpoint, or 50th percentile, of all patients' treatment times; therefore, 50% of patients will have been treated before this time and 50% will have waited longer. All the clinical indicators above are nationally defined and monitored. Local peer comparison:


Executive Summary:



RTT - 18 Week Pathway Children awaiting operations at the end of July:


Executive Summary:



The number has increased from 104 since June, ENT has experienced the greatest increase 96 from 69. This is due to patient choice and surgical capacity related annual leave. 52 week breaches: There have been 18 instances of submitted 52 week breaches for the year to date. These relate to 10 patients, all of whose RTT waits have now completed. Actions going forward: • Working with CCG to agree a backlog recovery plan, key specialties – Ophthalmology, Cardiology, Thoracic Medicine. • Recruitment of medical staff in Ophthalmology. • FOUREYES working with specialties to determine capacity and productivity opportunities. • Relaunch of RTT rules to all staff, following revision of Access

Policy. • In Sept additional capacity has been identified for ENT, out-sourcing continues with Ophthalmology, Respiratory have

recruited a locum to increase out-patient capacity. • 4 Eyes analysis has identified areas of capacity opportunity in MSK, ENT and general surgery which will be maximized in

Sept/Oct Table: July incompletes by specialty RTT incompletes local peer comparison:

RTT Reporting Specialty

Cardiology

Ear, Nose & Throat (ENT)

Gastroenterology

General Medicine

General Surgery

Geriatric Medicine

Gynaecology

Neurology

Neurosurgery

Ophthalmology

Oral Surgery

Other

Rheumatology

Thoracic Medicine

Trauma & Orthopaedics

Urology

Grand Total

76.63%

Performance %

89.48%

85.79%

96.80%

97.10%

83.58%

100.00%

89.33%

100.00%

100.00%

73.72%

92.88%

89.77%

100.00%

83.61%

83.70%

80.97%


Executive Summary:



Short notice Cancellations For the month of July the level of cancellations has reduced to 30 (from 79 in June). Of the cancellations in June the majori ty of the cases cancelled were due to environmental factors in the eye unit theatres and emergency capacity required in main theatre. T he overall reduction in cancellations in July - the lowest level since September 2016 - reflects the overall improved elective bed availability across the Trust, however some patients have been cancelled to accommodate emergency trauma cases.

Month Adm

inis

trat

ion

Erro

r

Canc

elle

d fo

r em

erge

ncy

Equi

pmen

t Fai

lure

/ U

nava

ilabl

e

Hea

lth C

are

Prof

essi

onal

Unw

ell /

Una

vaila

ble

Med

ical

Pra

ctiti

oner

Unw

ell /

Una

vaila

ble

No

Bed

Ava

ilabl

e

Thea

tre

Una

vaila

ble

List

Am

endm

ent

Hos

pita

l Inc

iden

t

List

ove

rrun

.

Hos

pita

l Can

celle

d -

Pros

th/I

mp/

Dru

gs/I

nst u

nava

ilabl

e

Op

requ

ires

spe

cial

ist D

octo

r

Op

requ

ires

spe

cial

ist D

r

Spec

ialis

t con

sulta

nt r

equi

red

Spec

ialis

t Dr

requ

ired

.

No

Tran

slat

or a

vaila

ble

Tran

spor

t Pro

blem

Gra

nd T

otal

Jul-16 0 3 6 6 7 13 2 1 0 0 0 0 0 0 0 0 0 38

Aug-16 4 2 13 1 5 11 1 4 0 0 0 0 0 0 0 0 0 41

Sep-16 3 3 1 4 0 5 4 0 0 0 0 0 0 0 0 0 0 20

Oct-16 3 7 2 3 1 19 2 2 0 2 0 0 0 0 0 0 0 41

Nov-16 2 4 4 7 8 39 2 0 0 0 0 0 0 0 0 0 0 66

Dec-16 2 3 1 1 7 7 6 1 11 0 0 0 0 0 0 0 0 39

Jan-17 1 8 7 0 7 16 16 1 0 0 1 0 0 0 0 0 0 57

Feb-17 0 5 1 1 6 8 21 2 0 0 0 1 1 0 0 0 0 46

Mar-17 0 11 3 5 1 8 14 2 0 0 0 0 0 1 0 0 0 45

Apr-17 1 6 0 3 0 2 9 1 0 0 0 0 0 0 0 0 0 22

May-17 3 9 3 1 1 4 8 3 0 0 0 0 0 0 1 1 1 35

Jun-17 1 16 3 1 0 2 55 1 0 0 0 0 0 0 0 0 0 79

Jul-17 4 9 4 0 2 2 6 3 0 0 0 0 0 0 0 0 0 30


Executive Summary:



Cancer Standards Confirmed performance for June 2017 indicates compliance with all standards except: • 31 day First Treatment – theatre capacity and clinical availability for Urology • 31 day Subsequent Surgery – theatre capacity and clinical availability for Urology • 62 day 2WW Suspected Cancer First Treatment Provisional performance figures for July 2017 indicate that the following standards will not be met: • 31 day subsequent surgery – theatre capacity for Urology • 62 day 2WW Suspected Cancer First Treatment Key reasons improving the 62 day performance: • Late referrals have been reduced through partnership working from other hospitals • Late referrals from other tumour sites has been tightened through daily PTL monitoring • Theatre Capacity has been increased for urology • Complex pathways remains an issue, but good escalation in process • Capacity for diagnostic tests – a lot of work has been carried out to improve turnaround time Patients over 104 days: At the end of July there were 10 patients waiting over 104 days on a 2 week wait (2ww) 62 day pathway. The longest wait is currently 208 days. This patient was referred to St Marys to discuss different treatment options and has since decided to be treated Basildon. Of the 10 patients, 1, is going to Basildon, 7 have a treatment date and 2 are complex still in diagnostic phase. The patients who have waited over 104 days for care are reviewed weekly. The cancer tracking team monitor these patients daily. Harm reviews are carried out on all 104+ day patients.


Executive Summary:



Actions: • Weekly performance monitoring mechanisms are in place to track patient pathways. • Robust action plans, owned by each speciality for the delivery of cancer are in place. • The revised 62 day recovery plan is being monitored weekly to determine performance improvement against each action. • Daily Communication meetings are held to progress actions. • Additional Surgical capacity is being facilitated to support the eradication of 104 day waits. • The Cancer Programme Director is working with Mid Essex, Southend, and Basildon Trusts to align pathways and create

efficiencies within the pathways. • A single Cancer Patient Tracking List across Mid Essex, Southend, and Basildon will be in place from September with the aim of

reducing delays in patient pathways. Local peer comparison:


Executive Summary:



30 day Readmissions Non-elective readmissions indicator is exceeding its target, monthly and ytd. A full evaluation of the reporting approach has been completed to ensure the methodology accounts for changing clinical pathways, such as ambulatory care. The recommended approach was reviewed and agreed by the SLT and has now been implemented enabling a more meaningful monitoring of readmission rates. Maximum 6-week wait for diagnostic procedures (DM01) Compliance against the DM01 99% standard has not been achieved in July (97.63%), capacity to meet the required activity levels was available, however, patient choice prevented compliance. The performance reflects a month on month improvement in performance since April 2017. Endoscopy capacity continues to be challenged, it is planned for compliance with the standard for September 2017, this requires additional external support currently. Actions going forward:- • Continue to provide additional capacity for the Endoscopy service by utilising an insource company ‘Your World’ who are

providing Nursing and Medical staff. • Redesigning administrative process to improve efficiency of bookings. • FOUREYES external support team are reviewing the capacity within the unit to identify any workforce shortfalls and

productivity efficiencies. Delayed Discharges The 3 main areas of increase in delay days for July were: • Intermediate care delays increased from 30 days in June to 60 days in July. This was mainly due to lack of Home rehabilitation

and also Early stroke Discharge team start dates. These are EPUT services. • Care package delays increased from 27 days in June to 41 days in July. • CHC delays increased from 5 days in June to 41 days in July. – A new pilot has commenced in CPR CCG, and has increased

some waits, but there are meetings planned to resolve this. We expect these to decrease in August, although there are still delays with intermediate care.

Indicator Target Jun-17 YTD

Elective ≤ 3.47 2.86% 2.52%

Non-elective ≤ 9.69 12.44% 12.29%

Time Period


Executive Summary:



All graphs are as up to date as possible, up to the end of the reporting month


Patient Access - Yvonne Blücher

Target

Internal /

External

Data

Month

≥ 92%Monitor &

CCGJul-17 83.58% q

Target of zero CCG Jul-17 18 4 u

≤ 180 (Target change 01/12/2014) Internal Jul-17 1926 p

Rate below 5% CCG 6.9% 6.9% q

95th% equal to or below 4 hours CCG 04:59 05:10 q

Rate below 5% CCG 1.4% 2.0% p

95th% below 15mins for

ambulance casesCCG 00:51 00:55 p

Less than or equal to median of

60 minsCCG 00:58 01:07 p

≥ 95% of all cases to be seen

w ithin 4 hours. (SITREP data)

Monitor &

CCGJul-17 92.3% 91.7% p

Trolley Waits None Over 12 hours CCG Jul-17 1 0 u

Arrival to handover (≥ 85% w ithin

15 mins)CCG Jul-17 43.4% p

Arrival to handover w aits 30-60

minutes (Target is '0' Breaches)CCG Jul-17 862 250 q

Arrival to handover w aits over 60

minutes (Target is '0' Breaches)CCG Jul-17 122 47 p

< 0.8% FFCE's cancelled w ith

short notice.Internal Jul-17 0.88% 0.62% q

0' cancellations re-booked outside

28 days. External CCG Jul-17 34 4 q

Target of '0' External CCG Jul-17 0 0 u

< 1% Internal Jul-17 0.24% 0.16% q

all cancers (> 93%)Monitor &

CCGJul-17 95.4% 95.2% p

symptomatic breast (> 93%)Monitor &

CCGJul-17 96.1% 95.3% q

> 96%Monitor &

CCGJul-17 95.1% 98.2% p

Drug treatments (98%)Monitor &

CCGJul-17 99.5% 99.1% q

Surgery (> 94%)Monitor &

CCGJul-17 87.9% 87.5% p

Radiotherapy (> 94%)Monitor &

CCGJul-17 98.1% 95.7% q

from urgent GP referral to

treatment. All Pathw ays (> 85%)

Monitor &

CCGJul-17 70.0% 77.3% p

from urgent GP referral to

treatment. Southend Only (> 85%)Internal Jul-17 78.6% 82.8% p

from cons screening service

referral (> 90%)

Monitor &

CCGJul-17 97.7% 92.3% q

from cons decision to upgrade

priority. (>90%)CCG KPI Jul-17 69.0% 50.0% q

% of Occupied Bed

Days< 3.5% External CCG Jul-17 3.29% 2.6% p

> 99% External Jul-17 92.01% 97.63% p

> 99% External CCG Jul-17 98.62% 99.05% p

Number of measures compliant 21 q

Number in compliance range. 3 p

Number non-compliant 5 p

Data not provided/no target 5 p

< 7.45% Jul-17 6.46% 6.42% p

≤ 3.47 Internal 2.52% 2.86% p

≤ 9.69 Internal 12.29% 12.44% p

External CCG Jun-17 98.75% 98.72% q≥ 95% (Data now only updated on a quarterly basis)

Jun-17

-

ElectiveReadmissions

(30 Day)

2 w eek w ait from referral to

date f irst seen

Jul-17

Time to treatment

Cancellations

IP - Short Notice cancelllations

rebooked w ithin target

VTE Testing

Diagnostics (6

Wk Target) DM01 KPI - Diagnostic Breaches in

month

All Cancers: 31 day w ait

diagnosis to 1st treatment

All Cancers: 31 Day w ait for 2nd

or subsequent treatment,

comprising either:

DM01 - Waiting list as at month

end for Unify

Maternity

Dashboard

Various clinical and operational

Measures

All Cancers: 62 Day w ait for

f irst treatment comprising either:

Non-Elective

Delayed Transfers of Care

Movement on previous over 13 month period

Maximum 4 hour w ait

IP - Short notice cancellations

(non-medical)

Compliance -

YTD

Incomplete (not yet stopped)

Compliance -

Report MonthStandard / Target

Admitted Backlog

Ambulance Turnaround (now

based upon calendar month as

per Sitrep)

Unplanned re-attendance (w ithin

7 days any condition)

Time spent in A&E

Submitted pathw ay over 52

w eeks

Left w ithout being seen

Time to initial assessment

18 Week RTT

(Referral to

Treatment)

OP - Short notice clinic

cancellations via Call Centre

A&E

IP - Urgent operations cancelled

for a second time

Pre-op Bed Days (Elective)

Cancer

Jul-17


Executive Summary:



Complaints: 91 new contacts were received from people wishing to raise a complaint during July 2017, 57 of which were managed as formal complaints. 24% of the concerns received were managed through the rapid response early resolution process, following agreement with the complainant. The key themes raised in complaints were unchanged; Clinical Treatment, Clinical Judgement, Outpatient Appointments/Delays and Communication. 95 complaints were closed during July 2017 and actions included: Clearance of overgrown foliage around the perimeter of the hospital Improvements made to referral process for Cystic Fibrosis (‘CF’) patients to ensure only clinically appropriate patients are seen in the service. This action

was put in place as a result of a patient being referred to the service inappropriately from the community. This led to a delay in their eventual diagnosis which was not CF related.

Implementation of ‘Patient Diaries’ on ICU for patients and families to document activities and help patients and families understand care that has been provided during their stay

Outpatients clinics for the Women’s clinic will be reviewed 6 weeks in advance to ensure clinicians availability after an unassigned ad-hoc clinic had to be cancelled on the day due to no clinician being available

Eye department unable to accommodate guide dog for sight-impaired patient – refurbishment of unit planned for near future to avoid this problem reoccurring.

Bereaved family taken to viewing of different patient’s body with same name as family’s deceased. Out of hours viewings suspended whilst staff were retrained and new processes introduced to avoid reoccurrence

Complaints Backlog

The number of complaints in the backlog decreased in July to 71. The majority of complaints in the backlog (n.50) require advice from the clinical directorates in order to prepare a final response, and 11 responses were returned to clinical directorates requiring further information to enable a response to be finalised. Total in Backlog Over 6 Months: 6/7 Total in Backlog 3-6 Months: 12/13 Total in Backlog 0-3 Months: 53/54 Therefore the majority of overdue complaints are those which have been received in the past 3 months and the complaints team are waiting for the advice from the Directorates. The graph below shows the reduction in overdue complaints over the past 6 months: The complaints team have set an internal target to reduce the backlog to no more than 20% of ‘live’ complaints by the 31st October 2017. This is monitored weekly by the Head of Patient Experience and Deputy Director of Nursing. Current performance is 32% against a target of 26%. The graph below shows the current performance against this target.


Executive Summary:



Complaints (continued) Complaints and PALS team update Following the restructure of the Patient Experience Team in April 2017, we have now recruited to all vacant posts within the complaints team and by the end of August 2017 all staff will be in post. To maintain momentum in reducing the backlog of complaints we have trained our PALS team to assist with the drafting of complaints and the management of some rapid response queries. This has helped to increase the capacity of the complaints officers and allow more options to backfill during periods of leave within the team. We also have two patient experience assistants within the team who carry out administration tasks including setting up complaint meetings. Following the relocation of PALS in May 2017 the team have seen an increase in walk-in queries. The PALS team have been working hard to make the space as accessible as possible e.g. improving the office layout and creating a small waiting area for users to wait if they are assisting others. We have also ordered new signage for the office to ensure that service users can locate the office easily and the feedback on the new location has been very positive thus far. Friends and Family Friends and Family (In-patient and Day Case): The response rate increased very slightly from 25.27% in June to 25.36% for July and the percentage of inpatients who would recommend also has increased from 91.88% to 92.84% for July. Postcards continue to be distributed to all inpatient wards and staff are frequently reminded to hand these to their patients to try to further increase the number of people completing the survey. It has been noted that when volunteers are not present, particularly over weekends, the number of responses reduce and we have brought this to the attention of the wards affected with immediate effect. ED Friends and Family: The response rate decreased from 18.15% for June to 16.67% for July. The percentage recommend has also decreased for July from 87.23% in June to 86.90%. The team leader for patient experience has scheduled a meeting with ED to discuss the decline in results and will be looking to carry out a bespoke survey for the area to identify key areas of concern. Top two themes from positive comments: Staffing efficiency and treatment Top two themes of negative comments: Waiting times and staffing The aim for the bespoke survey will be to gather more detail as to the negative themes and develop areas for improvement in conjunction with ED. A further update will be provided once we have this data. Friends and Family (Maternity): We noted an increase in the response rate from 13.89% in June to 19.94% in July and also an increase in the percentage that would recommend from the 93.26% for June to 95.24%. SMS and IVM for Maternity commenced on 26 June 2017 and this mirrors in the increase in responses above. No issues with the new SMS and IVM system have been reported. Top two themes for negative comments: Communication and lack of staffing Top two themes for positive comments: staff and care/treatment given As with ED, the team leader for patient experience will carry out bespoke surveys to determine the detail behind these results and actions will be agreed within the directorate in line with the results obtained. A further update will be provided once complete. Friends and Family (Outpatients): We have noted a slight decrease in the percentage that would recommend (93.40% in June and 92.46% in July) and a decrease in the response rate (17.73% in June and 16.90% in July). Whilst this is a very small decrease, the patient experience team are carrying out a detailed analysis of the results to identify any specific cause(s) for this change and to determine whether any specific work needs to be done to target the lower performing areas. Often this area fluctuates without any key themes however a further update will be provided in the next report.


Executive Summary:



Falls: In July there were 81 adult inpatient falls which is 5.6 per 1,000 bed days which is still below the national average. There was 1 extreme severity fall and 3 moderate severity falls. The initiative to increase vigilance on Princess Anne Ward to reduce falls is extremely promising, showing a drop to 3 falls in July (average for the preceding six months was 6 falls). A post falls sticker is being trialled on Eleanor Hobbs and Windsor wards with the aim of improving compliance with the post falls protocol. These initiatives once trialled will be rolled out further in the Trust Pressure Ulcers: There were 2 hospital acquired pressure ulcers in July which were deemed to be avoidable. One was G2 and there was insufficient evidence of regular repositioning being carried out. The other was G3, and the RCA meeting is yet to be held. Maternity: Caesarean Section Births: The caesarean section rate July was 28%, which is encouraging. This is in line with the trajectory set by the Directorate. The improved position was largely due to the reduction in elective rates. Antenatal Bookings: the antenatal bookings are now being reported with the adjusted risk and we are now compliant with ensuring 90% of bookings are completed before 12 weeks of pregnancy. Breast Feeding: Breast feeding rates continue to fluctuate and although there are variations each month, July was a good month with 79% initiation of breast feeding at birth. All the good work in relation to the Breast Feeding Initiative (BFI) achievement continues however it is important to ensure the focus is on all methods of infant feeding and that all women get the right level of support regardless of chosen method of feeding. Infection Control:


Executive Summary:



Safety Thermometer Chart: Safety thermometer results (overall harm-free care %, and harm-free care % for new harms only)


Target

Internal /

External

Data

Month

External Qtr-1 1.174 p

Internal Jul-17 -3.79% 5.56% q

- Jul-17 254 57 q

No targets decided at present - Jul-17 5.63 p

10% reduction on 2015/16 (12 for

year, <=1 per month)Internal Jul-17 6 3 p

10% reduction on 2015/16 (12 for

year, <2 per month)Internal Jul-17 5 1 q

CQUIN Required

Response RateNational average (Variable) Internal Jul-17 25.4% p

Recommended % National top quartile (Variable) Internal Jul-17 92.8% p

CQUIN Required

Response RateNational average (Variable) Internal Jul-17 16.9% q

Recommended % National top quartile (Variable) Internal Jul-17 92.5% q

CQUIN Required

Response RateNational average (Variable) Internal Jul-17 16.7% q

Recommended % National top quartile (Variable) Internal Jul-17 86.9% q

Response Rate National average (Variable) Internal Jul-17 19.9% p

Recommended % National top quartile (Variable) Internal Jul-17 95.2% p

Average across

business units

≥ 90% (YTD show s 12 month

rolling average)Internal Jul-17 96.9% 96.2% q

≤ 25% (YTD is a rolling average) Internal Jul-17 30.9% 28.0% q

≥ 60% Internal Jul-17 61.3% q

≥ 70% Internal Jul-17 79.0% p

≥ 90% Internal Jun-17 92.0% q

Extreme Internal 0 0 u

High Internal 0 0 u

External:

CCGJul-17 0 0 u

<3 per month in accordance w ith

maintining previous reductionInternal Jul-17 8 2 q

Maintaining previous reduction,

cumulative (<=0.10%) Internal Jul-17 0.07% 0.07% q

Current Target: 94%External:

NationalJul-17 93.55% 92.29% q

External:

CCGJul-17 1 0 u

Jul-17Medication Errors (High &

Extreme only)

Total Hospital Acquired

(Avoidable)

Safety Thermometer

Target is 0 Breaches

Pressure Ulcers

(Grade 2 and

above)

Target of '0' (Chart & YTD figure show rolling 12

months)

Hospital Acquired as % of Total

Admissions (Avoidable)

Never Events

Single Sex Accommodation

Complaints

Zero Tolerance

S.V.D - Normal deliveryMaternity failing

compliance/

target in the last

13 Months

Bookings before 12 + 6

Movement on previous over 13 month periodCompliance -

YTD

Compliance -

Report MonthStandard / Target

Quarterly

10% reduction on previous year. Measured on YTD

compliance against previous cumulative YTD

Number of formal complaints per month

Total rate - All LSCS

Head Nurse Quality

Indicators (HNQI)

Maternity

A&E

Outpatients

FallsNo. of Falls resulting in

moderate harm

Ratio of falls per 1000 OBD

No. of Falls resulting in

high/extreme harm

Inpatients

Summary Hospital-level

Mortality Indicator (SHMI)

Friends & Family

(RR Targets

based on CQUIN,

'Recommended'

targets based on

National top 20%)

Initiation of Breast Feeding

Quality - Denise Townsend

0

Quality - Diane Sarkar


http://sohweb002/dashboards/201202-Summaries/201202RedKPI.xls

Reporting Month: Jul-17

FFT ModuleWould

Recommend

SUHFT (%)

Target Score:

Top Quartile of

National Trusts

Would NOT

Recommend

SUHFT (%)

Response Rate

(%)

IPDC: June 2017 91.88% i -0.41% 98.00% 3.90% h 0.13% 25.27% i -2.46%

IPDC: July 2017 92.84% h 0.96% n/a 3.22% i -0.68% 25.36% h 0.09%

ED: June 2017 87.23% h 0.55% 94.08% 7.42% h 0.13% 18.15% i -1.00%

ED: July 2017 86.90% i -0.32% n/a 7.50% h 0.08% 16.67% i -1.48%

Maternity: June 2017 93.26% i -6.74% 98.33% 5.62% h 5.62% 13.89% h 4.26%

Maternity: July 2017 95.24% h 1.98% n/a 3.17% h -2.44% 19.94% h 6.05%

Outpatient: June 2017 93.40% h 0.23% 98.28% 2.40% i -0.22% 17.73% i -1.86%

Outpatient: July 2017 92.46% i -0.94% n/a 3.10% h 0.70% 16.90% i -0.83%

Top and Bottom Scoring Wards (*where survey sample of 15% or more of IP discharges, and a minimum sample size of 10*)

The Friends and Family Test at Southend University Hospital NHS Foundation Trust

Change %

Recommend

Change % NOT

Recommend

Change % Response

Rate

0%

20%

40%

60%

80%

100%

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Mar

Inpatient and Day Case Friends & Family Scores and Response Rates 2017-18 YTD against 2016-17,

including National Rates

National Top Quartile Score (2016-17) National Avg Response Rate (2016-17)

% Recommend (2017-18) % Not Recommend (2017-18)

% Response Rate (2017-18) % Recommend (2016-17)

% Not Recommend (2016-17) Response Rate (2016-17)

0%

20%

40%

60%

80%

100%

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Mar

Emergency Department Friends & Family Scores and Response Rates 2017-18 YTD against 2016-17,





% Not Recommend (2016-17) % Response Rate (2016-17)

0%

20%

40%

60%

80%

100%

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Mar

Maternity Friends & Family Scores and Response Rates 2017-18 YTD against 2016-17,






0%

20%

40%

60%

80%

100%

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Mar

Outpatient Friends & Family Scores and Response Rates 2017-18 YTD against 2016-17,


National Average Response Rate (2016-17) National Top Quartile (2016-17)




Ward Name

No. of

Patients

% of

Patients

(% Wouldn't

Recommend)

Minor Operations Unit 32 of 32 100.00% 0.00%

Benfleet Ward 29 of 29 100.00% 0.00%

MSK Infusion Suite 23 of 23 100.00% 0.00%

Cardiac Care Unit (Sita Lumsden) 15 of 15 100.00% 0.00%

Bedwell Haematology and Oncology Unit 13 of 13 100.00% 0.00%

Wards Where Greatest % of Respondants Would

Recommend:

Ward Name

No. of

Patients

% of

Patients

(% Would

Recommend)

Ambulatory Emergency Care (on DAU) 5 of 46 10.87% 76.09%

Castlepoint Ward 3 of 33 9.09% 87.88%

Hockley Ward 3 of 33 9.09% 90.91%

Estuary Short Stay Medical 3 of 35 8.57% 88.57%

Ambulatory Emergency Care (Medical) 7 of 85 8.24% 88.24%

Wards Where Greatest % of Respondants Would NOT

Recommend:


Executive Summary:



Compliance With 3 Day and 60 Day Report KPI Duty of Candour - Eligible Incidents where Duty of Candour applies

Number of SI/NE In Reporting Period

Serious Incidents Never Events

45 1

Serious Incident by Category Serious Incidents

Target - Serious Incidents should be reported within 72 hours of being identified. Following this a 3 day report is submitted to ensure immediate actions are taken to prevent reoccurrence. A report at 45 days from the incident is undertaken to ensure that lessons are learnt and disseminated. Outstanding actions from individual SIs beyond their completion date will be reported to QAC .

0

2

4

6

8

10

12

Apr

il

May

June July

Aug

ust

Sept

embe

r

Oct

ober

Nov

embe

r

Dec

embe

r

Janu

ary

Febr

uary

Mar

ch

2017/18

Total Number of Incidents Verbal Completed Written Completed Within 10 Days

0

2

4

6

8

10

12

14

16

18

20

April

May

Jun

e

July

Augu

st

Sept

embe

r

Oct

ober

No

vem

ber

Dec

embe

r

Janu

ary

Febr

uary

Mar

ch

2015/16

2016/17

2017/18

71.4

%

100.

0%

100.

0%

100.

0%

77.8

%

62.5

%

55.6

%

80.0

%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

3 Day Achieved 60 Day Achieved

2

5

24

241

1

2

1

11

1

11

5 2

4

1

1

2

1

1

0

2

4

6

8

10

12

14

16

18

April 2017 May 2017 June 2017 July 2017

Access , Appointment, Admission, Transfer, Discharge Treatment, procedure inc operations

Implementation of care or ongoing monitoring/review inc. pressure ulcers Medication

Diagnosis, failed or delayed Clinical assessment (investigations , images and lab tes ts)

Accident that may result in personal injury Infrastructure or resources (staffing, facilities, environment)

Patient Information (records, documents, test results, scans)


Executive Summary:



Serious Incidents 3,396 patient safety incidents, near misses and concerns were reported on DATIX between 1 st April and the 31st July. Forty five Serious Incidents were declared involving seven directorates. The latest information available from the National Reporting and Learning Service from June 2017 shows 85% of all patient safety incidents report no harm. The Trust continues to show high levels of reporting with low harm, which can demonstrate a positive safer culture. Serious Incident April to July 2017 *Access, Appointment, Admission, Transfer, Discharge, ** Treatment, procedure including operations

Duty of Candour

Compliance with the written Duty of Candour regulation was 100%, however, there was a delay in compliance with the ten day

verbal compliance requirements in some cases. Some of the challenges in the non-compliance with the verbal requirement relate

to patients who are transferred to other care settings, or when patient harm has been detected a significant time after the event,

for e.g. a hospital acquired thrombosis up to three months following admission or the failure to document the patient has been

informed.

Completed RCA investigations

70% of RCA investigations did not meet the 60-day target for completion. Delays in Investigations occur for a variety of reasons,

including points of clarification or additional action requested as well as delayed submission. There is also a patient safety update

at the monthly core brief and patient safety messages in the Friday Round Up.

Lessons learnt from closed serious incident investigations

The Risk & Patient Safety Team produce a twice-monthly newsletter, distributed to all hospital staff for shared learning. The Team

regularly attend directorate meetings to discuss patient safety related issues.

Incident: A recent Never Event investigation found that the tag from a large surgical swab inadvertently became detached in a

patient. The incident was discovered when the patient returned to theatre for an unrelated issue during their hospital stay and did

not suffer any ill effects. The incident was reported to the Medicines and Healthcare products Regulatory Agency (MHRA) as swabs

have short tags that are not radio-opaque and cannot be detected on x-ray and research has failed to find a suitable replacement.

The integrity of swabs has been highlighted as part of the swab checking process and the process updated.

Incident: As part of pre-operative assessment, a chest x-ray was requested and the incorrect assumption made that the anaesthetist would review the x-ray prior to surgery. This did not happen as the patient had no respiratory concerns. A chest x-ray was undertaken a year later and a malignancy confirmed. On review the lesion could be seen on the pre-op x-ray. New systems have been put in place to ensure radiology findings suspicious of malignancy or incidental malignancy are communicated to the clinical team in a timely manner.


Executive Summary:



Lessons learnt from closed serious incident investigations (Continued)

Incident: An extensive investigation into the circumstances surrounding a patient developing MRSA bacteraemia identified a

number of learning and practice issues which have been addressed. This includes increasing our education programme for our staff

and patients to ensure they understand the screening and prophylaxis process.

Incident: A patient was found to have a wound swab in a deep wound. It was identified as a non-theatre swab based on size and

lack of radio opaque line and thought most likely to be a normal gauze dressing swab from previous wound dressings. The gauze

was intentionally retained as standard practice with wounds requiring Eusol but was not removed at the next dressing change. A

change of practice has been introduced to eliminate the possibility of this happening again and including complex deep wounds

will be packed with gauze roll rather than individual gauze dressings and development of a new guidance.

Incident: Patient undergoing a minor day stay procedure in an outpatient clinic suffered a sudden deterioration in health and

required transfer to a ward. The investigation identified concerns regarding documentation and pre-procedure risk assessment. A

new Standard Operating Procedure has been developed and approved to include pre-assessment and post assessment of patient

undergoing these particular procedures.

Patient Fall Incidents: Despite the processes and interventions already in place to reduce the number of falls sustained by patients

in the trust there has been an increase in patient falls where harm has occurred, the following actions to aid falls prevention are in

progress:

Baywatch safety programme is being rolled out to targeted wards in the tower block Governance folders in medicine have detailed updates on ward falls Introduction of safety crosses for falls Development of a programme of learning from the personal impact of falls from patient perspective Targeted training programme on lying and standing blood pressures Trial has begun of the post falls care stickers in the medical record Sharing of information and learning with ESR hospitals Lessons learnt and actions included in trust wide incident news sheet


Executive Summary:



Maintenance The following categories have failed to reach their KPI targets: Priority 3 - 57.84% against a target of 65% Priority 4 - 64.34% against a target of 80% Priority 5 - 56.25% against a target of 90% Statutory PPM - 98.82% against a target of 100% 1 Stat PPM failure due to new pest control contract being procured. A post of Operational Performance Manager has been established in order to improve upon the under achievement of the lower priority KPI’s. Clarification of roles and responsibilities following the appointment of the Operational Performance Manager will be undertaken to improve the departments operation performance and responsiveness. Domestic Cleaning Services The overall average as per the C4C audit tool was achieved in all categories, as some audits maybe lower / higher, this report highlights failed consecutive audit trends in the last three months: PTO


Executive Summary:



Domestic Cleaning Services (continued)

May-17 Jun-17 Jul-17

Very High Risk (98%) Kitty Hubbard Ward

Endoscopy

Day Stay Theatre 97.37%

Day Stay Theatre recovery 96.88%

SSD 97.44%

Sterile Scope

A/E Majors /Minors 95.95% 91.14% 94.81%

Orthodontics

CDS Theatre 96.51%

CDS Ward

MEMS Equipment-Store BSM

Paediatrics Emergency dept

Blenheim

Hillborough Building- SSD

Chemotherapy -CC GF

Eye Theatres

MEMS Equipment-Store BSM

Elizabeth Loury

Carlinford Centre

Eastwood 97.63%

Radiotherapy 97.55%

Renal unit

Oral Surgery

Oncology GF

J.Alfred Lee (Theatres) 97.50%

Minor Ops 97.22%

High Risk (95%) MB2 94.63%

MB1

Corridor 1st 92.68%

Corridor 2nd 94.59% 92.11%

Corridor Grd 91.54%

X-ray 1st

X-ray 2nd

X-Ray Ground floor

Canvey Clinic

Tyrells Clinic 94.82%

Phlebotomy 93.20%

Princess Anne

Castlepoint

Sita Lumsden

Breast Unit

Outpatient Department

Benfleet Ward

Rehab/Physio

Neptune

Medical Photography

CDMS 94.38%

light house

Eye Clinic

Lifts 89.74% 84.52%

Estuary ward 93.73%

Windsor

Heart and chest clinic 89.86%

Dowsette 93.53%

FMC

Westcliff 94.44%

CT Scanner (X-Ray)

Significant Risk (85%) Pharmacy PHA GF 77.14%

Porters stairs

Bereavement suite

Palliative care

Tower basement

Low Risk (75%) Chapel

Domestics managerial cleaning audit failure trend 2016


Executive Summary:



Domestic Cleaning Services (continued) On average cleaning risk categories achieved/exceeded their targets. Please note that the average scores are based on actual first instance cleaning audit scores. Very High Risk: A total of 32 managerial cleaning audits were conducted and 2 areas failed to achieve the target in the first managerial cleaning audit. A&E -three incidences of dust -rectified. J Alfred Lee Theatre - waste receptical dust - rectified High Risk: A total of 60 managerial cleaning audits were conducted and 8 areas failed to achieve the first managerial cleaning audit. MB2 - three incidences of dust -rectified. 2nd floor corridor - radiator and low surface dust - rectified. ground floor corridor - four incidences of dust -rectified. Phlebotomy - Low surface dust, sink grime build up at edges - rectified. CMDS - high surface dust, dusty chair, dirt under sink, dirt an floor. - rectified. Westcliffe - waste recepticle dusty, sink has limescale - rectified Lifts - dirty floor, wall to be cleaned - rectified Significant Risk: A total of 14 managerial cleaning audits were conducted and 1 area failed to achieve the KPI cleaning audit target. pharmacy - seven issues of dust Low Risk: 1 managerial cleaning audit was conducted and achieved 86.11%. All wards/ departments that failed the first instance managerial cleaning audit have had an action and rectification plan completed. Trends identified to staff and areas to improve communicated. Catering Average cleaning scores for ward kitchen achieved 98.48%, Retail Outlet kitchen achieved 99.28% and Education Centre restaurant 100%. All catering KPI risk categories achieved their contractual targets. Laundry and linen service Quality: EFM audit 21/6/17- 98% and QA audit 13/7/17- 99%. Average 98.50%. Feedback provided to laundry: Sheets - Improvement in fabric quality and whiteness. Garments - There was some improvement second half of the month, and new finishing equipment being trialled in laundry.


Executive Summary:



Portering Service Additional porters added to A&E to meet demands of A&E increased footfall. Telephony Service Telecoms Team have objectives to meet call answer time targets in line with Trust standards. Priority lines and Monthly Service Level Agreements: Priority 1: Internal Trust Emergency calls – 95% calls to be answered within 5 seconds Priority 2: GP calls – 95% calls to be answered within 20 seconds Priority 3: External calls – 95% calls to be answered within 40 seconds Priority 4: Internal calls – 85% calls to be answered within 50 seconds Priority 1 - Emergency Calls 87.20% There is an IT issue relating to how these calls are timed. The 5 seconds SLA timing starts immediately the phone is picked up by the person about to place the call and not when the call is received in telephony service or time used to deal with the call in telephony service. The issue is being discussed with IT Priority 2 - GP Calls 93.20% Calls are answered by the switchboard within KPI time, measure is at point of answer by the ward/dept. Priority 3 - External Calls 93.10% Calls are answered by the switchboard within KPI time, measure is at point of answer by the ward/dept. Priority 4 - Internal Calls 89.50% KPI target met


Executive Summary:



MEMS Helpdesk: Target – 95% of incoming calls to be answered within 50 seconds. In July, 89% (714) of calls were answered within the 50 second target time. Total calls answered 799 with an average wait time of 1 minute 16 seconds. Pressure Relieving Devices (Air Therapy Mattresses (ATM) - In July, 100% (134) of requests for Pressure Relieving devices were fulfilled from the 134 requests received. Overall Stats for All Loan Equipment Requests (Inc. ATMs) - Received during our normal operating hours (08:00hrs-17:00hrs Monday –Friday excluding Bank Holidays) is as follows: In July, 96% (196) of requests for all Device types were fulfilled from the 205 requests received. ***These results are reflective of Trust Seasonal Pressures*** KPI Overview The MEMS Department monitors its performance against a range of key performance indicators established by the National Performance Advisory Group -Clinical Engineering. Although not exhaustive, the following summarises the major KPIs reported on a monthly basis. Turnaround Time - Percentage of quoted turnaround times achieved for equipment repairs, Target 85%: Critical no more than one day 92% PASS High no more than three days 82% PASS Medium no more than 14 days 88% PASS Turnaround time is often affected by circumstances outside of the control of MEMS such as the procurement of exclusive spare parts, OEM / external contractor involvement, equipment access and authorisation (external organisations). The user of the equipment is made aware if the equipment requires a lengthy repair and substitute or loan equipment is arranged if required. Response Time Percentage of quoted response times achieved to attend equipment faults, Target 85%: Critical respond within two hours 96% PASS High respond within one working day 85% PASS Routine respond within four working days 95% PASS Planned Preventative Maintenance (PPM): Target 78% of all planned maintenance should be completed. Actual: 79.4% PASS From May we have removed the external community contract measurement from this value due to on-going issues with timely access to equipment. EFM Helpdesk Incoming telephone calls. Target 95% answered within 50 seconds. The KPI achievement settled at 91.46% in July with an average wait time of 25 seconds. Focus on on-line reporting to enable speedier response times from operators. Customer emails. Target 95% processed within 2 working days. SLA Achieved.


Estates & Facilities - Carin Charlton

Data

Month

- Jul-17 1258 q

- Jul-17 293 p

95% completed w ithin 4 hours Jul-17 100.0% u

75% completed w ithin 24 hours Jul-17 93.2% p

65% completed w ithin 7 days Jul-17 57.8% q



- Jul-17 7

75% of 2000 PPM activities

completed w ithin 24 hoursJul-17 99.3% p

100% completed w ithin service

level agreement response timesJul-17 99.8% p

Very High Risk - 99% Jul-17 99.0% u

High Risk - >98% Jul-17 98.0% u

Signif icant Risk - >98% Jul-17 98.0% u

Low Risk - >97% Jul-17 98.0% u

Very High Risk - 98% Jul-17 99.3% p

High Risk - >95% Jul-17 96.0% q

Signif icant Risk - >85% Jul-17 94.8% q

Low Risk - >75% Jul-17 86.1% p

95% w ithin 5 seconds Jul-17 87.2% p





Within 2 w orking days Jul-17 100% u

Very High Risk - 98% Jul-17 95.5% p

High Risk - >95% Jul-17 94.7% p

Signif icant Risk - >85% Jul-17 93.1% p

Low Risk - >75% Jul-17 0.0% u

- Jul-17 1348 q

85% completed w ithin 1 day Jul-17 92.0% p


85% completed w ithin 14 days Jul-17 88.0% p

78% of PPM activities completed Jul-17 79.4% q

95% answ ered w ithin 50

secondsJul-17 89.4% q

- Jul-17 96.0% p

EFM Jobs remaining open at the

end of each Calendar Month

EFM Reactive Maintenance

Priority Five Target

MEMS

Total Activity

Turnaround Critical

Turnaround High

Turnaround Medium

PPM Compliance

Telephone Helpdesk

Medical Equipment Loan

Percentage

Nurses

Monitoring of cleaning

standards at audit, split by four

risk categories

Priority 3 External incoming calls

Priority 1 Internal Emergency

calls

Priority 2 Incoming General

Practitioner calls

Monitoring of cleaning

standards at audit, split by four

risk categories

Priority 4 Internal calls

Standard / TargetCompliance -

YTD

Compliance -

Report MonthMovement on previous over 13 month period

EFM Helpdesk

Catering

Maintenance

EFM Total Referrals each month

Domestics

Telephony

Monitoring of Catering service

KPI at audit, split by four risk

categories

Incoming telephone calls

Customer E-mails


Priority one Target


Priority Tw o Target

EFM Planned Preventative

Maintenance (PPM)

EFM Statutory PPM

Repeat Jobs w ithin 7 days


Priority Three Target


Priority Four Target


Executive Summary:



Workforce Overview

Vacancy Profile

• Vacancy rate reduced to 12.14% in July from 12.59% in June. Net reduction due to increase in new starters in Medical

workforce.

10 Consultants (8 substantive & 2 bank) recruited (offered & accepted) in July

o Radiology 4

o Cellular Pathology 1

o Stroke 2

o Gastroenterology 1

o Paediatrics 1

o Anaesthetics 1

112 Medical offers (excluding Deanery doctors) have been made since January - increase of 14 offers in July over June.

Recruitment is developing a report to illustrate translation of offers to start and to track the drop out ratio which will be

available for next board meeting. The lead time between interview and start date for overseas doctors reduced in the last

month from five to two months.

ED has confirmed that the department is now satisfactorily staffed from a medical perspective due to successful recruitment

in recent months. ED continues to run 2 locum consultant positions which will remain in place for until we source

consultants (hard to find category).

Workforce

Budget Staff Vacancy Budget Staff Vacancy

Nursing / Midwifery 1,255 1,091 164 1,259 1,085 175

HCA 576 490 86 578 495 83

Doctors 587 476 110 596 505 91

Total Clinical 2,418 2,057 361 2,433 2,084 348

Non Clinical 1,902 1,719 183 1,893 1,716 177

TOTAL 4,320 3,776 544 4,326 3,801 525

Jun-17 Jul-17


Executive Summary:



Vacancy Profile (Continued)

Establishment increased by 5 WTE in Nursing & Midwifery and 9 WTE in Medical.

It is forecast that W&C establishment will increase further next month due to the approval of additional 17.8 FTE in

midwifery.

A RAG rated recruitment trajectory is in place to monitor achievement towards meeting the Trust’s vacancy rates for

nursing staff.

Rolling adverts are now in place for HCA’s and Band 5 & 6 nurses.

24 HCA’s (7.4 internal, 16.8 external) and 34.5 Nursing & Midwifery staff (21.4 internal, 13.13 external) started with the

trust in July. A Head of Nursing (HON) for Surgery was successfully recruited in July. The positions of HON ED & HON

Medicine were converted from secondment to substantive in July.

Recruitment & Practise Development interviewed 29 RN’s in Finland resulting in 27 offers; the first of these are due to start

in November.

Further work is underway to develop more collaborative working between HR, Finance and Directorates including more

efficient weekly meetings, review of pipeline, iterative reconciliation and agreement of workforce status, rolling adverts and

strategies for hard to recruit areas.

Temporary costs are forecast to increase in departments undergoing consultation as substantive positions have to be held

to offer suitable alternative employment opportunities for ‘at risk’ staff.

Bank & Agency

• Agency cost has remained static between June and July despite an increase in substantive medical starters. This is due to an

increase in agency cost per candidate. The Trust is focussing on reducing this spend by working with the agencies to agree a

step down on their charge rate, reducing the usage of top 20 cost agency staff via weekly review and developing measures

to encourage substantive staff to join the bank as well as converting agency staff to bank.

• A nursing agency review meeting was held at SUH on July 21st 2017 with all nursing providers led by EoE Collaborative

Procurement Hub. All agency charge and fill rates were reviewed and operating principals communicated to agencies with

associated penalties in case of lack of compliance. A similar review is scheduled with medical agencies for October.


Executive Summary:



Bank & Agency (Continued)

• Bank Initiatives include enhanced rates to match fringe high cost supplement, reviewing the training provision offered to

these staff and automatic process of inviting retirees to return on bank.

• A working group across SUHFT, BUH and MEH has been established with a view to standardising rates across the three

trusts.

Staff Turnover

• Staff turnover has increased from 13.07% in June to 13.49% in July 2017 – July 2016 12.26%. Review of turnover with

analysis of reasons forms part of the Directorate / HRBP meetings and hot spot areas are analysed as part of speciality

reviews.

• New retention initiatives have been identified and are being taken forward to target leaver trends. The Staff survey, health

and wellbeing and staff benefit initiatives continue to support this work.

• With high turnover levels across all sites, SUHT have commenced work with BUHT and MEHT to understand best practice

and capitalise on the opportunities of the Success Regime. However it is anticipated that uncertainty related to

transformation and restructuring of services will continue to impact on the turnover rates.

Appraisals

• The Trust appraisal compliance rate has increased from 72% in June to 74% in July, continuing on an upward trend - July

2016 completion rate was 67%. The Trust continues to work on improving appraisal completion rates, with all areas

focussing on their overdue appraisals to ensure that these are scheduled. HRBP’s are working with the Directorates to

target particular areas of concern.

• 182 staff members (6%) have been identified with appraisals outstanding for more than 12 months of whom 45 (1.4%) have

been outstanding for more than 18 months. These names will be reviewed with the Directorates at the monthly board

meetings going forward.

• An updated improvement plan with monthly targets has been agreed by the Site Leadership Team effective from July to

meet the agreed target of 90% by the end of the financial year. Please see Appendix 1. Further work is underway to

identify efficiencies in the reporting process.

Sickness Absence

• Sickness absence rate has reduced from 3.88% YTD in June 2017 to 3.84% YTD in July 2017 - July 2016 YTD sickness % was

4.11%. Targeted interventions continue to tackle short term and long term absence to reach the Trust target of 3.5%.

Health and wellbeing is promoted in the Trust complimented by the recent launch of ‘Your healthy self’ campaign in

addition to stress management and resilience workshops.

Statutory and mandatory training

• Mandatory training has remained static in June 2017 continuing to meet the Trust compliance rate of 85%.


Executive Summary:



Directorate

Eligible Staff for

Appraisals as at

June 2017

May-16 May-17Current as at

June 2017

Current as at

July 2017Aug Sept Oct Nov Dec Jan Feb Mar

Capital 13 46% 64% 62% 58% 63% 68% 73% 78% 83% 88% 89% 90%

Chief Executive 23 75% 70% 57% 62% 68% 75% 80% 85% 87% 88% 89% 90%

D & T 415 73% 69% 70% 73% 76% 78% 82% 85% 87% 88% 89% 90%

Finance 158 63% 70% 72% 73% 78% 81% 83% 85% 87% 88% 89% 90%

HR 67 64% 89% 94% 85% 90% 90% 90% 90% 90% 90% 90% 90%

Nursing 35 56% 57% 63% 55% 60% 65% 70% 75% 80% 85% 89% 90%

Medical Director 42 44% 56% 64% 60% 70% 75% 80% 85% 87% 88% 89% 90%

Emergency 97 63% 67% 71% 76% 80% 82% 83% 85% 87% 88% 89% 90%

Facilities 299 35% 58% 54% 65% 68% 70% 72% 74% 78% 82% 85% 90%

Medicine 554 64% 69% 69% 71% 74% 77% 80% 85% 87% 88% 89% 90%

MSK 338 63% 68% 67% 68% 72% 75% 78% 85% 87% 88% 89% 90%

Surgery 426 73% 81% 84% 84% 87% 89% 90% 90% 90% 90% 90% 90%

T&CC 194 69% 76% 76% 77% 79% 82% 83% 85% 87% 88% 89% 90%

W&C 364 61% 73% 85% 85% 87% 89% 90% 90% 90% 90% 90% 90%

Total 3090 63% 70% 72% 74% 75% 73% 76% 78% 80% 82% 83% 84%

Notes: Key:

Trajectory takes into account winter pressures and

cumulative impact to meet revised SR target of 90% at end

on financial year. Trust target previously 85%.

Approaching Target (5% or less from

target).

> = Target

Data is accurate at time of report and may not include

appraisals submitted after the reporting deadline (usually

2nd of each month)

APPENDIX 1: Appraisal Trajectory 2017/18

2017 2018

Special focus on Directorates who are

currently below 65%

%age is based on a rolling year.

RAG for June 2017 is based on the target of 90%, this will

be updated from July using the monthly directorate targets

as in the 2017 remedial plan

> 5% below target


Wokforce - Mary Foulkes

What's

Good?Move Trend Graph

73.82% 46.99% p p

99.08% p q

8.87% 8.99% q q

6.99% 8.21% q p

17.19% 18.80% q p

4,431 p

4,131.07 4,326 q p

96% 87.86% p q

4,305 p

12.07% 11.75% q

3.84% 3.17% q q

All Leavers 9.50% 14.95% p

Voluntary Leavers 9.50% 13.49% p

Left w ithin 2 Years 42.49% q p

Statutory

Mandatory

Training

Combined Reported

Disciplines 85.19% p q

4 0 q p

56 29 q p

4% 12.14% q p

No set targets 13.77% q q

Vacancy Rate

Based on Establishment minus In Post

Based on Requistions against Establishment

Target is to reach 85% compliance for all staff to be

trained in each 12 month period based on number

trained vs. a headcount

Employment Tribunals N/A

Grievances Raised N/A

Sickness Absence Rate (rolling 12

months)3.50%

Excluding Junior Doctors

(FTE)

Staff Turnover

Rate

Staff Levels

Headcount (permanent, f ixed term temp and

locum staff only)

Establishment (FTE)

FTE (permanent, f ixed term temp and locum

staff only)

FTE (permanent, f ixed term temp and locum

staff plus bank)

Bank Staff Rate

11.50%

Agency Spend as % of Pay Bill 10.00%

Bank, Agency and *Additional Non-

Contractual Payments Total

Bank Spend as % of Pay Bill

Appraisals 90%

Induction

Standard TargetCompliance - YTD/(QTD

A&E)Compliance - Month

99% (permanent and f ixed term temp

staff only, excludes doctors)


http://sohweb002/dashboards/201202-Summaries/201202RedKPI.xls

Documents

Board of Directors’ Meeting Report – 5th September 2017 ... · RTT Reporting Specialty Cardiology Ear, Nose & Throat (ENT) Gastroenterology General Medicine General Surgery Geriatric