Date of Meeting: 25th · 5.4.3 The number of falls in April equates to 5.17 per 1,000 bed days against a national figure of 6.63.3 Of the 34 falls reported as resultingin harm in

This report can be made available in other formats and in other languages. To discuss your requirements please contact Andy Gray, Company Secretary, on [email protected] or 01903 285288.

To: Trust Board

Date of Meeting: 25th May 2017 Agenda Item: 5

Title

Patient First Metrics Report

Responsible Executive Director

Pete Landstrom, Chief Operating Officer

Prepared by

Pete Landstrom, Chief Operating Officer

Status

Disclosable

Summary of Proposal

The purpose of this report is to update the Trust Board on True North Metrics alongside Breakthrough Objectives, Strategic Initiatives and Corporate Projects.

Implications for Quality of Care

The Patient First Improvement Programme, under which the True North metrics have been developed, is the Trust’s key quality improvement initiative.

Link to Strategic Objectives/Board Assurance Framework

Links to the Trust’s Patient First Improvement Programme.

Financial Implications

No specific issues identified at this stage.

Human Resource Implications

No specific issues identified at this stage.

Recommendation

The Board is asked to NOTE the report.

Communication and Consultation

Trust Board and Trust Executive Committee.

Appendices

N/A

mailto:[email protected]

Patient First Board Report – May 2017

Family and Friends Score

Budget Management

Staff Engagement

HSMR Patient Safety Thermometer

Referral to Treatment Time

A&E 4 Hours

Reduce the numbers of Falls

Reduce MFFD Delays

Reduce the amount of Agency

spend

Staff are able to make

Improvements

Patient First Improvement Programme

Sustainability & Transformation

Plan

Workforce Transformation

WS Eye Care @ Southlands

CWS MSK Integrated

Services

Junior Doctor Contract

Clinical Document Management

Portal

True North

Breakthrough Objectives

Strategic Initiatives

Corporate Projects

Outpatient Transformation

Acute Surgical Review

Pathology LIMS

Arrows indicate: Metrics improving Metrics stable Metrics worsening

Achieving target/project on track

Not achieving target/not on track

Friends and Family

Score

A&E 4 Hours

True North

Owner : Nicola Ranger

What are we trying to achieve? • Aim to achieve rates >97% positive

recommendation. • Not to exceed 0.7% of not

recommended. • Achieve response rate of >40% for

inpatients .

What is it important to know? • Recommendation rates are above

95% for all touch points except A&E, which at 84.4% is a 2% reduction compared to last month.

• Inpatient FFT return rate has increased to 32.7%.

What’s gone well? • All internal targets

(recommendation, return and not recommend rate) met by maternity birth touch point in April.

What are the current challenges? • Inconsistent process of collection of

feedback in outpatients. • A&E not recommend rate has

increased from 7.1% to 8%. • Delay on purchase of A&E kiosks.

What are we doing about them? • Encouraging A&E receptionists to

record patients mobile numbers and their consent to activate FFT SMS service.

• Increased visual prompts for FFT in A&E (pamphlets, posters, large picture).

What are the Organisational Risks? • As a result of patients having a

poor experience we incur adverse feedback which impacts on our Friends and Family Test scores.

How are we managing them? • Strategy Deployment will result in

increased engagement with Divisions to focus on highlighted specialties to improve causal factors of poor experience .

Status is RED and IMPROVING

Patie

nt

95%

100%

Apr-15 Jul-15 Oct-15 Jan-16 Apr-16 Jul-16 Oct-16 Jan-17 Apr-17

Friends and Family Test - Positive Recommendation rate %

source: Dr Foster

Board Assurance Risk Score

Target 6

M1 7

True North

Owner : Karen Geoghegan

What are we trying to achieve? • The Trust is required to deliver its

financial plan of £3.4m surplus in order to fund service developments and ensure sustainability.

• Delivery of the financial plan enables the Trust to access the STF income. A total of £11.6m is available to the Trust.

• Metric is variance to financial plan.

What is it important to know? • The Trust reported a deficit of

£2.3m in M1 which was £1.6m adverse to plan.

• Non-elective activity continued at similar levels to Q4 2016/17 and planned growth did not materialise.

• The Trust was unable to achieve capacity reductions to offset the reduction in income.

What’s gone well? • In aggregate, elective income was

on plan in April. It should be noted that April has the lowest possible number of working days and this was reflected in the income plan. Increases in elective activity and income are expected over the next 3 months.

What are the current challenges? • Achieving a flex down of capacity and cost

in line with activity changes. • Managing of overall pay-bill and reducing

demand for premium rate staffing solutions.

What are we doing about them? • Executive led review of options to

flex capacity and cost in response to demand.

• Executive review of agency positions • Targeted efficiency schemes to

reduce premium rate pay.

What are the Organisational Risks? • Local health economy

sustainability and ability of commissioners to afford activity levels.

• Achievement of the financial control total in order to be eligible to receive STF income of £11.6m.

How are we managing them? • Close working with commissioners

to agree an approach to 2017/18 contract that is affordable and sustainable for both parties.

• Delivery of efficiency and transformation schemes.

• Executive led review of capacity flexing.

Status is RED and DETERIORATING


Target 12

M1 20

Sust

aina

bilit

y

(5,000)

(3,000)

(1,000)

1,000

3,000

5,000


Financial Variance From Budget (£000s) Budget

Management

True North

Owner : Denise Farmer

What are we trying to achieve? Ensure that all staff are fully engaged in the work of the Trust. Three key elements: 1. Able to make improvements 2. Healthy culture 3. Motivation at work

What is it important to know? • Staff conferences (21 September & 12

October) theme “Our People”. • STAR awards launched. • Improved position across all Divisions. • In addition to engagement score,

divisions now receiving results broken down of 9 engagement questions .

• H&S days being reviewed to improve engagement and align with true north.

• Kaizen support for EFC division and medical records .

What’s gone well? • Divisional SDR metrics in place. Counter

measure summaries being developed. • E&D and Human Rights week 15 May well

attended. • Patient First Roadshows.

What are the current challenges? • Communicating results to all

teams. • Data analysis capacity within HR

team to support continuing requests.

What are we doing about them? • Developing StaffNet pages for staff

engagement. • Early publication of results. • Theme of the week – violence and

aggression and discrimination.

What are the Organisational Risks? • Operational pressures and

available capacity impact on staff availability to engage.

• Dissonance in organisational values and staff experience.

How are we managing them? • Leadership Strategy and

Development Plan being developed. • Staff care and engagement groups

in Divisions . • Strategy deployment roll out.

Status is GREEN and IMPROVING


Target 9

M1 9

Peop

le

3.6

3.7

3.8

3.9

4.0

4.1

Jul-16 Sep-16 Nov-16 Jan-17 Mar-17

Staff Engagement Score

source: Staff Survey

Staff Engagement

Score

HSMR

True North

Owner : George Findlay

What are we trying to achieve? • Reduce the mortality rate for non-

elective patients, we want to reduce the number of potentially avoidable deaths.

• To be in top 20% of trusts as measured by Dr Foster.

What is it important to know? • HSMR is 90.69 (12mths to January

2017) . With 1907 observed vs 2103 expected deaths.

• Performance in this period puts WSHFT inside the top 20% of Trusts on the 15th centile.

• HSMR by site SRH 85.88 / WH 94.69. • Crude mortality rate 2.80% year to

date (limit set at 3.13%).

What are the current challenges? • Implementing sepsis bundle and

achieving antibiotic administration within 1 hour.

• Fully Implementing process for screening of all deaths , full review and identifying time within job plans to deliver the programme of work.

What are we doing about them? • Continued Kaizen support for

sepsis pathway and oversight at Quality Board.

• Full report on retrospective case review and data quality issues related to site specific differences will be presented to Trust Board in June.

• Facilitation of a learning/sharing event for KSS in July.

What are the Organisational Risks? • Cohorts of patients with high

HSMR have partial visibility due to focus on Trust wide measure.

• Potentially avoidable deaths not identified and learnt from.

How are we managing them? • Detailed Dr Foster monthly reports

continue to be shared with divisions and oversight via Quality Board.

• A business case for managing the review and learning process is being developed to deliver the full review element of the process, ensure ongoing maintenance of screening and maximise the learning and triangulation of the outputs from review..

Status is GREEN and STABLE


Target 9

M1 9

Qua

lity

Impr

ovem

ent

80

85

90

95

100Hospital Standardised Mortality Ratio

source: Dr Foster

What’s gone well? • The electronic screening tool

enabling a consultant review of all deaths went live on 1s t April 2017 April. In April 70% of deaths were screened by a consultant.

• Generally feedback from the consultant body has been positive and constructive.

True North

Owner : Nicola Ranger

What are we trying to achieve? • Reduce the number of patients

suffering harm during their stay in WSHT, this can impact on wellbeing, length of stay and recommendation.

• Harm is measured monthly using the National Safety Thermometer.

What are the Organisational Risks? • Safety thermometer is a once a

month prevalence measure and does not measure all harms.

How are we managing them? • All harms reported via Datix system . • Oversight of all harms via Triangulation

Committee.

Status is RED and STABLE


Target 8

M1 12

Qua

lity

Impr

ovem

ent

90%

95%

100%

Apr-15 Aug-15 Dec-15 Apr-16 Aug-16 Dec-16 Apr-17

% P

atie

nts a

udite

d

Patient Safety Thermometer - % Patients with no new harms

d li d

What is it important to know? • 98.73% New Harm free care . • Seven patients with new cat 2

pressure ulcers(increased compared to previous months).

What’s gone well? • Best month to date for falls project.. • Pressure ulcer 10% reduction goal

achieved in month. • Full roll out of purpose T on patient

track achieved in month.

What are the current challenges? • Extended gaps in Repositioning

remains a recurring theme for patients with pressure damage.

• Staffing gaps also ongoing challenge.

What are we doing about them? • SSKIN bundle education continues. • Divisions are producing SDR plans for

falls and pressure ulcers. • Safer care module roll out to support

staff deployment.

Patient Safety Thermometer

Referral to Treatment

Times

A&E 4 Hours

Syst

ems a

nd P

artn

ersh

ips

True North

Owner : Pete Landstrom

What are we trying to achieve? • Reduce the number of patients

waiting an unacceptable time for elective treatments and appointments which leads to a poor patient experience.

• Metric is percentage of patient pathways completed in less than 18 weeks.

What is it important to know? • Achieved 90.7% <18 wks for April with

no >52 week patients. • Non-compliant with National target

and below the 17/18 STF trajectory. • Compliance impacted by lower

working days and activity in Easter and specific specialty challenges in OMFS.

What’s gone well? • Although anticipated, the drop in

activity in Easter in April had less impact on overall compliance than in the previous 3 years.

• Specific challenged specialties in OMFS have developed and are implementing recovery plans and actions following demand spikes.

What are the current challenges? • Workforce constraints in a number

of specialties are impacting on performance but plans are being implemented .

• May to date performance shows improvement and signs of recovery with un-validated position circa 1% higher mid month than April.

What are we doing about them? • Recovery actions in place for Max

Facs and Restorative Dentistry positions, including diversion of referrals where appropriate and additional core & insource capacity.

• Specialty level recovery and stretch plans developed and being implemented

What are the Organisational Risks? • Increased volumes, reduced flow,

and non-delivery of activity volumes lead to a poor patient experience and waiting times.

• Failure to achieve National RTT 18wk constitutional target (condition of the Sustainability & Transformation Fund).

How are we managing them? • RTT incomplete position discussed

through Strategy Deployment Room. • Activity and pathway management

programme in place tracking speciality level delivery .

• Weekly specialty level improvement and delivery review with DDOs and Divisions weekly.



Target 9

M1 12

Target, 92%

75%

80%

85%

90%

95%RTT Incomplete pathways - % waiting less than 18 weeks

source: RTT Monthly Return

A&E 4 Hour Waiting Times

A&E 4 Hours

Syst

ems a

nd P

artn

ersh

ips

True North


What are we trying to achieve? • Demands in the urgent care

system lead to patient flow being compromised and poor patient experience.

• Metric is percentage of patients attending A&E seen within 4 hours - aiming to achieve 95% within 4 hours.

What is it important to know? • 0 patients waited >12 hrs in April. • Achieved 94.9% which represents

missing the target by 14 patients over the total months activity.

• A&E attendances were +3.6% higher than April 2016.

• Emergency Admissions were +3.0% higher than April 2016.

What’s gone well? • Improved performance was

maintained in April despite missing the overall target.

• Easter weekend performance dipped 95% on three of the days but remained >90% on the others.

• Overall average LOS reduced in April by 0.5days releasing capacity.

What are the current challenges? • There was a +6.5% increase in

patients >65yrs old, which when compared to last year indicated a significant change in presentation to later into the OOH period (+13% more attendances between 8pm-4am) when staffing is less resilient.

What are we doing about them? • Maintaining actions to increase

and maintain bed flow and reduced occupancy as part of NEL Flow Improvement Project.

• Increased Senior Management and On-call focus on supporting OOH pressures where possible.

What are the Organisational Risks? • Changes to system wide capacity

increases demand on hospital services and impacts on A&E delivery and potential failure to meet STF metrics.

• Highly reliant on temporary staffing with possible shortfalls with changes in IR 35 rules impacting existing staff.

How are we managing them? • A&E 4hr position discussed

through Strategy Deployment Room and A&E Delivery Board.

• System wide Resilience Plan and performance to be monitored through A&E Delivery Board.

• Daily escalation and monitoring.


85%

90%

95%

100%


A&E - % Patients seen within 4 hours

source: A&E Monthly Return


Target 8

M1 9

Reduce the Number of

Falls


Owner : George Findlay

What are we trying to achieve? • Reduce the number of

patients that suffer falls in our Trust, this causes harm and has an impact on length of stay and our reputation.

• Falls are measured continuously via Datix.

What is it important to know? • A total of 329 less falls since the

project began(compared to the same period last year).

What’s gone well? • 7 Project wards had 30% reduction. • Non project wards also had a very

good month.

What are the current challenges? • Sensor alarm provision continues

to be a challenge. • Environment audits have shown a

number of areas for improvement particularly in bathrooms.

What are we doing about them? • Education and business case for

sensor alarms. • Linking with F and E division to

review opportunities for improving environment.

What are the Organisational Risks? • Focus on falls prevention results in

other types of harm increasing.

How are we managing them? • All harms reported via Datix system.

Oversight of all harms via triangulation committee.

Status is GREEN and STABLE


Target 9

M1 9

Target (30%

reduction), 130 80

130

180

230


Number of Falls

source: Dr Foster

Qua

lity

Impr

ovem

ent

Reduce MFFD Delays

A&E 4 Hours

Syst

ems a

nd P

artn

ersh

ips



What are we trying to achieve? • Reduce the number of patients in

our hospitals that are medically fit for discharge.

• MFFD patients in hospital beds can compromise patient flow, and impact on A&E wait and LOS.

• Metric is to reduce average patient days delayed by 50% .

What is it important to know? • MFFD average patient days

delayed fell from 1,213 to 1,176 in April.

• Number of patients delayed each day decreased to 120 on average.

• Numbers of delayed pts were very variable and fluctuated between 92 on 23/4 from 146 on 7/4.

What’s gone well? • Formal DTOCs reduced slightly

again from the already improved March position to 3.12%.

• Flow to community hospital beds from the multi-agency Live List improved.

• Overall occupancy.

What are the current challenges? • Flow has continued to be broadly

good in April and May to date, but with short peaks of significant pressure which is difficult to respond to quickly.

• Improved occupancy presents challenges with flexing down capacity to mitigate staffing costs.

What are we doing about them? • For 2017/18 the Executive has

agreed to switch the Breakthrough Objective to focus on increasing discharges.

• A 7% improvement on average discharge rates (achieving the 60th percentile of 2016/17 performance) releases the equivalent of 50 beds.

What are the Organisational Risks? • Failure to reduce MFFD patients

occupying acute hospital beds adversely impacts delivery of A&E and elective targets.

• Patients own health and wellbeing can be compromised by staying in hospital longer than required.

How are we managing them? • Weekly MFFD multi agency

meetings on both acute sites as per national recommendations.

• Daily Board Round collection of delays and next step information by Discharge Team Daily SITREP reporting of formal DTOC patient numbers and reasons.

Status is RED and IMPROVING


Target 9

M1 9

Target, 750

80

580

1,080

1,580

Dec-15 Feb-16 Apr-16 Jun-16 Aug-16 Oct-16 Dec-16 Feb-17 Apr-17

MFFD – Average Patient Days Delayed

source: MFFD Database

Reduce the amount of premium rate pay spend


Owner : Karen Geoghegan

What are we trying to achieve? • Reduce the amount spent on

premium rate workforce solutions . • Remain within the agency ceiling set

by NHS Improvement. • Reduce medical agency expenditure

by £1.0m compared to 2016/17 in line with target set by NHSI.

What is it important to know? • Agency spend decreased to £1.2m in

April. • Spend was £0.4m below the agency

ceiling for April. • The metric currently measures agency

spend against agency ceiling but will be amended to incorporate other premium pay spend from May.

What’s gone well? • Reduction in medical agency

expenditure of £0.2m in month. • No high cost nursing agency use in

April.

What are the current challenges? • Exiting high cost and long-term

agency placements . • Achieving cap compliance across

all staffing groups. • Impact of IR35 on temporary

staffing market.

What are we doing about them? • Bilateral meetings to review key

areas of spend and exit plans for medical agency.

• Regular reporting and review, including Chief Executive approval, of high cost and long-term placements.

What are the Organisational Risks? • Premium rate pay expenditure is

unsustainable and Trust is unable to deliver I&E control total and therefore not able to access Sustainability and Transformation fund.

How are we managing them? • Weekly reporting of agency spend

at Executive Agency Review Meeting.

• Targeted divisional focus through strategy deploymnt.

• Weekly scrutiny of agency spend against overall ceiling trajectory plan.



Target 9

M1 12

(5,000)

(3,000)

(1,000)

1,000

3,000

5,000


Agency Spend (£000s)

Sust

aina

bilit

y

A&E 4 Hours


Owner : Denise Farmer

What are we trying to achieve? • Enable staff to have the

opportunities, tools and support to identify and make improvements in their area of work.

What is it important to know? • Breakthrough target to be top

Trust by 2018 remains. • Survey data now available at cost

centre level. • Kaizen workshop held 18 May for

F&E and Medical Records.

What’s gone well? • Results of breakthrough by

division set out in posters. • PFIS areas showing most

improvement.

What are the current challenges? • Capacity to maintain support

activities. • Sustaining breakthrough

consistently. • Analytical capacity and capability

in HR constrained.

What are we doing about them? • Focusing on priority areas

identified at cost centre level. • Staff Care and Engagement Group

to share case studies and communicate results.

• PF session at health and safety days to be amended to share successes and bring to life .

What are the Organisational Risks? • Roll out of PFIS to non clinical

areas too slow.

How are we managing them? • Strategy deployment roll out. A3’s

being developed and counter measure summaries .



Target 12

M1 9

Peop

le

Target, 63%

0%

10%

20%

30%

40%

50%

60%

70%I am able to make improvements in my area of work

source: Staff Survey

Staff are able to make

improvements

Capacity and

Capability

Insert project

Patient First Pa

tient

Q

ualit

y Im

prov

emen

t


Lean Projects

PFIS

Peop

le

What are we trying to achieve? How are we doing? What is important to know?

• Development of continuous improvement (Kaizen) Strategy that supports True North and Patient First objectives within the Trust to empower staff to solve problems and make improvements.

• The objectives under each of the 5 Pillars have been shared with the Execs.

• Kaizen team project priorities are captured via X-Matrix from SDR and Divisional projects to ensure full alignment and focus on coach, support and delivery.

• Lean management systems (PFIS) implemented across the whole organisation with full support and engagement from all teams, operationalised to the required standard to enable staff to make improvements.

• PFIS Wave 4 comprising of 7 units at St Richards started in Jan 2017 is now completed.

• PFIS Wave 5 has started on Emergency Floor, A&E, Castle and Ditchling (Worthing) with good support from staff from each of these areas.

• To ensure all staff have knowledge, skills to participate in Lean based improvement activities in helping to build a culture of continuous improvement in supporting True North and objectives of Patient First.

• Yellow Belts training programme has started and is scheduled on Monthly basis, with trainees working on agreed improvement projects.

• Divisional Teams have nominated staff to attend Yellow Belt training (May) as part of Strategy Deployment and Divisional projects kick off.

• The Lean Improvement Projects are assigned to the Kaizen Team who provide coaching and mentoring, A3 approach and Problem Solving working within a collaborative team environment.

• Kaizen Team currently supporting Falls, Sepsis, APM, Outpatients, Non-Elective Flow, Staff engagement workshops, Health & Wellbeing, MSK, Mental Health in A&E CQuin, Coaching & Mentoring of YB staff.

• Kaizen alignment to the new SDR priorities has started.

Owner: Anil Mathew

Qua

lity

Impr

ovem

ent

260

25 W5 (4)

Sustainability and

Transformation Plan

Coastal Care

Patie

nt

Sust

aina

bilit

y Q

ualit

y Im

prov

emen

t


What are we trying to achieve? • Ensure the provision of high quality stroke

services meeting the National Stroke Strategy 2007 clinical standards .

• Sussex-wide review of Stroke Services supported by the Sussex Collaborative Delivery Team and funded by the seven Sussex Clinical Commissioning Groups.

How are we doing? • CWS CCG and WSHFT have

collaborated to implement the activity, bed capacity and financial analysis re-work recommended by Clinical Senate.

What is important to know? • CCG & WSHFT are in process of

agreeing a joint recommendation which will to take into account the STP planning process.

What are we trying to achieve? • Deliver a system wide plan to deliver

the 5 year forward view and close gaps in health and wellbeing, care and quality and finance across Sussex and East Surrey.

How are we doing? • CCG continues to work on

developing Local Community Networks as outlined within ‘Inspiring Healthier Communities’.

What is important to know? • Marie Dodd, CCG, Single Point of

Leadership for Coastal West Sussex at STP Board.

• CCG starting to engage partners in new discussions.

• WSHFT remains engaged in STP process.

What are we trying to achieve? • A population based approach for Coastal

West Sussex delivered through increasing integration in order to improve standards, manage demand and make the system financially sustainable.

• Strategy includes Health and Social Care.

How are we doing? • ACO Development Stalled.

What is important to know? • Discussion ongoing regarding WSHFT

future strategy for engagement with Primary Care.

• New Director of Primary Care commences in June 2017.

Stroke Reconfiguration

Owner: Andy Gray

Outpatient Transformation

Time taken to process referrals

Patie

nt

Sust

aina

bilit

y Q

ualit

y Im

prov

emen

t


Demand and Capacity

Patient on-site waiting

times

What are we trying to achieve? • To improve every outpatient

appointment interaction. • To improve patient experience

and simultaneously make the best use of Trust resources.

What is important to know? • Improvement programme includes: PFIS, Referral Management, Clinic Optimisation and Call

Centre development. • 2017/18 CQUINs now also included:

• 100% of new appointments available and 100% of referrals referred through national e-Referral management (formerly Choose & Book); and,

• Advice & Guidance service available to GPs for 75% of services.

What is important to know? • E-Referral Management System: contract

awarded to Docman. • First project meeting end May 2017. • Implementation June 2017 – February 2018 . • Appointment cancellations: Priority specialties:

Ophthalmology, ENT, Urology & Orthopaedics • A3s under development.

What is important to know? • FFT recommendation rate remains above

target. Response rate being improved through a Counter Measure Summary.

• Immediate actions in place. • PFIS maturity assessment completed and

actions in place to attain level 3.

What are we trying to achieve? • When patients come to our

Outpatients, they are waiting too long to be seen. Our objective is to reduce these waiting times - prioritising specialties with longer waits.

Syst

ems a

nd

Part

ners

hips

What are we trying to achieve? • Once a referral is received,

manual processes are needed. Achieving best practice could reduce the time taken to manage and grade referrals by an average of 8 days.

What are we trying to achieve? • This transformational programme

will support specialties to review clinic capacity . We anticipate this will reduce on-day delays and improve overall capacity to see more patients with the same resource.

What is important to know • Current DNA rate 6.8% Target 5.4% to achieve

top 15% in peer group. • Text reminder project to improve DNA rate in

testing phase. Expected go-live during May 2017.

• Top contributors by specialty identified. A3 groups being established to identify specific speciality based actions.

Owner: George Findlay

Workforce Transformation


Peop

le

Owner: Denise Farmer

What are we trying to achieve? • 3-5 year plan to address long standing

workforce gaps. • Undertaking a range of actions to

address both internal and external factors that impact on our nursing and medical staffing groups, including market management of agencies as well as reducing Trust reliance on high-cost temporary staff.

What is important to know? • In the next period, re-tiering of Tier 2

nursing agencies will take place with agencies contacted to request rate reductions to retain notice periods for shift requests.

• Market management actions will take place in medical staffing, similar to nursing, with top volume agencies being contacted.

How are we doing? • Workstreams identified, with governance

arrangements being finalised . • Nursing market management actions

have enabled exit from Tier 3 and 4 supply of general nurses, with work taking place to exit a small number of Tier 3 specialist nurses .

• Progression of A3’s to identify new opportunities within Trust, to limit impact of hard-to-recruit positions.

Patie

nt

Corporate Projects

CWS MSK Integrated

Service

Owner: Karen Geoghegan

What are we trying to achieve? • Relocate Worthing Ophthalmology to

Southlands. • Provide capacity to achieve 18 week RTT

and meet anticipated future demand . • Improve patient experience by redesigning

patient pathways.

What is important to know? • Construction is complete – building

handed over on 12th April. • Commissioning of the new building

under way. • Final equipment being purchased. • Snagging near to completion. • Car parking plan approved. • Staff transport between Worthing

and Southlands approved. • Evolve has gone live – issues being

worked through.

Key Risks: • Emergency and OOH pathways need

final confirmation. • Risk that operational services are not

reorganised in readiness for opening of new unit.

• IT solution (Evolve) needs careful management in roll out.

• Car parking solution not in place for patients and staff on go live.

Mitigations: • Operational programme team in place to

oversee service changes and manage risk. • Equipment costs being tightly managed. • Joint work with Estates to implement car

parking requirement.

Target Date Workstream Progress

Spring 2017 Building programme

complete

Dec 16 Staff consultation Complete

complete Job Planning Complete

Upon opening

Recruitment & training plan On track

Upon opening

Development of new patient pathways - to be tested

On track

Q1 17/18 Service Transition Plan On track

ongoing Equipment plan & training On track

Q1 17/18 Operational Policy On track

27.03/17 Evolve go live Risk

Owner: Pete Landstrom

Target9

M1 9

West Sussex Eye Care @ Southlands

Corporate Projects

CWS MSK Integrated

Service

What are we trying to achieve? Improved patient outcomes, shorten waiting times & control health economy costs by: • Redesigning MSK Pathways for

elective and outpatient care . • Lead on delivering an integrated

service collaboratively with SCFT & 3rd parties.

Syst

ems a

nd

Part

ners

hips

Target 8

M1 20

Owner: Peter Landstrom What is important to know? • CCG sent draft letter of intent

17.03.2017 to which the Trust has responded. Final letter of intent has not been received. Further meeting held with the CCG on 03.04.2017. Financial baseline, risk/gain share and contract negotiation schedule discussed with the CCG and actions agreed to move forward.

• MSK Programme Team Leadership configuration confirmed for Q1.

• Resource plan with cost base being tested and refreshed.

Key Risks: • Lack of contractual agreement with

CCG impacts on ability to implement full service model.

• Delays in progress towards start date mean loss of momentum and staff engagement .

• Reduced capacity in the programme team stops redesign.

Mitigations: • On-going dialogue with CCG at

executive level to resolve. • Progress to mobilisation to deliver

some agreed service changes ahead of commercial contract. Core DDO in discussions with CWS CCG Operational Lead for MSK..

• Ongoing communication with Staff.

Junior Doctor Contract Junior Doctor Contract

Corporate Projects

What are we trying to achieve? • Improved patient outcomes, shorten

waiting times & control health economy costs by:

• Redesigning MSK Pathways for elective and outpatient care

• Lead on delivering an integrated service collaboratively with SCFT & 3rd parties.


Peop

le


Junior Doctor Contract

What are we trying to achieve? • Implementation of new terms and

conditions for junior doctors by August 2017.


Target tbc

M1 4

What is important to know? • April transfer implementation. • Joint preparation for August

changeover ongoing. • Themes from exception

reporting to be identified.

Key Risks: • Exception reports continue to

highlight safety issues , hours or education breaches.

Mitigations: • Educational supervisors

receiving training via HEKSS and locally.

• Service development request agreed.

• Meetings between Chiefs and Guardian established.

Junior Doctor

Contract

DATE SPECIALTY 5th October 2016 Obs &Gynae ST3 + 30th November 2016 F1 (2nd placements) 6th March 2017 Paediatrics – all grades 5th April 2017 Orthopaedics (SHO)

General Surgery Urology Psychiatry

2nd August 2017 Ophthalmology

Dental Anaesthetics A&E Obs & Gynae (SHO) Radiology GPs in Practices Trainees in St Wilfreds and St Barnabas All Medicine Microbiology/Histopathology/Haematology (ST3+)

September/October 2017

All remaining higher Trainees when existing contract expires *ENT *MFU (highers only) *Orthopaedics (highers only)

Corporate Projects

Patie

nt

Clinical Portal

Patie

nt

Clinical Document

Management Portal

Key Risks: • Risk of lack of resources to support and

develop programme to agreed timescale.

Mitigations: • Plans in place to use current

resources as efficiently as possible.

What are we trying to achieve? • All patient records to be

paperless at WSHFT by 2020.

Owner: Ian Arbuthnot

Target 9

M1 9

What is important to know? • Number of patients converted to an

electronic record – 39,166 . • Number of clinical users in April 17 -

1,139 . • Number of staff trained in total – 1,469

and 709 attended Demo’s.

• The clinical forms analysis and development is taking significantly longer than expected. Work is ongoing to look at the roll out timeline and make key amendments to reflect the current position and keep the project moving forwards.

In progress

Jul-17 Green

Go live Dates

Action Progress

Paediatric Inpatients

TBC – subject to delivery of electronic care plans

Worthing Ophthalmology

Mar-17

Urology

Live

Apr-17 Chichester Ophthalmology

Live

Corporate Projects

Patie

nt

Target 6

M1 6

How are we doing? • Programme Board established. • Initial communications undertaken. • Engagement sessions - completed. • Survey monkey completed. • Data analytics group in situ (6 weeks)

completed. • Clinical Experts contacted and external sites

visited – completed. • Stakeholder feedback session April/May 17 –

completed. • Meeting with Medical Director planned to

feedback initial findings with a view to closing down review and commissioning 17/18 programme of works to implement recommendations – completed.

• Final Report presented to TEC – April 17 – completed.

What are we trying to achieve? • Service review to ensure we are

operating emergency and urgent surgery across the St Richard’s and Worthing sites in the most effective way.

What is important to know? • Data mining exercise not possible

due to poor coding of data. • 114 responses to survey monkey. • Over 40 consultants interviewed. • Recommendations presented to

TEC early April 17. • No major reconfiguration

recommended. • 16 recommendations in total – part

of Surgery SDR 17/18. • Resource plan being drafted.

Owner: George Findlay

Key Risks: • Potential for negative public

perception due to misunderstanding of scope.

• Risk of lack of engagement by staff. • Data analysis must be robust – tight

timeframe to complete this work. • Risk outcome may not be accepted by

surgeons who feel the review has take too long and not addressed key issues.

Mitigations: • communication and engagement

plans in place to communicate outcome.

• Project governance further supported by PMO.

• Key recommendations to try and address concerns of clinicians – some like cross site working may not be popular but deemed necessary for cross collegiate working to improve.

Acute Surgical Review


What are we trying to achieve? • Install a new laboratory information

management system and order comms system as part of the Abbott pathology managed equipment service which will support full service integration and delivery of the process and workforce efficiencies associated with the planned automated hot and cold site lab configuration for WSHFT.

How are we doing? • The LIMS implementation project

has run into several technical difficulties, resulting in a now 22 month go-live delay.

• Project teams from supplier and Trust had been working through these but ceased April 16 pending contractual negotiation outcome.

• It is planned that a move to a new version of the LIMS will overcome some of the obstacles to go live.

• Contract change control as yet unsigned. Clinisys will not progress implementation until this happens.

What is important to know? • Commercial negotiations completed to

recoup some Trust costs as a result of delay and agree zero cost for system changes made by Clinisys to date.

• Upgraded software agreed by supplier and demonstration of functionality provided .

• New project plan, enhanced governance arrangements and go-live date to be established on conclusion of negotiations.

• Total financial risk associated with Legacy system support increases post March 17 go live.

• All parties actively working on securing CCN terms within that are acceptable to all.

• Concerns regards suitability of Cyberlab OCS system for future use by Imaging.

Key Risks: • New LIMS does not deliver planned

functionality /service efficiencies necessitating additional resource and/or service remodelling.

• Unexpected system critical changes within new software.

• Pathology staff resources are inadequate to support implementation at pace required.

• Compatibility of Cyberlab OCS system with Imaging governance.

Target9

M1 15

Pathology LIMS

Corporate Projects

Patie

nt

Mitigations: • Enhanced project governance

and mobilisation package currently being defined.

• Completion of full user acceptance testing of new version of software.

• Staff capacity around project milestones supplemented with bank and agency support.

• Review of Imaging use of OCS system at other User sites.

Title Month 1, 2017/18 Monthly Quality Report

Responsible Executive Director Dr George Findlay (Executive Medical Director) and Nicola Ranger (Executive Director of Nursing and Patient Safety)

Prepared by Lynn Woolley (Head of Clinical Governance)

Status Disclosable

Summary of Proposal Not applicable

Implications for Quality of Care Describes performance against quality outcome KPIs, including safety, infection control, experience, effectiveness and mortality.

Link to Strategic Objectives/Board Assurance Framework This report pulls together key national, regional and local quality indicators relating to quality and safety providing assurance for the Board and (if necessary) highlighting issues.

Financial Implications Describes KPIs that have potential financial impact (e.g. CQUIN)

Human Resource Implications Describes KPIs linked to workforce

Recommendation The Board is asked to: Note the contents of this report.

Communication and Consultation Not applicable

Appendices Appendix I: Quality Scorecard Appendix II: Ward Staffing Scorecard

To: Trust Board Date of Meeting: 25th May 2017

Agenda Item: 5.1

1 Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board

Lynn Woolley Head of Clinical Governance

1 INTRODUCTION

1.1 This report brings together key national, regional and local indicators relating to quality and safety.

The purpose of the report is to bring to the attention of the Trust Board quality performance within

Western Sussex Hospitals Foundation Trust (WSHFT).

1.2 The paper describes performance on an exceptional basis determined by RAG (red/amber/green)

ratings based on national, regional or local targets.

2 2017/18 REFRESH

2.1 There will be a refresh of the Monthly Quality Report for 2017/18 to reflect the key quality objectives

for the next year. For April however, the report follows the same format as previously using the same

suite of metrics, with only the targets being revised using similar logic to that applied for 2016/17:-

• If 2016/17 performance exceeded target, then 2016/17 actuals used as 2017/18 target

• If 2016/17 performance did not meet target then 2016/17 target remains the same for 2017/18

• If there is a national or set target then that will continue as the measure

• Any metrics with no target set continue as before

2.2 The new scorecard is in the early stages of development and will incorporate a more extensive range

of metrics and targets.

3 KEY QUALITY OBJECTIVES

3.1 Scorecard Definitions

3.1.1 The full Clinical Quality Scorecard is presented as Appendix I. Figures are in-month figures (e.g. the

number of falls reported in April) unless otherwise stated. The Scorecard shows 13 months to allow

trends to be identified, although some data items are reported retrospectively. Year to date

actuals/targets are based on financial years unless otherwise stated (standardised mortality ratios are

recorded as 12 month positions for example). A subset of the key measures from the report is

presented at 3.3. These remain the same sub-set as last year and will be refreshed when the new

scorecard is established.

3.1.2 Exception reports are included under the relevant section of this report (Effectiveness, Safety and

Patient Experience).

3.1.3 Although the scorecard reflects 13 months of data, only the current financial year and year to date

values are RAG rated - with the exception of those metrics reported in arrears where the most recent

data-point of last year is RAG rated.



3.2 Domain scores

3.2.1 The score is an overall indication of the performance in relation to each of the domains -

Effectiveness, Safety and Patient Experience. The score is calculated as follows: Each RAG rated

indicator for a month is scored: red scores 1, amber scores 2, green scores 3. These scores are then

totalled and divided by the total number of indicators with RAG ratings to give a score for the domain

as a whole between 1 and 3. This final score can then itself be RAG rated with >2.5 giving an overall

green, 1.5 to 2.5 amber and <1.5 an overall red score for the domain as a whole. For example if a

domain had two greens and a red the calculation would be as follows:

3 (green) + 3 (green) + 1 (red) = 7

7 / 3 (i.e. the total number of metrics) = 2.33 i.e. amber overall.

3.2.2 Domain scores are calculated based on the year to date RAG ratings for each metric. Previous

months are retrospectively updated to take account of any measures reported in arrears. As with any

aggregate indicator, it remains essential that the Board retains sight of the individual elements as well

as the domain score as a whole.

3.3 Overview of Key Quality Objectives

3.3.1 The following table shows performance against key quality objectives.

Indicator Feb 2017 Mar 2017 April 2017 2017/18 to date

2017/18 Target /

limit Effectiveness Domain Score 2.57 2.38 2.59 2.59 2.5

Safety Domain Score 2.36 2.04 2.54 2.54 2.5

Experience Domain Score 2.13 2.19 2.43 2.43 2.5

E01 Trust crude mortality rate (non-elective) 3.48% 3.46% 2.80% 2.80% 3.13%

E03 Hospital Standardised Mortality Ratio for top 56 diagnoses (Dr Foster, based on rolling 12 months)

90.07 <92

S06 Number of Serious Incidents Requiring Investigation (number reported in month)

0 4 3 3 60

S14 Numbers of hospital attributable MRSA 0 0 0 0 0

S28 Numbers of hospital C. diff where a lapse in the quality of care was noted

2 3 0 0 16

X38 The Friends and Family Test: Percentage Recommending Inpatients

96.6% 96.7% 97.0% 97.0% 97%

X39 The Friends and Family Test: Percentage Recommending A&E

88.0% 86.6% 84.6% 84.6% 93%

X13 Mixed Sex Accommodation breaches (number of breaches)

0 0 0 0 0

X18 Number of complaints 44 46 35 35 570



4 EFFECTIVENESS

4. 1 Crude Trust Mortality

4.1.1 Due to the low level of mortality experienced in elective care, the Trust measures mortality in relation

to non-elective activity using the previous year as a benchmark.

4.1.2 Crude non-elective mortality fell from 3.46% in March to 2.8% in April. This is lower than the equivalent

month in 2016 (April 2016 = 3.46%). The number of non-elective patients who died in April was 155

(from 5536 discharges). The year to date mortality rate is 2.80% and the rolling 12 month mortality

rate is 3.13%. The limit for both measures is 3.13%. 4.2 Hospital Standardised Mortality Ratio (HSMR)

4.2.1 There is a delay in data being available in Dr Foster tools to allow for coding and processing by the

Health and Social Care Information Centre and Dr Foster. The most recent data available is January

2017.

4.2.2 The Trust’s HSMR for the twelve months to January 2017 is 90.69 (where 100 is the level predicted by

the Dr Foster model using the June 2016 benchmark).

4.2.3 The twelve month HSMR to January 2017 split by site continues to be lower for St Richard’s (85.88)

than for Worthing (94.69), however both remain lower than 100. Work is continuing to examine this

difference in greater detail. 4.2.4 A further report is available to clinical leaders in the Trust showing the clinical diagnostic areas with

high actual versus expected mortality and any mortality CuSum alerts.

4.2.5 The Trust has set the goal of achieving a position within the top 20% of Trusts as measured by

HSMR. For the twelve months to December 2016 performance using this measure places us within

the top 20% of Trusts on the 18th centile

4.3 Summary Hospital-Level Mortality Indicator (SHMI) 4.3.1 The latest data made available by the Health and Social Care Information Centre is for the period to

March 2016. The Trust value is 0.99 (where 1.00 is the national average), with the Trust banded as

‘as expected’.



4.4 Exception Reports Relating to Effectiveness

4.4.1 E13. C-Section rate. C-Section rate was 24.3% against a target of 26.5%, the lowest level in over a

year. Each case where a woman has a caesarean delivery undergoes a review process to look for

learning opportunities. No systemic causes or trends have been identified and practice is very much

in line with national recommendations for safe practice and NICE guidance. Increasing normal birth

continues to be an area of focus for the division and rates are closely monitored via monthly divisional

performance reviews.

4.4.2 E42. Night time moves in patients with dementia. Significant numbers of patients with dementia

continue to be subject to ward moves. Although there has been a positive downward trend since

January, the number of moves is still well outside the Trust goal. Tracking bed moves for patients with

dementia continues and the Matron for Dementia is actively monitoring progress.

4.4.3 E43. Completion of Knowing Me document for patients with dementia. There has been further

deterioration in compliance. A number of actions have been taken by the Matron for Dementia to

better understand the fall in compliance in order to effect a return to previously good levels of

completion:

• Review of the last 3 months of data by ward to identify trends and specific areas that require

support. This information has been shared with Heads of Nursing.

• Refresh on the education of matrons as to how to access the required information from

Patientrack.

• Knowing Me has been included in this week’s Theme of the Week on Dementia to raise

awareness more widely across the organisation via the safety huddles

5 SAFETY

5.1 Central Alert System (CAS) Safety Alerts

5.1.1 There are no outstanding alerts for the Trust up to April 2017.

5.2 Serious Incidents Requiring Investigation (SIRIs)

5.2.1 There were 3 incidents reported that have been categorised as serious incidents requiring

investigation in April. One case involved wrong site surgery (a Never event). Due to the

circumstances of the error the patient suffered a very low level of harm and will not require additional

corrective surgery. This incident is being investigated under the SIRI framework and interim action

has been taken in relation to what happened. The patient and family have been offered a full apology

and initial explanation. The other incidents involved a delay in diagnosis for a patient and an ill

newborn baby. These incidents are also under investigation. A detailed serious incident report is

provided to the Committee section of the Trust Board. The Board should note there can be slight

variation in the month-by-month numbers between the SIRI report and the number of significant



incidents – this is because incidents are attributed to the month in which they occur whereas the SIRI

data is based on the month in which the SIRI was raised.

5.2.2 Any incidents that are reported as causing significant harm (moderate, severe or resulting in the death

of a patient) are notified immediately to the senior team in the Trust including the Director of Nursing

and Medical Director with at least weekly updates on progress.

5.2.3 On a monthly basis there is triangulation of information arising out of complaints, claims, incidents and

inquests to identify any areas of learning or for focus.

5.3 Infection control

5.3.1 There were no cases of hospital-attributable Clostridium difficile during April. The allocated Trust

target limit for 2017/18 is set at 391 (unchanged from last year). The national average for 2015/16 was

14.9 cases per 100,000 bed days.2

5.4 Falls

5.4.1 In April there were 138 inpatient falls with 34 resulting in harm against a target of 38.

5.4.2 There was 1 fall resulting in significant but not severe harm to a patient who sustained soft tissue

injury.

5.4.3 The number of falls in April equates to 5.17 per 1,000 bed days against a national figure of 6.63.3 Of

the 34 falls reported as resulting in harm in April, those causing significant harm equate to 0.03 per

1000 bed days against the national figure of 0.19.

5.5 Tissue Viability

5.5.1 Changes to the way the Trust is required to report pressure ulcers meant that more grade 2 and

grade 3 ulcers were reported in 2015/16 than in previous years. This pattern of reporting changed

from October 2016 and grade 3 or greater damage will not be routinely reported as a serious incident

unless it meets the national threshold for SIRI reporting. Internal scrutiny of cases continues exactly

as before with robust follow through of actions.

5.5.2 During April the Trust reported 17 cases of grade 2 hospital acquired pressure ulcers and one grade

3. Damage to the sacrum, buttocks and heels remains the most common form of pressure damage.

1 NHSI (2017) Clostridium difficile infection objectives for NHS organisations in 2017/18 and guidance on sanction implementation. Page 5 2 https://www.gov.uk/government/statistics/clostridium-difficile-infection-annual-data. 3 Royal College of Physicians. National Audit of Inpatient Falls: audit report 2015. London: RCP, 2015.

https://www.gov.uk/government/statistics/clostridium-difficile-infection-annual-data



Lapses in care were identified in 7 of the care reviews. Inadequate documentation of skin assessment

and changes of position is a recurring theme. There are ongoing challenges with mattress availability

with stock levels not meeting the rising demand resulting in the need for ad hoc hiring of mattresses.

Kaizen is supporting with the piece of work to look at the process. There is intensive education and

audit of SSKIN bundles and Purpose T assessment has now been fully rolled out on Patientrack.

5.5.3 The incidence of pressure ulcers, Grade 2 and above including those developing within 72 hours after

admission per 1000 bed days in March was 0.7 against a national rate of 0.9 (as per the Safety

thermometer data). The Trust goal of achieving a 10% reduction in pressure damage has been

achieved.

5.5.4 There were 165 patients admitted to the Trust from the Community with existing pressure damage.

5.6 NHS Patient Safety Thermometer

5.6.1 The NHS Patient Safety Thermometer is used across all relevant acute wards. This tool looks at point

prevalence of four key harms - falls, pressure ulcers, urinary tract infections and deep vein thrombosis

(DVT) and pulmonary embolism (PE) in all patients on a specific day in the month. A dashboard is

available to each ward showing Trust-wide and ward-level data for each individual harm as well as the

harm-free care score. These numbers are also shared via the new ward screens.

5.6.2 The harm-free care score for the Trust in April was 94.5% (indicator S02) against the target of 95.7%.

5.6.3 The Safety Thermometer includes harms suffered by the patient in healthcare settings prior to

admission. The actual number of patients who suffered no new harm during their inpatient stay at

WSHFT (indicator S03) in April was 98.7%, again very positive against a national average of 97.7%

and close to achieving the challenging target of 99% set by the organisation.

5.6.4 2 patients were diagnosed as having hospital acquired VTE during the point prevalence audit. Both

are subject to RCA and the outcome in terms of avoidability will be highlighted at the panel meeting.

Compliance with VTE assessment of patients improved this month to 95.0% against a target of 95%.

5.6.5 National data relating to the NHS safety thermometer is available here:

http://www.safetythermometer.nhs.uk/

5.7 Exception Reports Relating to Safety

5.7.1 S23 Falls assessment 88% of falls risk assessments were undertaken within 24 hours of admission

against a target of 80%.

http://www.safetythermometer.nhs.uk/



6 PATIENT EXPERIENCE

6.3 PALS and Complaints

6.3.1 During April the Trust received 35 complaints, a similar level to last month and significantly less than

in the same period last year when 63 complaints were received. The Trust is working on improving

response times for complaints and Divisions are beginning to embed a more proactive response to

new complaints to try to facilitate resolution quickly for patients and families to avoid the need for

escalation to formal complaint.

6.3.2 The Quarterly Complaints Report provides an in-depth analysis of trends and lessons learned. This is

reviewed by the Patient Experience and Feedback Committee and is presented to the Trust Board.

6.4 Friends and Family Test (FFT)

6.4.1 Patients who access hospital services are asked whether they would recommend WSHFT to their

friends or family if they needed similar treatment. Patients who access inpatient, outpatient, day-case,

A&E and maternity are all offered the opportunity to respond to the question.

6.4.2 Immediate feedback is provided to wards and departments on a continuous basis to ensure staff can

address problems or get positive feedback as quickly as possible. In addition to this, a dashboard is

available giving wards access to their individual scores and a poster printed with ward performance to

display to the public. Ward ‘recommend’ rates are shown on the screens installed on wards.

6.4.3 Friends and Family Test Response Rates:

6.4.4 Work continues to improve response rates towards a target this year of 40% (with an interim target for

A&E of 23%). The average response rate in 2015/16 for NHS acute trusts was 24.7%. Response

rates for Inpatient and A&E are below the Trust target but are improving. Maternity achieved and

exceeded the goal of 40% for Delivery Care for a second month with 42.8% response rate.

6.4.5 While acknowledging work still to be done in achieving better response rates particularly in A&E, the

proportion of patients who would have recommended our services to friends and family in April

compares favourably with national median benchmark and with the exception of A&E also against our

internal target as per the table below:

Percentage recommending WSHFT in April (plus YTD)

Target

Inpatient care 97.0% (97.0%) 97%

A&E 84.6% (84.6%) 93%

Maternity: Delivery care 98.8% (98.8%) 97%



Outpatient care 96.8% (96.8%) 97%

Maternity: Antenatal care 100% (100%) 97%

Maternity: Postnatal ward 98.1% (98.1%) 97%

Maternity: Postnatal community care

100% (100%) 97%

7 CARE QUALITY COMMISSION (CQC)

7.3 CQC Inspection

7.3.1 The CQC undertook inspection of the Trust on 8th to 11th December 2015. A summary of actions on

areas identified for improvement has been provided to the CQC. These actions are monitored through

the CQC Steering Group and updates provided to the Trust Executive Committee each month. The

action plan is overseen by the Quality and Risk Committee. A mock inspection was undertaken by

internal staff with the support of some external representatives on 10th and 13th October 2016. A full

report of findings was presented to Trust Executive Committee and the Quality and Risk Committee.

A further programme of internal inspection is planned for later in the year using CQC methodology.

7.3.2 Steering Group will oversee progress under its future extended function as an overarching quality

assurance group, the Terms of Reference for which are being developed.

8 RECOMMENDATION

8.3 The Board is asked to note the contents of this report.

Operational Planning and Performance: Quality

5.1a Copy of Copy of Quality scorecard 1718_M01_v5 gf.Quality Scorecard Page 1 of 6 Printed 24/05/2017 10:25

APRIL 2017APR May Jun JUL AUG SEP OCT NOV DEC JAN FEB MAR APR YTD

ActualYTD

TargetTarget Trend

EFFECTIVENESSEffectiveness domain score 2.29 2.29 2.36 2.46 2.39 2.43 2.29 2.36 2.29 2.13 2.26 2.29 2.77 2.77

Trust-wide mortality

E01 Trust crude mortality rate (non-elective) 3.46% 3.33% 2.57% 2.88% 2.63% 2.57% 3.43% 3.23% 3.29% 4.15% 3.48% 3.46% 2.80% 2.80% 3.13% 3.13%

E02 Crude mortality rate (non-elective): 12 month rolling 3.15% 3.20% 3.16% 3.17% 3.13% 3.12% 3.16% 3.13% 3.13% 3.19% 3.22% 3.21% 3.16% 3.16% 3.13% 3.13%

E03 Trust Hospital Standardised Mortality Ratio (HSMR) 90.4 91.5 89.8 90.1 89.9 91.2 92.4 91.3 91.1 90.7 90.7 92 92

E04 Summary Hospital-level Mortality Indicator (SHMI) (rolling 12M) 1 1

Improve mortality in specific conditions

E07 Crude non-elective mortality for Renal failure 27.3% 20.0% 6.7% 16.7% 9.1% 16.1% 9.4% 9.4% 20.0% 26.3% 12.1% 20.7% 11.4% 11.4% 15.50% 15.50%

Reduce mortality following hip fracture

E09 SMR for hip fracture (all diagnoses/procedures) (rolling 12M) 80.0 76.6 68.6 68.8 76.4 76.9 79.5 80.5 93.6 94.2 94.2 100 100

E09a Worthing SMR for hip fracture (all diagnoses/procedures) (rolling 12M) 88.8 83.3 67.3 71.0 83.4 79.5 80.1 86.6 100.1 104.3 104.3 100 100

E09b St Richard's SMR for hip fracture (all diagnoses/procedures) (rolling 12M) 67.7 67.6 70.5 65.8 66.9 73.3 78.6 72.1 84.4 80.2 80.2 100 100

E10 30 day mortaliy rate following hip fracture (rolling 12M) 5.7% 5.4% 4.8% 4.9% 5.3% 5.2% 5.4% 5.5% 6.4% 6.4% 6.4% 5.70% 5.70%

Reduce the rate of readmission following discharge from the Trust

E11 Emergency readmissions within 30 days % 12.9% 13.8% 13.7% 14.4% 14.2% 15.1% 14.1% 13.6% 13.7% 14.2% 13.9% 13.6% 14.4% 14.4% 13% 13%

To improve maternity care by encouraging natural chilbirth

E13 C-Section Rate 25.8% 25.3% 30.0% 27.0% 25.9% 31.3% 32.9% 30.3% 27.7% 28.2% 28.6% 28.5% 24.3% 24.3% 26.50% 26.50%

E14 % Mothers requiring forceps for delivery 12.1% 11.5% 11.5% 12.7% 11.6% 15.3% 11.2% 10.3% 13.6% 7.4% 14.0% 10.9% 14.8% 14.8% <15% <15%

E15 % Deliveries complicated by post-partum haemorrhage 0.7% 0.5% 0.5% 0.4% 1.3% 0.4% 0.2% 0.0% 1.0% 0.5% 0.3% 0.2% 0.5% 0.5% 1% 1%

E16 Maternal deaths 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

E17 Admission of term babies to neonatal care 1.9% 2.5% 3.4% 4.0% 3.7% 5.8% 2.9% 5.0% 3.0% 2.5% 3.6% 1.6% 2.4% 2.4% < 10% < 10%

0.99 0.97

QUALITY SCORECARD




ActualYTD

TargetTarget Trend

QUALITY SCORECARDCaring for the elderly patient

E18 % Emergency admissions staying over 72h screened for dementia 92.0% 88.0% 94.0% 95.5% 96.0% 94.4% 95.9% 98.0% 90.0% 92.5% 90.9% 91.0% 90.0% 90.0% 90% 90%

E19 % Patients identified as at risk of dementia for whom further investigations are carried out 94.0% 89.0% 88.0% 93.4% 93.0% 90.0% 87.3% 94.0% 94.0% 93.3% 93.9% 97.0% 92.4% 92.4% 90% 90%

E20 % Patients with identified dementia referred to specialist services 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 90% 90%

E25 Number of admissions for patients with dementia flag 223 202 217 264 219 193 204 274 275 308 272 270 221 221 NA NA

E39 Ward moves for patients flagged with dementia 181 194 201 207 182 161 239 241 212 337 270 213 184 184 198 2376

E42 Night-time ward moves for patients flagged with dementia (23:00 - 07:00) 34 44 48 39 27 32 51 57 45 82 63 33 34 34 42 500

E43 Documentation Audit: % patients with dementia with Knowing Me document 97.7% 99.7% 99.4% 99.4% 99.5% 99.4% 96.9% 98.0% 92.9% 87.7% 78.7% 73.1% 65.8% 65.8% 75% 75%

Stroke care

E26 % CT scans undertaken within 12 hours 93.5% 96.8% 94.3% 93.2% 88.3% 95.7% 96.9% 93.8% 97.7% 98.0% 98.6% 98.8% 95% 95%

E27 % Stroke thrombolysis within 60 minutes of hospital arrival 80.0% 33.3% 83.3% 100.0% 85.7% 66.7% 71.4% 90.9% 90.9% 71.4% 83.3% 54.5% 95% 95%

E28 % Swallow screen for stroke patients within 4 hours of admission 77.1% 75.0% 80.6% 93.9% 77.4% 84.6% 87.9% 93.0% 82.1% 83.7% 79.6% 70.0% 95% 95%

E29 % of stroke patients admitted to stroke unit within 4 hours of admission 57.8% 74.2% 82.9% 79.7% 63.2% 72.1% 67.7% 76.9% 76.2% 71.4% 68.1% 73.8% 90% 90%

E30 % high risk TIA patients seen within 24 hours 67.0% 57.0% 50.0% 43.0% 26.3% 66.7% 36.0% 46.7% 33.3% 40.0% 33.3% 60% 60%

Ensure active engagement with research

E21 Patients recruited to interventional studies within CRN portfolio 12 22 26 24 28 23 23 27 14 26 19 14 17 17 tbc tbc

E22 Patients recruited to observational studies within CRN portfolio 32 33 31 28 27 32 33 56 74 113 152 369 109 109 tbc tbc

E23 Local Clinical Research Network (LCRN) Score 92 143 161 148 167 147 148 191 144 243 247 440 194 194 189 2271

Data Quality

E24 NHS IC Data validity summary (YTD) 99.9 99.9 99.9 99.9 99.9 99.9 99.9 99.9 99.9 99.9 99.9 99.9 99.9 99.9

E37 % inpatients with electronic discharge summaries produced 84.1% 85.4% 88.3% 88.7% 92.9% 92.2% 93.4% 93.7% 93.3% 94.5% 94.3% 93.3% 94.3% 94.3% 94.2% 94.2%




ActualYTD

TargetTarget Trend

QUALITY SCORECARD

SAFETYSafety domain score (Patient Aggregate Safety Score - PASS) 2.04 2.32 2.24 2.52 2.36 2.17 2.00 2.40 2.28 2.28 2.36 2..12 2.54 2.54

Safer staffing

S36 Safer Staffing: Average fill rate - registered nurses/ midwives (day shifts) 95.8% 97.6% 98.1% 96.2% 96.0% 96.5% 96.9% 97.5% 96.8% 95.4% 94.0% 94.0% 97.3% 97.3% 95% 95%

S37 Safer Staffing: Average fill rate - registered nurses/ midwives (night shifts) 96.2% 97.3% 98.4% 96.7% 97.4% 97.4% 97.4% 97.9% 98.1% 96.1% 95.9% 96.5% 97.7% 97.7% 95% 95%

S38 Safer Staffing: Average fill rate - care staff (day shifts) 89.0% 92.5% 93.4% 92.8% 91.6% 90.4% 91.6% 90.6% 90.7% 91.7% 90.2% 90.5% 95.4% 95.4% 95% 95%

S39 Safer Staffing: Average fill rate - care staff (night shifts) 89.1% 93.2% 93.9% 93.8% 93.0% 92.4% 92.6% 91.4% 92.3% 92.5% 91.3% 92.4% 96.2% 96.2% 95% 95%

S41 Care Hours Per Patient Day (CHPPD) 6.20 6.40 6.70 6.40 6.80 6.60 6.50 6.50 6.60 6.30 6.30 6.60 6.80 6.80 tbc tbc

NHS safety thermometer

S02 Safety Thermometer: % of patients harm-free 95.1% 95.0% 96.1% 96.4% 96.3% 95.8% 94.7% 94.8% 93.9% 96.1% 94.6% 95.5% 94.5% 94.5% 95.70% 95.70%

S03 Safety Thermometer: % of patients with no new harms 97.7% 98.8% 98.4% 98.9% 98.7% 97.7% 98.8% 97.9% 98.4% 99.2% 98.8% 98.8% 98.7% 98.7% 99% 99%

S29 % of patients with catheters and UTIs where best practice protocol was not followed. 0.00% 0.00% 0.00% 0.11% 0.11% 0.23% 0.12% 0.00% 0.00% 0.00% 0.00% 0.22% 0.23% 0.23% 0.06% 0.06%

Monitoring of clinical incidents

S04 Total incidents 785 852 810 855 855 797 895 875 862 855 782 715 711 711 677-9158122 - 10988

S05 Total moderate, severe or death incidents 20 8 15 4 21 11 15 12 14 15 9 18 9 9 13 153

S06 Total serious incidents (SIRIs) 13 5 11 6 7 6 2 4 8 8 0 3 3 3 5 60

S07 Number of outstanding CAS alerts 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Improve safety of prescribing

S08 Total incidents involving drug/prescribing errors 94 105 88 92 84 84 110 82 95 90 79 85 68 68 88 -1191056 - 1428

S09 Moderate/severe incidents involving drug/prescribing errors 1 0 2 0 0 0 2 0 1 1 0 0 2 2 0 5

Reduce incidence of healthcare acquired infections

S14 Number of hospital attributable MRSA cases 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0

S15 Number of hospital C.diff cases 5 6 2 4 2 1 10 3 2 2 4 4 0 0 3 39

S28 Number of C. diff cases where a lapse in the quality of care was noted 2 2 2 2 1 1 6 2 0 1 2 3 0 0 1 16

S16 Number of reportable MSSA bacteraemia cases 7 12 11 6 11 13 10 10 7 6 13 7 9 9 tbc tbc

S17 Number of reportable E.coli cases 45 26 28 36 37 44 39 28 26 35 33 40 30 30 tbc tbc




ActualYTD

TargetTarget Trend

QUALITY SCORECARDImprove theatre safety for patients

S18 Full compliance with WHO Surgical Safety Checklist 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

S19 NEVER events 0 0 0 0 0 1 0 0 1 1 0 0 1 1 0 0

S30 SSIs: Total hip replacement (YTD is rolling 12 months) 1.10% 1.1%

S33 SSIs: Total knee replacement (YTD is rolling 12 months) 1.50% 1.5%

S34 SSIs: Large bowel surgery (YTD is rolling 12 months) 12.00% 12%

S35 SSIs: Breast surgery (YTD is rolling 12 months) 3.80% 3.8%

Reduce number of falls in hospital

S21 Falls resulting in harm 45 39 39 36 39 36 39 40 38 35 36 29 34 34 38 451

S22 Falls resulting in severe harm or death 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 1

S40 Repeat falls 14 11 8 3 3 6 12 9 9 9 9 4 8 8 8 97

S23 Falls assessment within 24hrs of admission 83.0% 82.0% 91.6% 90.8% 88.4% 66.2% 87.5% 91.0% 91.4% 93.0% 84.8% 92.2% 88.0% 88.0% 80% 80%

S24 Avoidable falls identified on the Safety Thermometer 0.65% 0.54% 0.23% 0.44% 0.79% 1.28% 1.40% 1.15% 0.53% 0.20% 0.33% 0.22% 0.69% 0.69% 0.65% 0.65%

Pressure ulcers

S25 Grade 2 pressure ulcers 15 21 10 12 17 17 27 29 15 18 26 18 17 17 13 156

S26 Grade 3 & 4 pressure ulcers 5 3 5 2 2 3 3 2 3 3 0 2 1 1 2 23

Other safety metrics

S11 VTE Assessment Compliance 96.1% 96.0% 96.0% 95.3% 95.8% 95.2% 94.0% 95.6% 95.4% 95.8% 95.2% 93.7% 95.0% 95.0% 95.30% 95.30%

3.2%

2.7%

2.8%

5.7%

3.7%

10.8%

5.0%

12.4%




ActualYTD

TargetTarget Trend

QUALITY SCORECARD

EXPERIENCEExperience domain score 2.06 2.00 1.88 1.94 2.00 2.13 1.94 2.25 2.06 2.13 2.13 2.19 2.39 2.39

Friends and Family Test

X38 Trust Friends and Family Recommend %: Inpatient 95.3% 95.2% 95.5% 95.8% 96.0% 96.0% 96.7% 96.1% 96.0% 97.0% 96.6% 96.7% 96.9% 96.9% 97% 97%

X39 Trust Friends and Family Recommend %: A&E 92.1% 91.4% 90.9% 89.2% 87.9% 86.7% 87.1% 89.3% 89.3% 88.4% 88.0% 86.6% 84.6% 84.6% 93% 93%

X40Maternity Friends and Family Recommend %: Antenatal care (36 weeks)

100.0% 93.8% 93.1% 95.0% 100.0% 100.0% 100.0% 96.7% 82.4% 100.0% 100.0% 100.0% 100.0% 100.0% 97% 97%

X41 Maternity Friends and Family Recommend %: Delivery care 93.2% 100.0% 95.9% 96.2% 95.5% 96.8% 97.8% 98.5% 96.8% 98.7% 100.0% 99.1% 98.8% 98.8% 97% 97%

X42 Maternity Friends and Family Recommend %: Postnatal ward 93.2% 100.0% 95.9% 96.2% 95.5% 96.8% 97.8% 98.5% 96.8% 98.7% 100.0% 99.1% 98.1% 98.1% 97% 97%

X43 Maternity Friends and Family Recommend %: Postnatal community care 100.0% 100.0% 100.0% 100.0% 98.0% 100.0% 92.9% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 97% 97%

X44 Trust Friends and Family Recommend %: Outpatient 93.6% 95.0% 94.1% 95.2% 96.3% 94.6% 96.6% 95.5% 95.3% 96.6% 96.3% 97.9% 96.8% 96.8% 97% 97%

Friends and Family Test response rates

X24 Trust Friends and Family Response Rate: Inpatient 35.1% 31.5% 38.3% 38.4% 37.0% 37.1% 37.2% 37.5% 32.0% 25.7% 30.7% 31.0% 31.8% 31.8% 40% 40%

X25 Trust Friends and Family Response Rate: A&E 16.1% 17.3% 15.3% 14.2% 13.4% 12.3% 10.6% 12.6% 10.1% 10.3% 8.7% 8.4% 9.0% 9.0% 23% 23%

X33 Maternity Friends and Family Response Rate: Delivery care 14.0% 9.3% 17.8% 17.1% 33.2% 34.1% 22.7% 34.6% 37.6% 36.1% 38.9% 56.7% 42.8% 42.8% 40% 40%

Reduction in patients suffering a bad experience dealing with the Trust

X08 Percentage of re-booked outpatient appointments 9.0% 8.0% 8.9% 9.0% 8.9% 8.0% 8.9% 7.7% 7.8% 7.7% 11.4% 12.1% 12.7% 12.7% 7.80% 7.80%

X09 Clinics cancelled with less than 6 weeks notice for annual/study leave 22 22 15 16 25 24 48 16 8 39 15 28 17 17 23 278

X11 PALS contacts relating to appointment problems (pior % of total appts) 0.08% 0.07% 0.08% 0.08% 0.11% 0.11% 0.08% 0.09% 0.09% 0.08% 0.10% 0.10% 0.14% 0.14% 0.08% 0.08%

X12 Reduce patients cancelled on the day of surgery for non-clinical reasons 12 28 30 57 31 16 37 31 50 41 10 18 14 14 28 337

X13 Breaches of mixed sex accommodation arrangements 0 6 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Nutritional Assessment

X14 Compliance with MUST tool after 24 hours 55.7% 67.5% 70.4% 71.5% 75.8% 76.6% 82.9% 85.4% 82.3% 79.2% 80.6% 83.8% 84.0% 84.0% 80% 80%

X15 Compliance with MUST tool after 7 days 93.7% 96.0% 97.9% 97.4% 97.9% 99.3% 99.5% 98.5% 98.9% 97.7% 98.6% 98.7% 98.1% 98.1% 95% 95%

Cleanliness / PLACE Survey

X16 Internal PLACE compliance : St Richard's Hospital 93% 98% 94% 97% 93% 95% 95% 91% 93% 92% 94% 95% 91% 91% 95% 95%

X17 Internal PLACE compliance : Worthing Hospital 96% 95% 94% 91% 94% 97% 98% 96% 94% 93% 95% 99% 97% 97% 95% 95%

Improve our customer service and become a more caring organisation

X18 Number of complaints 63 51 58 58 47 46 47 47 40 38 44 46 35 35 47 570

X19 Complaints where staff attitude or behaviour is an issue 2 3 5 8 7 2 6 7 7 4 3 5 4 4 4 54

X20 Complaints where staff communication is an issue 3 5 5 2 2 5 9 3 3 4 8 5 2 2 4 49

X21 Complaints about nursing 4 4 4 4 2 10 5 10 5 5 4 2 5 5 3 39




ActualYTD

TargetTarget Trend

QUALITY SCORECARD


5.1b Copy of Copy of SaferStaffingScorecard_1718_M01 SaferStaffingWardNurseScorecard 1 of 10 24/05/2017 10:25

April 2017Shift May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr

YTDActual

Trend

Day 97.6% 98.1% 96.2% 96.0% 96.5% 96.9% 97.5% 96.8% 95.4% 94.0% 94.0% 97.3% 97.3%Night 97.3% 98.4% 96.7% 97.4% 97.4% 97.4% 97.9% 98.1% 96.1% 95.9% 96.5% 97.7% 97.7%Day 95.2% 98.0% 93.2% 99.7% 98.0% 98.1% 97.0% 99.0% 95.5% 93.6% 93.5% 98.3% 98.3%

Night 94.4% 99.2% 94.4% 100.0% 98.3% 96.8% 96.7% 99.2% 96.8% 92.9% 92.7% 99.2% 99.2%

Day 93.9% 98.1% 93.5% 96.4% 95.9% 95.7% 96.7% 98.9% 92.5% 85.7% 92.1% 94.8% 94.8%

Night 88.7% 96.7% 85.5% 90.3% 93.3% 90.3% 93.3% 96.8% 80.6% 71.4% 80.6% 91.7% 91.7%

Day 94.9% 97.7% 94.9% 93.3% 94.8% 97.8% 98.6% 96.8% 96.8% 94.0% 95.7% 96.9% 96.9%

Night 98.4% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 98.4% 96.8% 100.0% 100.0% 100.0% 100.0%

Day 100.0% 100.0% 98.4% 98.7% 98.3% 96.8% 99.7% 97.4% 97.7% 96.4% 97.1% 98.0% 98.0%

Night 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Day 97.4% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 97.7% 100.0% 100.0%

Night 100.0% 100.0% 98.8% 100.0% 100.0% 100.0% 98.8% 94.8% 100.0% 100.0% 98.7% 95.1% 95.1%

Day 96.7% 100.0% 100.0% 99.1% 100.0% 99.1% 98.4% 100.0% 100.0% 95.5% 99.2% 100.0% 100.0%

Night 97.2% 100.0% 100.0% 98.9% 100.0% 97.4% 100.0% 100.0% 99.2% 100.0% 100.0% 100.0% 100.0%

Day 98.0% 97.9% 96.4% 97.2% 97.1% 98.0% 98.8% 98.4% 98.0% 95.5% 91.1% 97.9% 97.9%

Night 96.8% 100.0% 96.8% 98.4% 95.0% 96.8% 98.3% 98.4% 98.4% 91.1% 88.7% 96.7% 96.7%

Day 97.0% 98.1% 91.1% 91.1% 93.9% 94.4% 97.3% 92.6% 95.9% 94.3% 91.9% 95.4% 95.4%

Night 98.9% 98.9% 95.7% 100.0% 98.9% 100.0% 100.0% 97.8% 95.7% 98.8% 100.0% 100.0% 100.0%

Day 97.6% 97.9% 97.6% 98.8% 98.3% 97.6% 98.3% 97.6% 94.0% 91.5% 97.2% 99.6% 99.6%

Night 95.2% 96.7% 93.5% 98.4% 98.3% 95.2% 96.7% 95.2% 90.3% 85.7% 95.2% 100.0% 100.0%

WSHFT

Bluefin

Bosham

Botolphs

Acute Cardiac Unit

Ashling

Barrow

Beeding

Becket

Boxgrove

SAFER STAFFING SCORECARD - Registered Nurses




YTDActual

Trend

Day 97.6% 98.1% 96.2% 96.0% 96.5% 96.9% 97.5% 96.8% 95.4% 94.0% 94.0% 97.3% 97.3%Night 97.3% 98.4% 96.7% 97.4% 97.4% 97.4% 97.9% 98.1% 96.1% 95.9% 96.5% 97.7% 97.7%

WSHFT


Day 97.6% 99.0% 97.1% 94.7% 94.6% 98.1% 97.0% 96.2% 91.8% 91.0% 87.1% 96.0% 96.0%

Night 100.0% 100.0% 98.4% 100.0% 100.0% 100.0% 100.0% 96.8% 95.2% 100.0% 98.4% 100.0% 100.0%

Day 99.6% 98.2% 99.6% 94.4% 96.9% 94.6% 97.6% 92.9% 87.3% 92.8% 88.2% 95.6% 95.6%

Night 100.0% 98.6% 100.0% 97.4% 100.0% 98.4% 98.3% 100.0% 100.0% 98.2% 98.4% 96.7% 96.7%

Day 99.1% 96.9% 95.8% 94.3% 94.1% 97.8% 98.5% 96.1% 97.5% 96.4% 96.4% 99.3% 99.3%

Night 97.6% 98.3% 99.2% 97.6% 98.3% 97.8% 98.9% 98.9% 94.6% 98.8% 98.9% 98.9% 98.9%

Day 97.6% 95.3% 93.5% 94.3% 94.3% 93.9% 91.9% 94.4% 93.7% 92.1% 92.5% 95.8% 95.8%

Night 97.4% 95.0% 92.5% 94.3% 93.7% 92.1% 89.1% 93.9% 93.9% 91.7% 93.0% 96.8% 96.8%

Day 97.2% 99.0% 98.6% 99.1% 97.6% 97.6% 99.0% 98.6% 99.5% 99.0% 98.1% 99.0% 99.0%

Night 93.5% 98.3% 96.8% 98.4% 93.3% 91.9% 98.3% 98.4% 98.4% 96.4% 96.8% 96.7% 96.7%

Day 99.5% 99.5% 98.6% 93.8% 95.0% 96.4% 96.7% 94.8% 96.8% 95.5% 96.8% 98.8% 98.8%

Night 100.0% 100.0% 100.0% 98.4% 98.3% 100.0% 100.0% 100.0% 100.0% 100.0% 98.4% 100.0% 100.0%

Day 98.0% 98.8% 96.4% 96.4% 97.5% 95.2% 97.1% 96.4% 93.5% 96.4% 93.1% 97.9% 97.9%

Night 98.4% 93.3% 100.0% 93.5% 93.3% 98.4% 100.0% 96.8% 100.0% 96.4% 100.0% 96.7% 96.7%

Day 98.4% 98.8% 98.8% 96.0% 97.9% 95.2% 97.1% 97.2% 96.0% 93.8% 94.4% 98.8% 98.8%

Night 100.0% 100.0% 96.8% 100.0% 98.3% 100.0% 100.0% 100.0% 98.4% 100.0% 100.0% 100.0% 100.0%

Day 98.4% 98.8% 96.4% 97.2% 96.3% 98.4% 99.7% 98.4% 97.1% 96.1% 91.9% 97.7% 97.7%

Night 98.4% 99.2% 99.2% 97.6% 97.5% 99.4% 100.0% 98.7% 100.0% 99.3% 97.4% 99.3% 99.3%

Day 99.1% 98.1% 96.3% 97.7% 96.2% 98.2% 98.1% 94.5% 95.9% 96.4% 95.9% 99.0% 99.0%

Night 100.0% 100.0% 98.4% 100.0% 100.0% 100.0% 100.0% 100.0% 98.4% 100.0% 100.0% 100.0% 100.0%

Day 97.7% 98.1% 99.5% 91.2% 93.8% 98.6% 97.6% 98.2% 94.0% 92.9% 94.9% 98.1% 98.1%

Night 100.0% 100.0% 100.0% 100.0% 100.0% 98.4% 100.0% 100.0% 93.5% 100.0% 100.0% 100.0% 100.0%

Day 98.6% 97.6% 95.9% 95.4% 93.3% 91.1% 96.3% 99.6% 91.1% 92.4% 95.6% 97.5% 97.5%

Night 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 98.9% 100.0% 97.8% 100.0% 100.0% 100.0% 100.0%

Day 98.4% 97.1% 98.0% 92.3% 97.5% 97.8% 98.2% 93.9% 95.7% 96.2% 92.2% 97.3% 97.3%

Night 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 98.4% 100.0% 100.0% 100.0% 100.0%

Eartham

Eastbrook

Clapham

Coombes

Burlington

Courtlands

Ditchling

Durrington

Buckingham

Castle

Chilgrove

Chiltington

Chichester Emergency Floor




YTDActual

Trend

Day 97.6% 98.1% 96.2% 96.0% 96.5% 96.9% 97.5% 96.8% 95.4% 94.0% 94.0% 97.3% 97.3%Night 97.3% 98.4% 96.7% 97.4% 97.4% 97.4% 97.9% 98.1% 96.1% 95.9% 96.5% 97.7% 97.7%

WSHFT


Day 98.3% 99.4% 98.9% 94.4% 96.4% 95.7% 98.2% 95.0% 94.2% 91.4% 93.5% 95.8% 95.8%

Night 98.5% 97.6% 99.4% 97.9% 97.0% 98.7% 99.4% 98.9% 96.8% 98.5% 98.4% 98.9% 98.9%

Day 100.0% 100.0% 100.0% 99.2% 100.0% 100.0% 100.0% 100.0% 96.0% 99.1% 100.0% 99.2% 99.2%

Night 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 96.8% 100.0% 100.0% 100.0% 100.0%

Day 97.2% 100.0% 99.1% 95.9% 97.6% 99.1% 99.5% 96.8% 97.7% 94.9% 90.8% 97.6% 97.6%

Night 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 98.4% 100.0% 100.0% 100.0% 100.0%

Day 97.2% 96.7% 94.0% 99.2% 98.3% 98.0% 97.1% 97.6% 94.4% 93.8% 92.7% 97.1% 97.1%

Night 93.5% 96.7% 93.5% 95.2% 95.0% 96.8% 95.0% 96.8% 88.7% 89.3% 91.9% 95.0% 95.0%

Day 97.1% 95.7% 90.6% 96.1% 95.7% 96.5% 97.7% 98.4% 94.8% 92.5% 93.5% 94.3% 94.3%

Night 94.6% 96.7% 90.3% 91.4% 93.3% 93.5% 97.8% 97.8% 91.4% 88.1% 90.3% 90.0% 90.0%

Day 99.2% 98.0% 98.1% 100.0% 100.0% 100.0% 99.2% 100.0% 100.0% 97.3% 96.7% 100.0% 100.0%

Night 98.2% 100.0% 99.0% 100.0% 100.0% 95.2% 99.2% 100.0% 100.0% 98.2% 99.2% 90.5% 90.5%

Day 95.7% 97.4% 95.0% 95.7% 97.0% 96.1% 95.2% 96.4% 91.4% 89.7% 91.4% 94.1% 94.1%

Night 91.9% 95.0% 88.7% 91.9% 93.3% 88.7% 88.3% 93.5% 79.0% 80.4% 83.9% 91.7% 91.7%

Day 96.8% 97.9% 91.5% 95.6% 97.9% 98.0% 97.9% 99.6% 96.4% 95.1% 95.2% 96.7% 96.7%

Night 91.9% 98.3% 82.3% 88.7% 95.0% 95.2% 95.0% 100.0% 93.5% 91.1% 91.9% 95.0% 95.0%

Day 95.7% 98.7% 96.6% 98.9% 100.0% 100.0% 96.5% 100.0% 98.9% 98.7% 96.3% 100.0% 100.0%

Night 93.5% 98.6% 97.6% 97.7% 100.0% 100.0% 97.6% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Day 100.0% 98.9% 97.3% 100.0% 95.6% 98.4% 98.9% 98.4% 97.8% 96.4% 96.8% 99.4% 99.4%

Night 100.0% 100.0% 98.4% 100.0% 93.3% 98.4% 100.0% 98.4% 96.8% 96.4% 100.0% 100.0% 100.0%

Day 97.1% 97.4% 97.1% 94.2% 96.6% 97.9% 97.0% 95.8% 97.9% 95.8% 92.5% 96.5% 96.5%

Night 97.8% 98.9% 96.8% 91.4% 97.8% 98.9% 97.8% 94.6% 97.8% 96.4% 92.5% 96.7% 96.7%

Day 98.0% 97.9% 96.8% 97.2% 97.9% 99.2% 97.5% 96.8% 98.4% 98.7% 96.0% 99.6% 99.6%

Night 95.2% 96.7% 95.2% 96.8% 96.7% 98.4% 96.7% 96.8% 100.0% 98.2% 95.2% 100.0% 100.0%Wittering

Ford

Lavant

Neonatal Unit

Petworth

Enhanced Surgical Care Unit

Erringham

Fishbourne

Selsey

Emergency Floor Worthing

Howard Children's Unit

Middleton


5.1b Copy of Copy of SaferStaffingScorecard_1718_M01 SaferStaffingWardCareScorecard 4 of 10 24/05/2017 10:25


YTDActual

Trend

Day 92.5% 93.4% 92.8% 91.6% 90.4% 91.6% 90.6% 90.7% 91.7% 90.2% 90.5% 95.4% 95.4%Night 93.2% 93.9% 93.8% 93.0% 92.4% 92.6% 91.4% 92.3% 92.5% 91.3% 92.4% 96.2% 96.2%Day 98.7% 92.0% 96.8% 94.2% 94.7% 92.9% 92.7% 90.3% 85.8% 85.0% 88.4% 92.7% 92.7%

Night 93.5% 70.0% 87.1% 83.9% 93.3% 80.6% 80.0% 74.2% 64.5% 64.3% 74.2% 90.0% 90.0%

Day 89.9% 92.9% 95.9% 93.5% 92.4% 95.9% 91.9% 95.4% 91.7% 96.4% 97.2% 97.6% 97.6%

Night 79.0% 90.0% 95.2% 88.7% 85.0% 90.3% 88.3% 91.9% 85.5% 96.4% 98.4% 95.0% 95.0%

Day 88.0% 89.0% 88.7% 70.2% 69.2% 88.4% 93.6% 86.8% 91.1% 86.0% 83.6% 92.8% 92.8%

Night 98.4% 98.3% 95.2% 91.9% 93.3% 95.2% 95.8% 91.9% 96.8% 95.5% 96.0% 97.5% 97.5%

Day 83.1% 84.9% 86.9% 83.7% 83.1% 80.7% 82.4% 71.9% 76.0% 89.4% 85.7% 95.7% 95.7%

Night 100.0% 95.0% 96.8% 98.4% 95.0% 98.4% 98.3% 91.9% 88.7% 96.4% 95.2% 98.3% 98.3%

Day 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 95.2% 100.0% 100.0% 100.0% 92.6% 100.0% 100.0%

Night 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 90.9% 89.7% 100.0% 100.0% 95.8% 100.0% 100.0%

Day 96.7% 90.0% 94.1% 97.1% 89.7% 86.7% 96.9% 93.9% 96.8% 85.7% 89.7% 100.0% 100.0%

Night 100.0% 93.3% 96.7% 100.0% 93.3% 100.0% 93.3% 96.8% 96.6% 96.3% 77.8% 72.2% 72.2%

Day 96.1% 94.7% 94.8% 94.2% 80.7% 85.2% 92.0% 96.8% 94.2% 95.7% 96.1% 99.3% 99.3%

Night 93.5% 95.0% 95.2% 90.3% 75.0% 83.9% 90.0% 96.8% 93.5% 96.4% 98.4% 100.0% 100.0%

Day 90.7% 93.9% 90.0% 94.1% 84.0% 86.2% 97.7% 93.0% 94.1% 89.3% 91.5% 93.8% 93.8%

Night 93.5% 98.3% 96.8% 98.4% 88.3% 85.5% 98.3% 93.5% 93.5% 80.4% 85.5% 93.3% 93.3%

Day 91.2% 98.1% 91.2% 96.8% 94.8% 94.9% 88.6% 94.9% 89.4% 89.8% 91.2% 93.8% 93.8%

Night 82.3% 96.7% 80.6% 90.3% 90.0% 87.1% 75.0% 90.3% 80.6% 80.4% 85.5% 91.7% 91.7%

WSHFT

Acute Cardiac Unit

Boxgrove

Ashling

Beeding

Bluefin

Bosham

Botolphs

Becket

Barrow

SAFER STAFFING SCORECARD - Care Staff




YTDActual

Trend

Day 92.5% 93.4% 92.8% 91.6% 90.4% 91.6% 90.6% 90.7% 91.7% 90.2% 90.5% 95.4% 95.4%Night 93.2% 93.9% 93.8% 93.0% 92.4% 92.6% 91.4% 92.3% 92.5% 91.3% 92.4% 96.2% 96.2%

WSHFT


Day 94.2% 94.0% 83.2% 86.5% 90.0% 96.4% 81.0% 81.7% 82.3% 88.5% 87.1% 98.8% 98.8%

Night 98.4% 100.0% 100.0% 96.8% 95.0% 100.0% 83.3% 87.1% 91.9% 96.4% 98.4% 98.3% 98.3%

Day 89.3% 91.8% 92.0% 89.4% 91.8% 96.4% 89.9% 94.4% 92.9% 94.5% 95.8% 98.5% 98.5%

Night 100.0% 98.3% 95.2% 98.4% 98.3% 100.0% 93.3% 96.8% 87.1% 96.4% 96.8% 100.0% 100.0%

Day 89.5% 84.2% 93.5% 94.4% 94.2% 93.1% 90.5% 89.9% 89.9% 94.9% 90.3% 98.1% 98.1%

Night 83.9% 83.3% 90.3% 90.3% 96.7% 96.8% 98.3% 93.5% 96.8% 98.2% 95.2% 96.7% 96.7%

Day 93.0% 93.7% 94.1% 93.9% 93.1% 92.5% 88.2% 94.4% 94.1% 88.2% 89.6% 96.4% 96.4%

Night 84.9% 87.3% 86.2% 81.0% 83.1% 76.6% 74.6% 87.7% 87.7% 80.3% 83.7% 92.9% 92.9%

Day 87.9% 92.5% 91.1% 91.1% 90.0% 93.5% 90.0% 92.7% 97.6% 98.2% 96.0% 95.0% 95.0%

Night 87.1% 96.7% 95.2% 95.2% 93.3% 96.8% 93.3% 95.2% 98.4% 98.2% 98.4% 96.7% 96.7%

Day 99.0% 97.9% 97.4% 95.9% 97.3% 97.3% 86.1% 91.9% 87.6% 88.7% 84.9% 98.9% 98.9%

Night 100.0% 96.7% 96.8% 96.8% 95.0% 96.8% 93.3% 91.9% 93.5% 96.4% 98.4% 100.0% 100.0%

Day 96.1% 94.0% 96.8% 92.3% 98.7% 97.2% 90.5% 89.4% 95.9% 91.8% 87.1% 98.1% 98.1%

Night 96.8% 95.0% 95.2% 96.8% 98.3% 96.8% 88.3% 93.5% 95.2% 89.3% 93.5% 98.3% 98.3%

Day 94.2% 93.3% 95.5% 92.9% 89.3% 84.4% 88.3% 83.3% 84.4% 91.1% 89.2% 95.0% 95.0%

Night 96.8% 90.0% 100.0% 90.3% 91.7% 93.5% 93.3% 82.3% 93.5% 98.2% 96.8% 96.7% 96.7%

Day 84.7% 87.5% 89.5% 90.3% 87.5% 92.9% 90.7% 87.1% 92.3% 96.4% 96.1% 93.3% 93.3%

Night 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Day 94.6% 86.7% 88.2% 79.6% 85.6% 94.1% 83.9% 82.8% 87.1% 79.8% 94.1% 95.6% 95.6%

Night 100.0% 93.3% 96.8% 95.2% 95.0% 95.2% 96.7% 82.3% 93.5% 91.1% 93.5% 96.7% 96.7%

Day 87.6% 88.9% 87.6% 90.3% 84.4% 93.5% 95.0% 90.3% 86.3% 87.1% 89.5% 94.2% 94.2%

Night 96.8% 93.3% 96.8% 96.8% 95.0% 90.3% 88.3% 90.3% 96.8% 94.6% 90.3% 96.7% 96.7%

Day 82.2% 96.5% 99.3% 89.8% 78.9% 77.4% 76.0% 85.8% 93.5% 80.0% 75.5% 94.0% 94.0%

Night 96.8% 96.7% 100.0% 96.8% 93.3% 71.0% 93.3% 96.8% 77.4% 89.3% 83.9% 86.7% 86.7%

Day 87.7% 98.7% 96.8% 94.2% 91.3% 88.4% 86.0% 83.2% 96.1% 95.0% 87.1% 95.3% 95.3%

Night 96.8% 91.7% 98.4% 96.8% 95.0% 100.0% 91.7% 95.2% 95.2% 98.2% 88.7% 96.7% 96.7%

Chilgrove

Chiltington

Clapham

Eastbrook

Buckingham

Burlington

Coombes

Courtlands

Ditchling

Durrington

Eartham

Castle





YTDActual

Trend

Day 92.5% 93.4% 92.8% 91.6% 90.4% 91.6% 90.6% 90.7% 91.7% 90.2% 90.5% 95.4% 95.4%Night 93.2% 93.9% 93.8% 93.0% 92.4% 92.6% 91.4% 92.3% 92.5% 91.3% 92.4% 96.2% 96.2%

WSHFT


Day 97.1% 95.2% 97.8% 91.9% 90.9% 91.8% 92.7% 87.4% 95.2% 93.4% 92.7% 93.3% 93.3%

Night 98.7% 90.7% 96.8% 91.6% 93.3% 98.1% 96.3% 96.5% 96.8% 96.1% 95.8% 98.7% 98.7%

Day 96.8% 100.0% 96.8% 100.0% 96.7% 98.4% 98.3% 98.4% 98.4% 98.2% 99.2% 98.3% 98.3%

Night 100.0% 100.0% 90.0% 87.5% 87.5% 96.8% 96.7% 93.5% 100.0% 92.9% 100.0% 96.7% 96.7%

Day 95.7% 90.0% 84.4% 81.7% 84.4% 80.0% 92.7% 90.3% 89.0% 84.3% 87.1% 100.0% 100.0%

Night 100.0% 100.0% 100.0% 98.4% 96.7% 91.9% 100.0% 95.2% 93.5% 91.1% 98.4% 100.0% 100.0%

Day 90.3% 95.0% 91.4% 95.2% 90.0% 94.6% 95.0% 99.5% 90.3% 82.7% 95.2% 92.8% 92.8%

Night 80.6% 93.3% 85.5% 88.7% 86.7% 88.7% 95.0% 98.4% 90.3% 76.8% 93.5% 98.3% 98.3%

Day 93.5% 96.0% 88.4% 88.4% 94.0% 91.6% 91.3% 93.5% 91.6% 77.9% 92.3% 96.0% 96.0%

Night 91.9% 93.3% 90.3% 83.9% 91.7% 87.1% 88.3% 91.9% 90.3% 78.6% 91.9% 98.3% 98.3%

Day 96.8% 100.0% 100.0% 100.0% 100.0% 100.0% 96.8% 96.9% 100.0% 100.0% 96.8% 100.0% 100.0%

Night 77.4% 95.2% 100.0% 92.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 74.2% 100.0% 100.0%

Day 92.3% 92.9% 87.9% 96.8% 96.3% 91.5% 80.8% 95.2% 92.3% 88.8% 92.7% 92.1% 92.1%

Night 77.4% 86.7% 77.4% 95.2% 95.0% 80.6% 61.7% 87.1% 85.5% 78.6% 87.1% 88.3% 88.3%

Day 98.7% 98.7% 94.2% 96.8% 91.3% 97.4% 96.0% 92.9% 89.0% 94.3% 96.8% 98.0% 98.0%

Night 98.4% 98.3% 91.9% 98.4% 88.3% 98.4% 96.7% 93.5% 85.5% 96.4% 96.8% 98.3% 98.3%

Day 90.3% 96.4% 100.0% 90.9% 100.0% 97.1% 93.3% 88.9% 86.2% 96.2% 89.3% 100.0% 100.0%

Night 100.0% 90.9% 100.0% 100.0% 100.0% 100.0% 100.0% 80.0% 82.1% 64.3% 96.4% 96.2% 96.2%

Day 95.5% 94.0% 95.5% 96.1% 95.3% 93.5% 92.7% 95.5% 91.0% 92.1% 94.2% 92.7% 92.7%

Night 95.2% 95.0% 93.5% 95.2% 95.0% 90.3% 90.0% 93.5% 91.9% 89.3% 91.9% 93.3% 93.3%

Day 96.3% 97.3% 88.0% 88.4% 97.8% 92.1% 96.2% 94.2% 99.5% 93.0% 92.1% 94.6% 94.6%

Night 93.5% 100.0% 83.9% 80.6% 98.3% 90.3% 91.7% 88.7% 100.0% 91.1% 91.9% 93.3% 93.3%

Day 93.5% 86.7% 92.9% 91.0% 87.3% 86.5% 93.3% 98.1% 98.1% 92.9% 78.7% 94.0% 94.0%

Night 91.9% 86.7% 90.3% 88.7% 83.3% 80.6% 96.7% 96.8% 98.4% 92.9% 79.0% 98.3% 98.3%

Fishbourne

Wittering

Ford

Lavant

Neonatal Unit

Petworth

Selsey

Middleton



Erringham

Emergency Floor Worthing


5.1b Copy of Copy of SaferStaffingScorecard_1718_M01 SaferStaffingWardCHPPD 7 of 10 24/05/2017 10:25

April 2017Care Hours Per Patient

Day (CHPPD)May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr

YTDAverage

Trend

Nurse 3.9 4.1 3.8 4.1 4.0 3.9 3.9 3.9 3.7 3.7 3.9 4.0 4.0Care 2.5 2.7 2.5 2.7 2.6 2.6 2.6 2.6 2.6 2.6 2.7 2.8 2.8Overall 6.4 6.7 6.4 6.8 6.6 6.5 6.5 6.6 6.3 6.3 6.6 6.8 6.8Nurse 4.4 4.9 4.3 5.4 4.5 4.4 4.4 4.8 4.6 4.2 4.8 4.6 4.6

Care 1.9 1.9 1.9 2.1 1.9 1.8 1.8 1.8 1.7 1.6 1.9 1.9 1.9

Overall 6.3 6.7 6.1 7.5 6.4 6.2 6.2 6.6 6.2 5.7 6.8 6.5 6.5

Nurse 3.3 3.5 3.4 4.6 3.4 3.3 3.4 3.6 3.2 3.0 3.3 3.5 3.5

Care 2.5 2.7 2.9 3.7 2.7 2.7 2.6 2.8 2.6 2.8 2.9 2.9 2.9

Overall 5.8 6.2 6.2 8.3 6.1 6.1 6.0 6.4 5.8 5.8 6.1 6.4 6.4

Nurse 1.7 1.7 1.6 1.6 1.6 3.5 3.5 3.4 3.4 3.4 3.4 3.5 3.5

Care 1.4 1.4 1.4 1.1 1.2 3.2 3.4 3.1 3.2 3.1 3.1 3.3 3.3

Overall 3.1 3.1 3.0 2.8 2.8 6.7 6.9 6.6 6.6 6.5 6.5 6.8 6.8

Nurse 5.0 5.0 4.8 4.9 4.9 4.5 4.5 4.4 4.5 4.4 4.5 4.5 4.5

Care 2.6 2.6 2.6 2.6 2.5 2.2 2.2 2.0 2.0 2.3 2.3 2.5 2.5

Overall 7.6 7.5 7.4 7.4 7.4 6.7 6.8 6.4 6.5 6.8 6.7 7.0 7.0

Nurse 11.8 13.0 7.2 5.6 13.1 7.2 9.8 17.4 8.3 7.8 9.3 7.2 7.2

Care 4.2 4.5 2.8 1.9 4.8 2.6 2.4 5.7 2.9 2.6 2.8 2.3 2.3

Overall 16.1 17.5 10.0 7.5 17.9 9.9 12.2 23.1 11.2 10.5 12.1 9.5 9.5

Nurse 6.5 5.2 5.5 7.3 6.0 5.7 5.7 6.1 5.5 6.1 6.4 6.3 6.3

Care 1.7 1.5 1.8 2.3 1.8 1.4 1.4 1.5 1.3 1.4 1.3 1.1 1.1

Overall 8.2 6.8 7.3 9.6 7.8 7.1 7.0 7.6 6.8 7.5 7.7 7.4 7.4

Nurse 3.4 3.4 3.3 3.5 3.3 3.3 3.3 3.3 3.3 3.3 3.3 3.5 3.5

Care 2.3 2.3 2.3 2.4 1.9 2.0 2.1 2.3 2.2 2.3 2.5 2.5 2.5

Overall 5.7 5.7 5.6 5.9 5.2 5.3 5.4 5.6 5.4 5.6 5.8 6.0 6.0

Nurse 3.8 4.0 3.5 3.7 3.8 3.6 3.8 3.6 3.6 3.6 3.9 3.9 3.9

Care 3.2 3.5 3.2 3.4 3.1 3.0 3.5 3.3 3.2 3.0 3.5 3.5 3.5

Overall 7.0 7.4 6.7 7.1 6.8 6.6 7.2 6.9 6.8 6.7 7.4 7.4 7.4

Nurse 3.0 3.1 3.1 3.0 3.0 3.0 3.0 3.0 2.9 2.8 3.1 3.1 3.1

Care 2.5 2.8 2.5 2.6 2.6 2.6 2.4 2.6 2.4 2.4 2.6 2.6 2.6

Overall 5.5 5.8 5.6 5.7 5.6 5.6 5.4 5.6 5.3 5.2 5.7 5.8 5.8

Nurse 3.3 3.3 3.2 3.2 3.2 3.3 2.7 2.2 2.1 2.1 2.0 2.2 2.2

Care 2.6 2.6 2.3 2.4 2.4 2.7 1.9 1.6 1.6 1.7 1.7 1.9 1.9

Overall 5.9 5.9 5.6 5.5 5.6 6.0 4.5 3.8 3.6 3.7 3.7 4.1 4.1

Nurse 4.6 4.7 4.6 4.8 4.6 3.3 3.4 3.4 3.1 3.4 3.3 3.4 3.4

Care 3.0 3.1 3.0 3.2 3.0 2.5 2.4 2.5 2.4 2.6 2.6 2.6 2.6

Overall 7.6 7.8 7.6 8.0 7.6 5.8 5.8 5.9 5.5 6.0 5.9 6.1 6.1

Becket

Beeding

Bluefin

Bosham

WSHFT

Acute Cardiac Unit

Ashling

Barrow

Botolphs

Boxgrove

Buckingham

Burlington

SAFER STAFFING SCORECARD - CHPPD





YTDAverage

Trend

Nurse 3.9 4.1 3.8 4.1 4.0 3.9 3.9 3.9 3.7 3.7 3.9 4.0 4.0Care 2.5 2.7 2.5 2.7 2.6 2.6 2.6 2.6 2.6 2.6 2.7 2.8 2.8Overall 6.4 6.7 6.4 6.8 6.6 6.5 6.5 6.6 6.3 6.3 6.6 6.8 6.8

WSHFT


Nurse 4.7 4.7 4.7 4.6 4.7 3.8 3.8 3.7 3.6 3.6 3.6 3.7 3.7

Care 1.4 1.4 1.5 1.5 1.6 2.7 2.7 2.6 2.6 2.7 2.6 2.8 2.8

Overall 6.2 6.1 6.2 6.2 6.3 6.5 6.5 6.4 6.2 6.3 6.2 6.5 6.5

Nurse 4.5 4.6 4.2 4.4 4.3 3.9 4.0 4.3 4.0 4.0 4.6 4.6 4.6

Care 2.4 2.5 2.4 2.4 2.3 2.1 2.1 2.4 2.2 2.1 2.4 2.6 2.6

Overall 6.9 7.1 6.6 6.8 6.6 6.0 6.1 6.6 6.3 6.2 7.0 7.2 7.2

Nurse 3.5 3.7 3.6 3.9 3.4 3.5 3.6 3.7 3.7 3.7 3.8 5.1 5.1

Care 2.2 2.4 2.3 2.5 2.2 2.3 2.2 2.4 2.5 2.5 2.5 3.4 3.4

Overall 5.7 6.1 5.9 6.4 5.6 5.8 5.8 6.1 6.2 6.1 6.3 8.5 8.5

Nurse 3.8 3.7 3.6 3.4 3.5 4.1 4.3 4.0 4.0 4.1 4.2 4.4 4.4

Care 3.6 3.4 3.4 3.3 3.3 3.3 3.1 3.1 2.9 3.1 3.1 3.5 3.5

Overall 7.5 7.1 7.0 6.7 6.8 7.3 7.4 7.1 6.9 7.2 7.2 7.9 7.9

Nurse 3.1 3.2 3.1 3.3 3.1 3.2 3.2 3.1 3.0 3.0 3.0 3.3 3.3

Care 2.1 2.2 2.2 2.3 2.2 2.9 2.7 2.6 2.7 2.6 2.6 3.0 3.0

Overall 5.2 5.4 5.3 5.6 5.4 6.1 5.9 5.7 5.8 5.6 5.6 6.3 6.3

Nurse 3.1 3.1 3.1 3.2 3.1 3.0 3.2 3.2 3.1 3.2 3.1 3.2 3.2

Care 2.1 2.0 2.2 2.2 2.0 2.2 2.3 2.2 2.2 2.5 2.4 2.5 2.5

Overall 5.2 5.2 5.3 5.4 5.1 5.2 5.5 5.3 5.3 5.7 5.5 5.7 5.7

Castle


Chilgrove

Chiltington

Clapham

Coombes





YTDAverage

Trend


WSHFT


Nurse 6.6 6.5 6.5 6.8 6.5 7.6 7.9 8.1 7.7 7.4 7.7 8.4 8.4

Care 1.9 1.9 2.0 2.1 2.0 2.4 2.4 2.4 2.4 2.4 2.6 2.7 2.7

Overall 8.5 8.4 8.5 9.0 8.5 10.0 10.3 10.4 10.1 9.8 10.3 11.1 11.1

Nurse 3.1 3.1 3.1 3.1 3.0 3.1 3.1 3.0 3.0 3.0 3.2 3.2 3.2

Care 2.7 2.5 2.5 2.3 2.4 2.6 2.4 2.3 2.5 2.3 2.8 2.7 2.7

Overall 5.8 5.7 5.6 5.4 5.5 5.7 5.5 5.4 5.4 5.3 6.0 5.9 5.9

Nurse 3.3 3.2 3.2 13.5 6.0 3.2 3.2 3.2 3.1 3.1 3.2 3.3 3.3

Care 2.7 2.6 2.6 11.8 4.9 3.4 3.4 3.3 3.2 3.2 3.3 3.5 3.5

Overall 6.0 5.9 5.8 25.4 10.9 6.6 6.6 6.5 6.3 6.3 6.5 6.8 6.8

Nurse 3.6 3.5 3.5 3.5 3.5 4.1 4.2 4.3 4.1 4.1 4.2 4.3 4.3

Care 2.3 2.6 2.7 2.5 2.3 1.8 1.9 2.1 2.2 2.0 1.8 2.2 2.2

Overall 5.9 6.2 6.2 6.0 5.8 5.9 6.1 6.4 6.2 6.1 6.0 6.5 6.5

Nurse 3.7 3.7 3.6 3.5 3.7 3.4 3.4 3.3 3.3 3.3 3.3 3.4 3.4

Care 2.4 2.6 2.5 2.5 2.4 2.4 2.2 2.3 2.5 2.4 2.2 2.5 2.5

Overall 6.0 6.3 6.1 6.0 6.1 5.7 5.6 5.6 5.8 5.8 5.5 5.8 5.8

Nurse 5.0 5.0 4.8 4.8 5.0 4.8 4.8 4.7 4.5 4.7 4.9 5.1 5.1

Care 3.8 3.7 3.6 3.6 3.6 3.8 3.8 3.7 3.8 3.9 4.1 4.1 4.1

Overall 8.8 8.7 8.4 8.4 8.6 8.6 8.7 8.4 8.2 8.6 9.0 9.2 9.2

Nurse 10.7 11.8 10.8 10.9 10.6 9.8 9.1 8.4 9.0 8.8 9.8 8.9 8.9

Care 4.0 4.5 4.0 4.1 3.8 9.7 8.9 8.2 9.3 8.6 9.7 8.8 8.8

Overall 14.7 16.3 14.8 14.9 14.4 19.5 18.0 16.7 18.3 17.5 19.5 17.7 17.7

Nurse 3.4 3.5 3.4 3.4 3.5 3.4 3.4 3.4 3.3 3.3 3.2 3.4 3.4

Care 3.0 2.9 2.7 2.7 2.7 2.2 2.5 2.5 2.4 2.3 2.4 2.7 2.7

Overall 6.5 6.4 6.2 6.0 6.2 5.6 5.9 5.9 5.6 5.6 5.6 6.0 6.0

Nurse 3.3 3.3 3.1 3.3 3.2 3.2 3.1 3.3 3.1 3.0 3.2 3.2 3.2

Care 2.4 2.6 2.4 2.5 2.4 2.4 2.5 2.7 2.4 2.1 2.6 2.5 2.5

Overall 5.7 5.8 5.5 5.8 5.6 5.6 5.6 5.9 5.4 5.1 5.8 5.8 5.8

Emergency Floor

Courtlands

Ditchling

Durrington

Eartham

Eastbrook


Erringham

Fishbourne





YTDAverage

Trend


WSHFT


Nurse 4.4 4.8 4.1 4.7 4.1 4.0 4.2 4.5 4.0 3.8 4.3 4.1 4.1

Care 2.3 2.6 2.2 2.3 2.2 2.0 2.1 2.3 2.1 1.8 2.3 2.3 2.3

Overall 6.6 7.4 6.3 7.0 6.3 6.0 6.2 6.8 6.1 5.6 6.6 6.4 6.4

Nurse 8.2 6.7 6.6 7.5 7.0 8.2 6.8 7.4 7.8 6.3 6.4 8.2 8.2

Care 1.9 1.8 1.7 2.0 2.0 2.1 1.5 1.5 2.0 1.5 1.4 1.7 1.7

Overall 10.1 8.5 8.2 9.6 9.0 10.3 8.3 8.9 9.8 7.7 7.9 9.9 9.9

Nurse 3.7 3.5 3.5 3.5 3.6 3.3 3.4 3.6 3.1 3.1 3.3 3.3 3.3

Care 3.1 3.0 2.9 3.2 3.3 2.8 2.5 3.2 2.8 2.8 3.0 2.9 2.9

Overall 6.8 6.6 6.3 6.7 6.8 6.2 5.9 6.9 5.9 5.8 6.3 6.2 6.2

Nurse 3.1 3.2 2.9 3.7 7.5 3.8 3.1 3.2 3.0 3.0 3.1 3.2 3.2

Care 2.2 2.3 2.1 2.7 4.9 2.7 2.1 2.1 1.9 2.1 2.3 2.3 2.3

Overall 5.4 5.5 5.1 6.5 12.4 6.4 5.2 5.3 4.9 5.1 5.4 5.5 5.5

Nurse 6.4 7.9 9.6 7.3 6.7 6.6 7.0 10.3 7.3 7.7 8.5 10.9 10.9

Care 1.9 2.5 2.7 1.8 2.0 2.0 2.2 2.5 2.0 2.3 2.8 3.7 3.7

Overall 8.3 10.4 12.3 9.1 8.7 8.6 9.1 12.8 9.3 10.0 11.3 14.6 14.6

Nurse 3.3 3.3 3.4 4.5 5.4 3.6 3.3 3.3 3.3 3.2 3.3 3.3 3.3

Care 2.8 2.8 2.9 3.8 4.7 3.0 2.7 2.8 2.7 2.7 2.8 2.7 2.7

Overall 6.1 6.1 6.2 8.2 10.1 6.7 6.0 6.1 6.0 5.9 6.1 6.0 6.0

Nurse 4.0 4.3 4.6 4.8 4.3 4.7 4.8 4.6 4.0 4.5 4.7 4.8 4.8

Care 3.0 3.3 3.2 3.4 3.3 3.3 3.5 3.4 3.1 3.3 3.5 3.6 3.6

Overall 6.9 7.6 7.8 8.2 7.5 8.0 8.3 8.0 7.1 7.7 8.2 8.4 8.4

Nurse 3.3 3.4 3.3 3.4 3.3 3.3 3.4 3.4 3.3 3.5 3.3 3.7 3.7

Care 2.2 2.1 2.2 2.2 2.0 2.0 2.3 2.4 2.3 2.3 1.9 2.5 2.5

Overall 5.5 5.5 5.6 5.7 5.3 5.3 5.7 5.7 5.6 5.8 5.2 6.2 6.2

Wittering

Ford


Lavant

Middleton

Neonatal Unit

Petworth

Selsey

1

/

Title

Month 1, 2017-18 Performance Report


Peter Landstrom, Executive Director of Delivery and Strategy

Prepared by

Giles Frost, Assistant Director - Operational Planning and Performance

Status

Disclosable

Summary of Proposal The paper sets out organisational compliance against national and local key performance metrics. The report summarises both in year and projected year end performance for Western Sussex Hospitals NHS Foundation Trust, as detailed in dedicated performance scorecards relating to Quality Board indicators aligned to the Quality Strategy, the NHSI Single Oversight Framework and, when relevant, other indicators. This paper describes performance on an exceptional basis determined by RAG rating, key national/regulatory significance, or in year trend analysis.

Implications for Quality of Care

Describes Quality Outcome KPIs

Link to Strategic Objectives/Board Assurance Framework

Trust Strategic Theme B - Provide the highest possible quality of care to our patients. This we will do through focusing on a range of measures to improve clinical effectiveness. Trust Strategic Theme G - Ensure the sustainability of our organisation by exceeding our national targets and financial performance and investing in appropriate infrastructure and capacity. Trust Strategic Theme F - Improve our performance against a range of quality, access and productivity measures through the introduction and spread of best practice throughout the organisation.


Describes KPIs linked to financial performance


Describes KPIs linked to workforce

Recommendation

The Board is asked to: NOTE the Trust position against the NHS Single Oversight Framework and STF Performance Monitoring targets.

Communication and Consultation

Not applicable

Appendices

(1) Key Performance Deliverables, (2) Operational Performance Scorecard, (3) Single Oversight Framework Scorecard, (4) STF Performance Monitoring.

To: Trust Board

Date of Meeting: 25th May 2017 Agenda Item: 5.2

2

To: Trust Board Date: 25th May 2017

From: Pete Landstrom, Executive Director of Delivery & Strategy Agenda Item: 5.2

FOR INFORMATION

WSHFT PERFORMANCE REPORT: MONTH 1, 2017/18

1. INTRODUCTION

1.1 This report summarises the current in year performance for Western Sussex Hospitals NHS

Foundation Trust, with further detail provided in the appendices relating to:

• The NHSI Single Oversight Framework

• Key Performance Deliverables Report

• Operational Performance Scorecard

• Sustainability and Transformation Fund Performance Monitoring

1.2 This paper provides the Board with an update on performance on a specific basis determined by

RAG rating, national significance, or in year trend analysis.

1.3 Introduced as a condition of the National Sustainability and Transformation Programme and

Funding, all Trusts have again submitted joint performance trajectories on the key areas of A&E,

RTT, and Cancer. The detailed tracking of the Trust’s performance against this trajectory is

included in an Appendix of this report, and performance against the requirements is summarised

for each relevant performance area. The trajectory has changed for 2017/18 based on specific

criteria for all indicators, and diagnostic waiters are no longer included. The Sustainability and

Transformation Fund payments in 2017/18 are indicatively based on A&E performance against

trajectory only as per NHS Improvement advice, although official guidance confirming this has not

yet been received.

2. SUMMARY PERFORMANCE

2.1 Under the Single Oversight Framework, the Trust was compliant for Cancer and Diagnostic

metrics against National Constitutional Targets. A&E performance was fractionally below

National Constitutional Target and and RTT compliance reduced from previous compliant levels

to below National Constitutional target.

3

2.2 Operationally April saw continued high but variable levels of emergency demand both through

A&E and as emergency admissions, which were slightly above the levels seen at the same time

last year. It should also be noted that there were also less working days in April 2017 which

resulted in an expected drop in elective activity relative to previous months and last year.

• 11,571 A&E attendances compared to 11,170 in April 2016 (representing a +3.6%

increase on the same time last year).

• 4,647 emergency admissions compared to 4,511 in April 2016 (representing a +3.0%

increase on the same time last year).

• Formally reportable Delayed Transfers of Care totalled 3.12% for April 2017. This is a

marginal reduction from 3.15% in March 2017. Medically Fit for Discharge (MFFD)

patients reduced to an average of 120 per day, representing one of the lowest

average levels for the last 12 months.

• Average Inpatient Bed Occupancy was 94.1% in April, a slight increase on March

occupancy. The Trust was able to reduce the volume of escalation beds were open

over the period however so this actually equates to approximately 18 fewer beds

occupied overall than in March.

2.3 Of note, there was an increase of +5.7% in A&E attendances for patients aged 65 and over in

April, with a significant change in presentation. Compared to April 2016 there was a +13.0%

increase in over 65 year old patients attending the emergency departments between the hours of

8pm and 4am. Over 65 emergency admissions also increased in April 2017 by +2.1% compared

to April 2016.

3 TRUE NORTH AND BREAKTHROUGH OBJECTIVES

3.1 True North – Systems and Partnerships

3.1.1 The Trust is current Red but Stable against both the A&E and RTT True North metrics. Although

neither metric achieved the target they were relatively consistent against previous month’s

compliant position.

3.1.2 Recovery in both areas has already been seen in both areas, and in particular the focus on the

RTT recovery actions in elective specialties is underway and will impact in the next couple of

months.

4

3.2 Breakthrough Objectives – Systems and Partnerships

3.2.1 The current Breakthrough Objective of reducing Medically Fit for Discharge (MFFD) patients is

Red but Improving in April. There was a reduction in both the average number of MFFD

patients, and the average number of days delayed for each patient. In particular over April the

flow to Community Hospitals has improved, and in turn the number of beds occupied has also

reduced.

3.2.2 The Board should note that for 2017/18 the Trust will change the Breakthrough Objective for

Systems and Partnerships with the aim to increase the numbers of patients discharged on a daily

basis by 7% through both internal improvements and external flows. If achieved this would

release approximately 50 beds through improved flow through the hospital and support delivery

of the True North objectives.

4 KEY AREAS OF PERFORMANCE 4.1 A&E Compliance

4.1.1 The Trust was non-compliant against the National target in April, with 94.9% of patients waiting

less than four hours from arrival at A&E to admission, transfer, or discharge. This represents

missing the 95% target by just 14 patients out of 12,511 emergency attendances over the course

of the month.

4.1.2 April compliance was however ahead of the delivery requirements of the in-month Sustainability

and Transformation Fund trajectory for WSHFT of 93.6%.

4.1.3 Access to beds due to delayed transfers of care (DTOC) decreased marginally to 3.12% in April

2017 when compared to March 2017 (3.16%). April DTOCs peaked at 4.1% in the week ending

16th April with both sites above 4%. In real terms, this reflects an impact in ‘lost’ beds that

fluctuated between a minimum of c11 beds and a high of c44 beds during the month.

4.1.4 Patients who were medically fit for discharge (MFFD) reduced to 120 patients on average per day

in April compared to 133 in March. The number of patients medically fit for discharge fluctuated

between 146 patients on 7th April to 92 on the 23rd April.

4.1.5 Nationally and regionally A&E delivery has continued to be challenging. National performance

improved to 85.1% in March 2017. Regionally, compliance for the South of England was 85.9%,

with NHS England South (South East) Trusts (excluding WSHFT) generating aggregate

compliance of 88.1%

4.1.6 The publication of the latest national data confirms that WSHFT was the 9th highest performing

trust nationally in 2016/17 the best performing trust in NHS South.

5

4.2 Cancer

4.2.1 The Trust was compliant against 6 out of 7 metrics in April, and exceeded the Single Oversight

Framework 62 day treatment requirements with provisional performance of 91.6% against an

STF trajectory of 85.2%.

4.2.2 The provisional position for April shows the Trust to be non-compliant against 2 week breast

symptomatic patients where 91.6% of patients were seen within 2 weeks against a target of 93%.

This represents an additional 3 patients who waited longer than 2 weeks of the total 168 patients

seen on this pathway in April.

4.2.3 2 week breast symptomatic cancer referrals in March 2017 were 16.3% higher than observed in

March 2016, which impacted on the demand for appointments in April. Compounding this, patient

availability due to patient choice was constrained due to Easter holidays. The trust undertook

additional Saturday clinics to mitigate the risk of further breaches, and saw 9% more breast

symptomatic patients April 2017 than April 2016.

4.2.4 May to date for breast symptomatic referrals shows a provisional position of 100% against the

93% target.

4.2.5 The Trust achieved the Sustainability and Transformation Fund trajectory for 62 day patients

(following urgent referral and patients referred via screening) of 85.2% in April, with the Trust’s

provisional April compliance against this combined metric of 91.6%

4.2.6 For context, latest comparative nationally published data relating to March 2017 shows National

aggregate compliance for the cancer 62 day treatment to be 83.0% compared to WSHFT

performance of 90.8% and the National target of 85%. In March 2017, 46% of Trusts in England

were non-compliant against this standard.

4.3 Referral to Treatment (RTT/18 Weeks)

4.3.1 The Trust was non-compliant against the National Constitutional Target of 92% in April with

90.7% of pathways waiting less than 18 weeks.

4.3.2 The drop in compliance is as a result two key issues;

• A reduced numbers of completed pathways in April due to the Easter break, with

associated fewer working days (and patient choice). The 18 week pathway for patients

referred over the first part of the year continued, which resulted in an increased

number of patients becoming breaches at the same time as a drop in capacity.

Appropriately the Trust prioritised 2 week rule cancer and clinically urgent patients into

6

the available capacity, which reduced the ability to treat longer waiting routine patients

and impacted on overall performance.

• As noted in the March 2017 board report, there has also been an additional specialty

specific pressure relating to oral surgery/maxillo-facial surgery patients which

compounded the impact on aggregate compliance. The Trust has already

implementing a range of mitigating actions in collaboration with NHS England to

manage the demand spike and provide additional capacity to target this shortfall. Due

to the scale of the imbalance, and national challenges relating to long and short term

specialist oral surgeon recruitment, the board should note this is likely to continue to

impact overall compliance for at least the next few months.

4.3.3 The board should note that the current May provisional RTT performance shows signs of

recovery, with improvements in a number of specialties and stabilisation of the OMFS position.

4.3.4 Latest published national data relates to March 2017 and shows a slight improvement in national

compliance, at 89.8% inclusive of Trusts not currently reporting formally, with 34.7% of Trusts

overall non-compliant.

4.4 Diagnostic Test Waiting Times

4.4.1 The Trust compliance for April was 0.9% over 6 week waiters across all diagnostic modes, which

is compliant against the 1% national target, due to successful implementation of the recovery

actions noted in previous months’ board papers.

4.4.2 WSHFT performed slightly better than peers in March (the latest comparable national data); with

South of England Region aggregate compliance of 1.2% and National compliance at 1.1%,

compared to WSHFT March performance of 0.8%

5 RECOMMENDATION

5.1 The Board is asked to receive the Month 1 performance position.

5.2 The Board is asked to note the year to date compliance against the delivery requirements of the

Sustainability and Transformation Fund (STF) for Cancer and A&E, and non-compliant position

for RTT.

Giles Frost, Assistant Director - Operational Planning and Performance

19th May 2017

Mark Dennis, Head of Information Servicest: 01903 285273 (ext 5273)

5.2a Copy of Single Oversight Framework 1718 M01.3.SCORECARD Page 1 of 1 Printed 22/05/2017 08:40

APRIL 2017

Threshold Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarYear to

Date Trend

Operational Performance MetricsOP1

A&E: maximum waiting time of four hours from arrival to admission/transfer/discharge

95% 94.9% 94.9%

OP2Maximum time of 18 weeks from point of referral to treatment in aggregate – patients on an incomplete pathway

92% 90.7% 90.7%

OP3A All cancers : 62-day wait for first treatment following urgent GP Referral 85% 91.6% 91.6%

OP3BAll cancers : 62-day wait for first treatment following consultant screening service referral

90% 100.0% 100.0%

OP4 Maximum 6-week wait for diagnostic procedures 94% 0.9% 0.9%

NHS ImprovementSingle Oversight Framework


5.2b Copy of Operational Performance Scorecard 1718 M01.6.SCORECARD Page 1 of 3 Printed 22/05/2017 08:40

APRIL 2017

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar APR2017/18

YTD2017/18Target Trend

NATIONAL AND OPERATIONAL PERFORMANCE TARGETS

O01A&E : Four-hour maximum wait from arrival to admission, transfer or discharge

96.56% 95.99% 95.97% 93.85% 94.24% 95.86% 93.50% 94.38% 91.01% 91.08% 93.75% 95.81% 94.89% 94.89% 95%

O02 Cancer: 2 week GP referral to 1st outpatient1

95.42% 97.18% 97.62% 94.51% 94.19% 93.59% 97.05% 96.86% 97.38% 96.64% 97.94% 96.94% 93.71% 93.71% 93%

O03 Cancer: 2 week GP referral to 1st outpatient - breast symptoms1

96.75% 97.24% 98.33% 95.28% 95.54% 94.02% 90.06% 96.32% 95.42% 94.67% 97.40% 97.44% 91.62% 91.62% 93%

O04 Cancer: 31 day second or subsequent treatment - surgery1

100.0% 100.0% 100.0% 100.0% 95.8% 100.0% 100.0% 100.0% 100.0% 100.0% 0.0% 100.0% 100.0% 0.00% 94%

O05 Cancer: 31 day second or subsequent treatment - drug1

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 98%

O06 Cancer: 31 day diagnosis to treatment for all cancers1

99.14% 99.62% 100.00% 99.51% 98.00% 97.18% 97.74% 98.28% 100.00% 97.54% 100.00% 98.95% 100.00% 100.0% 96%

O07 Cancer: 62 day referral to treatment from screening 1

93.62% 96.08% 95.31% 100.00% 100.00% 93.94% 100.00% 100.00% 96.61% 97.37% 88.37% 100.00% 100.00% 100.0% 90%

O08 Cancer: 62 day referral to treatment from hospital specialist 1

76.92% 76.92% 87.50% 80.00% 100.00% 75.00% 87.50% 100.00% 92.86% 96.00% 91.67% 88.14% 73.33% 73.33% N/A

O09 Cancer: 62 days urgent GP referral to treatment of all cancers 1

86.09% 86.45% 85.91% 86.96% 85.83% 89.92% 88.85% 88.69% 86.23% 86.29% 87.13% 87.90% 91.60% 91.60% 85%

O14 RTT - Incomplete - 92% in 18 weeks 86.95% 88.15% 88.35% 88.41% 88.67% 89.20% 90.12% 91.76% 92.04% 92.01% 91.80% 92.01% 90.74% 90.74% 92%

O15RTT delivery in all specialties(Incomplete pathways)

11 11 11 12 11 11 8 5 5 5 7 6 8 8 0

O16 Diagnostic Test Waiting Times 2.41% 1.50% 1.28% 0.27% 0.49% 0.88% 0.97% 0.85% 0.95% 2.33% 1.51% 0.84% 0.92% 0.92% <1%

O17 Cancelled operations not re-booked within 28 days 0 1 0 0 0 0 0 4 0 3 4 0 2 14 -

O18 Urgent operations cancelled for the second time 0 0 0 0 0 0 0 0 0 0 0 0 0 0 -

O19Clinics cancelled with less than 6 weeks notice for annual/study leave

22 22 15 16 25 24 48 16 8 39 15 28 17 295 -

O20 Mixed Sex Accommodation breaches 0 6 0 0 0 0 0 0 0 0 0 0 0 6 0

O33 Delayed transfers of care2

3.54% 3.54% 3.82% 2.87% 3.34% 3.69% 3.80% 3.33% 3.80% 3.64% 4.09% 3.16% 3.12% 3.12% 3.0%

IMPROVING CLINICAL PROCESSES

O23 % hip fracture repair within 36 hours 88.3% 95.1% 76.2% 85.9% 75.9% 90.4% 92.9% 93.3% 91.7% 91.2% 94.8% 89.2% #N/A #N/A 90%

O24Patients that have spent more than 90% of their stay in hospital on a stroke unit+

193.0% 91.7% 89.8% 92.9% 75.0% #N/A #N/A 80%

OPERATIONAL PERFORMANCE SCORECARD

92.9%92.7%


5.2b Copy of Operational Performance Scorecard 1718 M01.6.SCORECARD Page 2 of 3 Printed 22/05/2017 08:40

APRIL 2017

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar APR2017/18

YTD2017/18Target Trend

OPERATIONAL PERFORMANCE SCORECARD

OPERATIONAL EFFICIENCY

O36 Average length of stay - Elective 2.93 3.49 3.04 2.89 3.67 3.09 3.01 3.01 3.53 3.27 3.22 3.19 3.19 3.19 3.72

O37 Average length of stay - Non-elective Surgery 5.65 5.66 5.77 5.21 5.21 5.72 6.10 5.41 5.66 5.81 5.49 5.51 5.16 5.16 6.07

O38 Average length of stay - Non-elective Medicine 8.05 7.43 7.58 7.79 7.87 7.58 7.66 8.01 7.66 8.15 8.36 8.50 7.60 7.60 7.80

O39Day case rate (CQC day case basket of procedures)source: Dr Foster (reported 2-3 months in arrears)

88.94% 88.22% 91.15% 89.45% 90.40% 88.78% 89.69% 90.68% 90.45% 93.90% #N/A #N/A #N/A #N/A 75.0%

O40 Elective day of surgery rate (DOSR) 98.4% 98.4% 98.6% 97.3% 98.6% 98.2% 97.5% 97.6% 98.2% 97.5% 98.6% 97.9% 97.2% 97.2% 90.0%

O41 Did not attend rate (outpatients) 6.71% 6.88% 7.25% 7.00% 7.27% 7.45% 7.07% 6.75% 6.80% 7.19% 6.74% 6.73% 6.85% 6.85% 7.65%

SUSTAINABILITY

O43 Bank staff - % of all staff pay 6.37% 5.88% 6.32% 6.94% 6.47% 6.90% 6.47% 6.48% 7.29% 6.49% 7.67% 9.43% 7.60% 6.95% 7%

O44 Agency staff - % of all staff pay 7.45% 7.18% 6.22% 6.24% 6.81% 6.82% 7.02% 7.28% 6.08% 6.42% 6.33% 6.03% 5.09% 6.54% 2%

O45 Nurse : occupied bed ratio 1.795 1.824 1.868 1.800 1.889 1.824 1.770 1.772 1.782 1.689 1.708 1.821 1.843 1.832 -

O46 % nurses who are registered 69.92% 69.99% 69.84% 69.58% 69.72% 69.43% 69.81% 69.79% 69.54% 69.30% 68.97% 68.75% 68.44% 68.44% -

O47 % Staff appraised 79.82% 82.20% 81.12% 78.80% 80.88% 82.44% 81.41% 82.49% 84.08% 83.31% 84.01% 83.95% 83.83% 83.83% 90%

O48Sickness Absence: % Sickness(reported one month in arrears)

33.66% 3.45% 3.43% 3.88% 3.66% 3.61% 3.68% 4.02% 4.10% 4.04% 3.78% 3.22% #N/A 3.71% 3.3%

O49 Staff Turnover: Turnover rate (YTD position) 8.54% 8.49% 8.44% 8.43% 8.19% 8.13% 7.86% 7.60% 7.94% 7.97% 8.15% 8.03% 8.46% 8.46% 11%

ACTIVITY

A01 Day Cases 5,232 5,231 5,856 5,620 5,451 5,663 5,480 6,108 4,994 5,429 5,176 5,855 4,410 4,410 4,696

A02 Elective Inpatients 605 650 686 632 667 746 609 696 590 521 578 683 539 539 536

A03 Non-elective inpatients 5,507 5,698 5,661 5,888 5,608 5,658 5,631 5,802 5,966 5,607 5,172 5,767 5,539 5,539 5,847

A04 Outpatient First attendances 15,705 16,147 17,415 15,625 16,647 16,675 16,271 18,062 15,158 16,833 15,372 17,367 13,974 13,974 14,742

A05 Outpatient Follow-up attendances 26,652 27,483 28,178 25,422 26,665 27,168 26,310 29,002 23,767 27,250 25,166 29,420 23,664 23,664 24,216

A06 Outpatients with procedure 5,551 5,871 6,526 5,587 6,181 6,367 6,523 7,389 5,619 6,768 6,030 6,165 5,690 5,690 6,006

A07 A&E Attendances 11,170 12,453 11,791 12,824 12,232 11,749 11,753 11,052 11,482 10,502 9,705 11,410 11,571 11,571 12,020

1 National reporting for these performance measures is on a quarterly basis. Data are subject to change up to the final submission deadline due to ongoing data validation and verification.

2 Data are provisional best estimates and will be amended to reflect the position signed-off in the relevant statutory returns in due course.

3 Staff sickness is reported one month in arrears.

Notes


5.2b Copy of Operational Performance Scorecard 1718 M01.6.Activity Trending Page 3 of 3 Printed 22/05/2017 08:40

Activity Trends

Day Cases Elective Inpatients Non-elective Inpatients

First Outpatients Follow-up Outpatients Outpatients with Procedure

A&E Attendances (age 0-64) A&E Attendances (age 65-84) A&E Attendances (age >85)

Emergency Admissions (age 0-64) Emergency Admissions (age 65-84) Emergency Admissions (age >85)

3,0003,5004,0004,5005,0005,5006,0006,500

M01

(Apr

)

M02

(M

ay)

M03

(Ju

n)

M04

(Ju

l)

M05

(Aug

)

M06

(Sep

)

M07

(O

ct)

M08

(N

ov)

M09

(D

ec)

M10

(Ja

n)

M11

(Fe

b)

M12

(M

ar)

2017/18 2016/17 2014/15

3,000

3,500

4,000

4,500

5,000

5,500

6,000

6,500

M01

(Apr

)

M02

(M

ay)

M03

(Ju

n)

M04

(Ju

l)

M05

(Aug

)

M06

(Sep

)

M07

(O

ct)

M08

(N

ov)

M09

(D

ec)

M10

(Ja

n)

M11

(Fe

b)

M12

(M

ar)

2017/18 2016/17 2014/15

400450500550600650700750800850

M01

(Apr

)

M02

(M

ay)

M03

(Ju

n)

M04

(Ju

l)

M05

(Aug

)

M06

(Sep

)

M07

(O

ct)

M08

(N

ov)

M09

(D

ec)

M10

(Ja

n)

M11

(Fe

b)

M12

(M

ar)

2017/18 2016/17 2014/15

10,000

11,000

12,000

13,000

14,000

15,000

16,000

17,000

M01

(Apr

)

M02

(M

ay)

M03

(Ju

n)

M04

(Ju

l)

M05

(Aug

)

M06

(Sep

)

M07

(O

ct)

M08

(N

ov)

M09

(D

ec)

M10

(Ja

n)

M11

(Fe

b)

M12

(M

ar)

2017/18 2016/17 2014/15

15,000

17,000

19,000

21,000

23,000

25,000

27,000

M01

(Apr

)

M02

(M

ay)

M03

(Ju

n)

M04

(Ju

l)

M05

(Aug

)

M06

(Sep

)

M07

(O

ct)

M08

(N

ov)

M09

(D

ec)

M10

(Ja

n)

M11

(Fe

b)

M12

(M

ar)

2017/18 2016/17 2014/15

2,5003,0003,5004,0004,5005,0005,5006,0006,500

M01

(Apr

)

M02

(M

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5.2c Copy of Key Deliverables Report 1718 M01.2.Exception Report Page 1 of 2 Printed 22/05/2017 08:40

APRIL 2017

Description / Comments / Actions

Month YTD Projected O/T

94.89% 94.89% >95%

Actions:1. Enhanced discharge planning arrangements 2. Augmented patient flow arrangements in conjunction with external partners3. Dedicated operational delivery review cycle under the leadership of the Chief Operating Officer4. Continued Primary Care Response in A&E until end of Q1.



93.71% 93.71% >93%

Actions:1. Management/tracking oversight through DDO led Cancer Delivery Group2. Dedicated weekly review led by Chief Operating Officer



91.62% 91.62% >93%


Cancer - 62 days from referral to treatment following screening contact Description / Comments / Actions


100.00% 100.00% >90%


Patients with cancer can expect to commence treatment within 62 days following referral after a positive screening test.

Target

90%

Delays in receipt of onward referral from screening which reduces the time to secure capacity to treat patients.

Cancer - Two weeks from urgent GP referral to first appt - Breast symptoms

Significant and sustained increases in demand level.

Cancer - Two weeks from urgent GP referral to first appointment

Target

Target Patients with breast symptoms can expect to be seen within 2 weeks following an urgent GP referral.

93%

Significant and sustained increases in demand level. Patient choice and loss of working days over Easter impacting low numbers of patients.

Key Performance Deliverables ReportA&E 4-hour waiting time target

Target

95%

Patients can expect to be admitted, transferred or discharged in 4 hours from arrival in A&E

Increased demand vs volume and acuity attending A&E particularly OOH challenging ability to maintain hospital/system flow essential to delivery of A&E waiting time. Vulnerability of OOH staffing both in A&E and core services.

93.0%

Patients can expect to be seen within 2 weeks following an urgent GP referral for suspected cancer.

50%55%60%65%70%75%80%85%90%95%

100%

Apr

May Jun Jul

Aug

Sept Oct

Nov De

c

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r

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100%

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Aug

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Nov De

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r

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Aug

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r


5.2c Copy of Key Deliverables Report 1718 M01.2.Exception Report Page 2 of 2 Printed 22/05/2017 08:40

APRIL 2017Key Performance Deliverables ReportDescription / Comments / Actions


91.60% 91.60% >85%




90.74% 90.74% >92%

Actions:1. Dedicated weekly Divisional review meeting, with overarching assurance review by Chief Operating Officer (also weekly)2. Specialty level tracking and monitoring with recovery plans in development / in train.

Non-compliance as a result of impact of reduced working days in April vs increased referrals and shape of WL converting to breach patients.Specific workforce challenges in certain specialties.

85%

Demand pressure exposing pathway efficiencies. Reduces the time to secure capacity to treat patients.

92.0%

Cancer - 62 days from referral to treatment following urgent referral by a GP.

Target

Referral to treatment - Incomplete Pathways

Target All patients can expect to commence treatment within 18 weeks of a referral to consultant.

Patients with cancer can expect to commence treatment within 62 days following urgent referral by a GP.

80%82%84%86%88%90%92%94%96%98%

100%

Apr

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Aug

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Nov De

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Giles Frost, AD Operational Planning PerformanceTEL: 01903 205111 (85545)

5.2d Copy of STF Performance Monitoring 1718 M01.1Printed 22/05/2017 08:41

APRIL 2017Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

A&E : FOUR-HOUR MAXIMUM WAIT FROM ARRIVAL TO ADMISSION, TRANSFER OR DISCHARGE

Trust Patients Seen 12,405 13,761 13,093 14,153 13,592 12,998 13,027 12,313 12,746 11,819 10,931 12,597

>4 Hours 794 881 838 760 730 698 911 861 892 1,054 682 629

Performance 93.6% 93.6% 93.6% 94.6% 94.6% 94.6% 93.0% 93.0% 93.0% 91.1% 93.8% 95.0%

Trust Patients Seen 12,511

>4 Hours 639

Performance 94.9%

Cumulative Performance 94.9%

CANCER 62 DAY PATHWAYS > 62 DAYS

Trust Patients Seen 149.0 170.0 190.0 148.0 152.0 148.0 175.0 195.0 161.0 188.0 198.0 181.0

>62 days wait 22.0 25.5 28.5 22.0 22.5 22.0 26.0 29.0 24.0 28.0 29.5 27.0

Performance 85.2% 85.0% 85.0% 85.1% 85.2% 85.1% 85.1% 85.1% 85.1% 85.1% 85.1% 85.1%

Trust Patients Seen 119.0

>62 days wait 10.0

Performance 91.6%

REFERRAL TO TREATMENT INCOMPLETE PATHWAYS > 18 WEEKS

52 Week Trajectory 0 0 0 0 0 0 0 0 0 0 0 0

Total Patients Waiting 33,949 33,949 33,949 33,949 33,949 33,949 33,949 33,949 33,949 33,949 33,949 33,949

Patients waiting >18 weeks 2,715 2,715 2,715 2,715 2,715 2,715 2,715 2,715 2,715 2,715 2,715 2,715

Compliance 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0%

52 Week Trajectory 0Total Patients Waiting 33,985

Patients waiting >18 weeks 3,147

Compliance 90.7%

STF PERFORMANCE TRAJECTORY MONITORING

Performance meets Constitutional Standard and STF Trajectory

Performance meets STF Trajectory but not Constitutional Standard

Performance doesn't meet STF Trajectory

Trajectory

Actual

Trajectory

Actual

Trajectory

Actual


To: Board


Title:

Report on Organisational Development and Workforce performance


Denise Farmer, Director of OD and Leadership

Prepared by:

Jennie Shore, Deputy Director of HR

Status:

Disclosable

Summary of Proposal: This report details the Trust’s performance in relation to the supply, development and engagement of its workforce and the organisations culture. Implications for Quality of Care: Provision of high quality, engaged staff has a direct impact on the quality of care. Financial Implications:

Supports good financial performance

Human Resource Implications:

As described

Recommendation The Board is asked to NOTE the report Consultation:

n/a

Appendices:


To: Trust Board

Date: 25th May 2017

From: Denise Farmer, Director of Organisational Development

and Leadership

Agenda Item: 5.3

FOR INFORMATION

ORGANISATIONAL DEVELOPMENT AND WORKFORCE REPORT 1.00 INTRODUCTION 1.01 This sets out the key headlines relating to the Trust’s workforce at 30 April 2017.

2.00 Workforce Capacity 2.01 The funded establishments were reset during Month 1 to reflect the outcome of budget setting

across the Trust. This has resulted in an overall reduction of 148.2 wte. Within the Core Division, pay budgets have been rebased by converting 96.9 wte budgeted vacancies into bank and agency lines. Budgets in the Medicine Division have been adjusted to account for the reduction in escalation beds on Apuldram and Brooklands wards. The division has bid for funding for these areas but the final budget position is still under discussion. 25 wte staff TUPE transferred to Compass as part of the retail catering contract and this is reflected within the Estates, Facilities and Capital Division. It should be noted that this also mirrored in staff turnover in April for this division.

The total wte used in month decreased by circa 172 wte. Whilst there was a net decrease in the number of substantive staff employed across the organisation (12 wte), taking account of the TUPE transfer, there was a significant reduction in the amount of temporary staffing used. This follows a late Easter and extended school holiday period when less staff are available to work.

2.02 Agency spend in month 1 was £1.2m (48% medical; 45% nursing; 5% other), and represents a

reduction of £227k (16% improvement) from last month and £0.52m from April 2016. The majority of reduction in month was from medical agency where the supply reduced. This follows the introduction of IR35 reforms and the challenging first few weeks in April noted in last month’s report.

2.03 An increase in spend in month reflects pay enhancements for the Easter bank holidays and

accrual for the 1% national pay award effective from 1 April 2017. 2.04 A further drive to reduce the cost of nurse agency has commenced. This includes a re-tiering

of agencies based on hourly rates with early access to shifts for less expensive agencies. The number of agencies supplying at NHSI capped rates is increasing and it is anticipated that the impact of IR35 will encourage more nurses to work directly for our hospitals either substantively or on the staff bank.

3.00 Update on impact of IR35 compliance 3.01 The implementation of the IR35 reforms has resulted in different outcomes for different staffing

groups. The supply of medical staff through employment agencies has continued to be

Page 2 of 7

challenging and in some specialties has led to a request for increased hourly rates. However the level of supply is slowly being restored to previous volumes.

For AHP staff, a number of employment opportunities exist outside of the NHS labour market

which has led to a small reduction in the supply through agencies. This was noted last month for three Sonographers who have moved to the private sector.

The impact for the supply registered nurses has been to the Trust’s advantage. It has enabled

us to start to re-align the hourly rate for those nurses who “switched” to a direct engagement on protected pay rates earlier in the year, and driven agencies to reduce the pay rates and/or reconsider their profit margins.

We will continue to monitor the impact on operational delivery.

4.00 Medical Recruitment Medical recruitment in particular continues to be focus and we have recently been successful

in appointing four Clinical Fellows for the middle grade rotas in Medicine to commence in August. Within the Surgery Division, a contract has been agreed for the supply of 137 hours per week Resident Medical Officers (RMOs) across general surgery, orthopaedics and urology. This will also become effective from August and will inform the Trust’s strategy for reducing reliance on medical agency.

A business case to trial the introduction of Doctors’ Assistants (a hybrid of clinical and

administrative responsibilities) within medicine is currently being developed. This is in addition to Physician Associates and Surgical Care Practitioner roles used to supplement the work undertaken by junior doctors.

Work is well advanced in the preparation for the changeover of junior doctors in August.

Additional controls are in place to mitigate the impact of the new terms and conditions of employment for the largest cohort due to transfer on 2 August. This includes an FAQ sheet, login and training for exception reporting and a revised induction programme. A weekly divisional status report on recruitment activity will be implemented as usual from end of May to inform risks and mitigations required.

4.00 Staff Turnover 4.01 Staff turnover increased marginally in month to 8.5%. With the exception of the Medicine

Division, all divisions experienced a small uplift in the number of staff leaving the organisation. The ceiling for 2017/18 has been reset to 8.5%. This will provide a stretch target across divisions and ensure it continues to receive attention.

A separate report on 2016/17 findings is attached.

5.00 Workforce Efficiency 5.01 Sickness absence decreased again during March to 3.2%. The year ended at 3.7%, compared

to 3.8% in 2016/17. 5.02 Breakdown by divisions shows that improvement in sickness rates has largely been

experienced within Core and Corporate Divisions, with deterioration in the Estates, Facilities and Capital Division.

Page 3 of 7

March 2016 March 2017 Trust wide 3.8% 3.7% Core 3.4% 3.0% Corporate 3.8% 2.9% Estates, Facilities and Capital 4.9% 5.2% Medicine 4.0% 4.1% Surgery 4.0% 3.9% Women and Children 3.5% 3.6%

5.03 The number of sickness episodes reduced again in month by a further 6.6% (91 episodes). 5.04 Long term sickness (more than 1 month) fell across all divisions and at 1.4% was at its lowest

level in the year. Short term sickness also fell during March to 1.8% and was at a similar level to May and June 2016.

6.00 Appraisals 6.01 Appraisal rates of 84% were maintained across the Trust again during April. There was

improvement within the Corporate, Surgery and Estates, Facilities and Capital Divisions, with deterioration within the Medicine Division. Increasing the number of staff who have had an appraisal in the last 12 months has become a driver metrics for the clinical divisions and counter measure summaries are now in place to drive improvement.

7.00 Staff Consultation Consultation on the new group management and leadership arrangements here and at

Brighton and Sussex University Hospitals has commenced and will close in early June. It is anticipated that at this stage approximately 12 staff at the Trust will be affected by the proposals. The Trust’s Managing Change policy will be followed and no redundancies are anticipated.

8.00 Family and Friends Test Staff advocacy of the Trust remains high with an overall engagement score of 3.92. Changes

to the Your Health and Safety day, where staff engagement is tested, are currently under development. These changes will include aligning all topics (eg. fire, IG, health and safety, adult and child protection) to the Trusts’s strategic themes; promoting key messages; sharing stories where improvements have been made and providing staff with tools to make improvements happen.

9.00 Workforce Skills and Development 9.01 Statutory and Mandatory Training

Whilst training attendance remains high, with the majority of mandatory modules remaining above the trust target of 90%, attendance on all statutory and mandatory modules has dropped slightly in the last month. This is due to 1 Your H&S Day and 2 Patient Handling courses being cancelled in March to allow for building work to take place at Ridgeworth House, Worthing. Further mandatory training was cancelled this month as the building work had to be rescheduled, and this will impact on next month’s training attendance statistics The postponement of the building work at Ridgeworth House on two occasions will mean that additional mandatory training courses will need to be cancelled for a third time to enable this work to be completed. Whilst, the building work will provide increased capacity on the Worthing

Page 4 of 7

site in the longer term (an additional 35 places a week), the cancellation of mandatory training will have an impact on training attendance in the short term.

The number of staff who have never attended any mandatory training (and started in the Trust more than 3 months ago) is currently six (five of whom are Medical staff). The names of the five individuals have been escalated to Chiefs/ DDOs and we will continue to work with Divisions to ensure that these individuals completed their training as soon as possible.

9.02 Widening participation

Work Experience - a range of new Work experience opportunities have been arranged at the Trust. Four students from Worthing College spent 1 day a week on the Wards over the past 10 weeks. A review of the programme is being undertaken. Last week 6 Health and Social care student spent the week on the Wards at St Richards including ACU, Lavant, Fishbourne and the Fernhurst centre. An evaluation on both programmes is currently being undertaken.

Later this month, twelve year 10 students from The Angmering School, Sir Woodard Academy and Durrington High will be on the ‘Introduction into the NHS Programme’ where sessions include maternity, pharmacy, dietitians etc.

We are also holding a taster day for the Princes Trust at the Laurels Day Centre in Rustington on the 23 May. We are offering 14 placements in total across the Wards, Pharmacy, and Estates. There will also be placements from West Sussex Council, Guildcare and Independent lives.

9.03 Apprenticeships

The Apprentice Levy commenced on the 6 April 2017, the Trusts first contribution of £92,133.00 will be paid into the trust Digital Account by the end of May. Contributions will vary each month dependent on payroll. The first candidates have been entered onto the system.

The process for procuring apprenticeship qualifications has changed since the 1st May. We are in the process of submitting our tender for apprenticeships; however this is a long process so in the meantime to be able to meet the needs of managers requiring apprentices we have to deal directly with providers outside of the new process.

The Apprentice Strategy and proposal to Standardise Apprentice Salaries are currently under review/waiting for approval prior to submission to the Trust Executive Committee. Further trailblazers (new apprentice standards) are continuing to be approved and developed, funding is available from Health Education England (£5000) to support trust staff to attend trailblazer meetings and complete actions over a 2 year period of the development of the degree apprenticeship standard.

The development of new standards will allow the Trust to develop new roles.

10.0 Communications, Engagement and Fundraising

10.01 Launch and promotion of Patient First Staff Achievement and Recognition Awards

(STARS)

The 2017 STAR awards were launched as planned in May providing a wonderful opportunity for colleagues and the local community to celebrate the work of staff at Western Sussex

Page 5 of 7

Hospitals. Managed by the communications team, the awards are now in their eighth year and are open to all staff and volunteers. The categories are below with nominations welcome online or in print.

Patient Champion, Mentor of the Year, Care for the Future Award, innovator of the Year, Extra Mile Award, Team of the Year, Compassionate Care Award, Award for Excellence, Volunteer of the year, Hospital Hero.

Closing date for entries midnight Monday 29 May and to nominate please go to: Westernsussexhospitals.nhs.uk/awards

10.02 Promoting the trust’s £7.5m investment in Southlands Eye Care

The communications team continued to support the development of Southlands Eye Care in line with the agreed communications plan. In May this has included:

• Media coverage confirming the completion of the building works for the new facility at Southlands Hospital

• Letters with enclosed Eye Care Update sent to a range of interested groups including GPs and opticians

• Eye Care Update 8-page brochure also widely available for ophthalmology patients at Worthing and St Richard’s and to pick up at all three hospitals

• A new 12-page Patient Information Booklet has been designed and is being delivered with every ophthalmology referral letters, which have also been redesigned to include graphic about the relocation of ophthalmology from Worthing to Shoreham. The booklets are also being and handed out in clinic

• GPs, opticians and other key stakeholders have been invited to a preview evening of

Western Sussex Eye Care | Southlands, on Thursday 1 June

• The divisional director of surgery has written to all affected staff and the majority of those who will be working in the new unit have had the chance to look around and receive a tour. Meanwhile, a series of Ophthalmology Open Forum events, hosted by the specialty team, continue to take place across the trust.

10.03 Promoting Patient First

A series of open staff briefings began this month, hosted by the executive team and designed to support the trust’s key objectives. The sessions, which have been well attended, include a reflection the year since the trust’s Outstanding rating, confirmation of the new working arrangements with BSUH and a description of our priorities for 17/18.

10.04 Council of Governors Meeting

The next Council of Governors’ meeting will take place on Tuesday June 13, Mickerson Hall, Chichester Medical Education Centre (CMEC) at St Richard’s Hospital starting at 09.30-12.30pm. All welcome.

Page 6 of 7

Annual General Meeting of the Council of Governors and Annual Members Meeting 2017 The AGM will take place at St Richard’s Hospital in Chichester Medical Education Centre (CMEC) on Tuesday 18 July. More details will be shared on our website, www.westernsussexhospitals.nhs.uk and in our emailed members’ newsletter @WesternSussex

10.05 Governor elections

Nominations have now closed for Governors to stand in our forthcoming elections later this month. Governors are a vital link between the organisation and our Foundation Trust membership and are part of the decision making process which shapes our services and future plans. We have three vacancies in the following constituencies - Chichester, Worthing and Patient, which represents out of area patients. Ongoing training and support is available to all Governors during their three year term of office. The election notice will be published on Thursday 25 May and voting packs will be dispatched on Friday 26 May. The election closes on Wednesday 21 June and the results will be declared on Thursday 22 June.

10.06 Love Your Hospital

The following describes the headline activities of the past month: Individual Giving Direct Marketing Planning is underway for the next cash appeal which will be asking supporters of Love Your Hospital to raise money to purchase new foetal heart monitoring equipment for St Richard’s Hospital. Crowdfunding Following the launch of our crowdfunding campaign three weeks ago, the focus now moves to local businesses who are being offered a selection of support packages. Community

• Neal Marsh broke his record breaking rowing challenge in Penguin Foyer 10-14 April in aid

of Bluefin ward. He raised £3662.08. The Love Your Hospital Ball ticket sales are going well and promotion is continuing until June 10. Sponsorship has been secured from Kier Construction and Rayner Intraocular Lenses totalling £7,500 for the Ball. Secured sales currently stand at £6,810.

http://www.westernsussexhospitals.nhs.uk/

Page 7 of 7

• The Ben Nevis Trek took place on May 20 with 27 people hiking with fundraising on track to reach the 10k target. The additional quiz evening to assist with fundraising on the 28th April raised £281.80.

Corporate

• Adur and Worthing Business Awards have chosen us as their charity of the year. They are

promoting us on all of their marketing collateral both off and online (see Marketing). • JSPC have donated a TV for Cardiology and Respiratory to assist the consultants and

secretaries. • Sponsorship of Southlands currently stands at £3500 with a mix of one waiting room

sponsored at £1500 and four plaques purchased at £500 each

11.00 RECOMMENDATION

The Board is asked to NOTE the report.

To: Trust Board Date: April 2017

From: Deputy Director of Human Resources Agenda Item: 5.3

FOR INFORMATION

STAFF TURNOVER 2016/17

1.0 INTRODUCTION

The purpose of this paper is to provide the Trust Board with an analysis of turnover during 2016/17, an update on the actions taken since May 2016 and proposed interventions to mitigate the continuing loss of required skills and competencies in the Trust.

2.0 BACKGROUND Reducing staff turnover has been a key tenant of the organisation’s workforce strategy for the last two years. A detailed analysis of turnover at the outset, informed by academic research and studies, identified that: a) A high percentage of those leaving the Trust had less than 2 years’ service and for some staff

groups (nursing and allied health professionals) this was higher b) Turnover at Worthing was greater than at Chichester in almost all areas c) The number of staff retiring each year is a key feature of turnover d) There are generational differences in the values, expectations, perceptions and motivations of

staff in the workplace that require a change to how career opportunities and workplace support is designed and delivered

Interventions to improve staff retention since April 2015 have included:

• Raising awareness of the generational characteristics of Baby Boomers, Generation X, Generation Y and the emerging Generation Z (see Appendix 1)

• Designing a framework for regular Stay interviews to be conducted for new joiners during the first two years; supplementing the annual appraisal cycle

• Rolling out training sessions for managers • Establishing retention groups for key staff groups • Analysing the findings from Exit questionnaires • Identifying hot spots with high turnover and poor job satisfaction • Engaging with staff to understand how to improve job satisfaction • Action learning through NHS Employers retention workshops

3.0 FINDINGS 2016/17 3.1 2016/17

Between 1 April 2016 and 31 March 2017, there were 554 leavers. This represented a Trust turnover of 8.15%. This compares to 580 leavers in 2015/16 and 562 leavers in 2014/15. The relative numbers of leavers are important, rather than the turnover percentage, where the denominator has changed. Nonetheless, there has been an improvement in the number of staff leaving the Trust by 6% in the last 12 months.

Page 2 of 11

74% of leavers were unplanned compared to 80% in 2015/16 and 74% in 2014/15. There is evidence that for the majority of staff groups the position is stable and/or is improving. This reflects targeted interventions particularly within the Core Division.

Staff group No. of leavers 2016/17

% staff group

No. of leavers 2015/16

% staff group


% staff group

Status in year

Medical and Dental Consultants Other

11 21

3.93 4.55

13 17

4.89 3.72

16 22

5.97 4.54

Improving Stable

Nursing and Midwifery Registered nurse HCA

146 81

7.50 8.80

148 67

7.01 8.00

166 86

8.36 10.53

Stable Deteriorating

Additional clinical services 36 8.86 43

10.83 28 7.49 Improving

Scientific, Technical and Professional

32 11.6 31 11.88 24 8.73 Stable

Healthcare Scientists

6 5.88 12 12.12 12 12.12 Improving

Allied Health Professionals

41 9.95 44 10.92 40 10.05 Stable

Admin and Clerical

139 10.4 152 11.99 112 9.20 Improving

Estates and ancillary

41 6.33* 53 8.01 51 7.72 Improving

Summary 554 8.15 580 9.1 557 8.4 Improving *5% of leavers were in pay band 7-9, representing 33% of the total number employed.

3.2 Benchmarks

Whilst benchmark data is not yet available for 2016/17, there is no reason to suggest that the Trust’s relative position in comparison to other NHS trusts in 2015/16 has changed. This is set out below:

*outturn at 31 March 2016

Page 3 of 11

3.3 Reasons for Leaving

The reasons for leaving compared to previous years are set out below:

Reason No. of leavers 2016/17

% of Leavers


% of Leavers


% of Leavers

Retirement 139 25% 110 18.7% 128 22.8% Dismissal 35 6.3% 14 2.4% 5 0.9% Redundancy 2 0.4% 3 0.5% 8 1.4% End of fixed term contract 2 0.4% 1 0.2% 7 1.3% Death 2 0.4% 3 0.5% 3 0.5% Voluntary resignation 374 67.8% 449 77.5% 411 73.1% Total 554 580 562 The number of staff retiring continued to be a feature of staff turnover in 2016/17. This is not

unexpected given the ageing workforce and the special class status retained by some staff groups that enables retirement at 55 years with full pension benefits. Whilst our HR systems do not enable us to report at a trust-wide level the number of staff who have returned to work, it is reported that a number do so and often on a part-time basis.

It is encouraging to note that during 2016/17, the number of staff who left by way of voluntary resignation reduced, demonstrating an improvement of 9% since 2014/15. Of the 554 leavers in 2016/17, 374 people (67%) left the Trust through voluntary resignation, of which 29% cited work life balance and 26% cited relocation as the main reasons for leaving.

Since the introduction of a drop-down box on the leaver form, the number of “other/not known

reason for voluntary resignation has significantly improved. 3.4 Length of Service

There have been concerns since 2014/15 about the high percentage of staff leaving the Trust within 2 years of joining. The table below shows that this has not improved and the number of staff leaving the organisation with less than 12 months’ service has increased from 15% to 18% since 2014/15.

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Whilst the number of staff leaving within 1-2 years has decreased from 23% to 19%, this still represents 37% of leavers with less than 2 years’ service.

3.5 Turnover by Length of Service and by Staff Group

In order to understand the poor retention of staff with less than 2 years’ service, a breakdown by staff group highlights the specific areas of concern.

Length of service No. of leavers 2016/17

% of leavers


% of leavers


% of leavers

Medical and Dental 32 30 38 < 1 Year 4 12.50% 7 23.33% 5 13.16% 1-2 Years 3 9.38% 3 10.00% 11 28.95% 3-5 Years 3 9.38% 6 20.00% 5 13.16% Nursing and Midwifery 146 148 166 < 1 Year 20 13.70% 17 11.49% 33 19.88% 1-2 Years 25 17.12% 40 27.03% 33 19.88% 3-5 Years 15 10.27% 21 14.19% 31 18.67% HCA/MCA 81 67 86 < 1 Year 26 32.10% 15 22.39% 15 17.44% 1-2 Years 20 24.69% 15 22.39% 25 29.07% 3-5 Years 18 22.22% 16 23.88% 17 19.77% Additional Clinical 36 43 28 < 1 Year 7 19.44% 10 23.26% 5 17.86% 1-2 Years 4 11.11% 11 25.58% 8 28.57% 3-5 Years 5 13.89% 10 23.26% 6 21.43% Add Prof Scien Tech 32 31 24 < 1 Year 9 28.12% 5 16.13% 3 12.50% 1-2 Years 7 21.87% 8 25.81% 4 16.67% 3-5 Years 8 25.00% 10 32.26% 11 45.83% Healthcare Scientists 6 12 12 < 1 Year 1 16.67% 1 8.33% 1 8.33% 1-2 Years 2 33.33% 4 33.33% 2 16.67%

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3-5 Years 2 33.33% 2 16.67% 3 25.00% Allied Health Profess 41 44 40 < 1 Year 7 17.07% 2 4.55% 6 15.00% 1-2 Years 11 26.83% 12 27.27% 13 32.50% 3-5 Years 12 29.27% 12 27.27% 6 15.00% Admin and Clerical 139 152 112 < 1 Year 25 17.99% 28 18.42% 15 13.39% 1-2 Years 28 20.14% 29 19.08% 21 18.75% 3-5 Years 19 13.67% 23 15.13% 23 20.54% Estates and Ancillary 41 53 51 < 1 Year 2 4.88% 10 18.87% 4 7.84% 1-2 Years 6 14.63% 8 15.09% 10 19.61% 3-5 Years 6 14.63% 6 11.32% 11 21.57%

This shows that the number of registered nurses and midwives who leave the Trust with less than 12 months’ service is a deteriorating position. Alarmingly over half of the 81 HCAs who left in 2016/17 did so within two years’ of joining the organisation, with 56% having less than 12 months’ service. Notwithstanding the impact this has on patient care and staffing levels, the direct recruitment costs for this staff group alone including selection, onboarding, induction and training costs is circa £2,000 per person. The other staff groups where retention remains a concern are AHPs, Scientific, Professional and Technical.

3.6 Turnover by Length of Service by Division

Length of Service

Core Corporate Medicine Surgery Estates, Facilities

and Capital

Women and

Children

< 1 Year 25 (16%) 9 (15%) 39 (25%) 19 (19%) 2 (4%) 7 (16%) 1-2 Years 31 (20%) 9 (15%) 40 (26%) 12 (12%) 5(10%) 9 (20%) 3-5 years 34 (22%) 10 (17%) 16 (10%) 14 (14%) 4 (8%) 8 (18%) Total number of leavers

151 59 153 102 48 44

With the exception of the Estates, Facilities and Capital Division, retention of staff in the first 2 years’ of service is lower than desired. Within the Medicine Division this is a particular issue and reflects the larger proportion of registered nurses and HCAs employed.

3.7 Leavers by Generation

41% of the 554 leavers in 2016/17 are in the Baby Boomer (born 1946-1964) generation, which is

replicated in all Divisions except Core. In this case 35.7% are Generation Y (born 1981-1994). Leavers in Generation Z (born 1995 to 2010) continue to remain small in number.

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The highest level of leavers by staff group by generation is as follows:

Baby Boomers Medical, Nursing and Midwifery, Additional Clinical services, Admin and Clerical, Estates & Ancillary

Generation X Professional and Technical, Healthcare Scientists Generation Y HCA/MCA and Allied Health Professionals

3.8 Areas of Concern

Turnover where the number of staff exceeds 5 or represents more than 10% identifies the following departments/wards as areas of concern: Core: Medical imaging, Worthing Pharmacy, Chichester

Physiotherapy, Worthing Medicine: AMU, Chichester

Emergency Floor, Worthing Barrow Ward, Worthing Buckingham Ward, Worthing Durrington Ward, Worthing

Surgery: Chiltington Ward, Worthing

3.9 Reasons why people leave

It was noted in last years’ report (May 2016) that the key reasons people leave their job are:

• The job or workplace was not as expected • There is a mismatch between the job and the person. 80% of workers feel they do not

use their strengths every day • Too little coaching and feedback • Too few growth and advancement opportunities • Feeling de-valued and unrecognized • Stress from overwork and work-life balance • Loss of confidence in leadership

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Studies in Denmark also show that in the first year from student to nurse, the demands in the workplace are overwhelming and there is a mismatch between the learning and the experience. In the second year, it was identified that continue support is vital to prevent burnout or attrition.

3.10 What our staff have already told us

Listening to our staff and responding to their feedback is fundamental to retaining their knowledge and skills. Using the data from Exit questionnaires, Stay interviews, staff forums and leaver forms, the underlying reasons why individuals leave is because their work life balance is not supported or they are relocating for development opportunities.

Feedback from staff has included:

• Not delivering what is promised at interview • Local induction lacking • Needing to overcome delays in agreeing start dates with ward/department area and

having the tools for the job (eg. Smartcard, ID badge) • Ensuring that the rostering of shifts is fair (last in get worst shifts and staff are moved to

night shifts) • Releasing staff for training problematic • Encouraging development of additional skills (eg IV training) • Unfair allocation of leave • Stay interviews/appraisals not being held • Not feeling valued/supported by manager

Stay interviews Despite the evidence that stay interviews undertaken at regular intervals and acted upon, are

more effective than exit interviews, these are not consistently undertaken in the organisation.

In some areas there is little appetite to embed these and without an alternative, managers will be unsighted on whether the individual’s needs and expectations are being met. For Generations Y and Z, they expect support, frequent feedback on progress, flexibility and work life balance. They are career motivated and will change employers if their needs are not met.

There is currently no methodology for the collation of themes at directorate and division level

that will inform future strategies. Exit questionnaires Uptake of exit questionnaires has improved although it remains lower than desired, particularly

in the absence of findings from stay interviews. However of the 203 exit questionnaires completed in 2016/17, 46 leavers stated that they could have been persuaded to stay.

Since last year, staff leaving have been offered the opportunity to meet with a Staff Governor or

Ambassador to discuss their reasons for leaving. Whilst uptake has been very small, it provides an alternative for those seeking to share their experience of the organisation.

New starter forums

There are a number of forums where new starters are invited to meet with Executive directors or

divisional senior managers to talk about their experience in an informal setting. These are well attended but it is unclear what themes have emerged and how these are being addressed.

4.0 RETENTION STRATEGIES

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It has previously been identified that generational differences impact on staff turnover and future

retention strategies need to reflect these. It is also clear that organisational culture has a direct bearing on an employee’s happiness at work and their decision to stay or leave an organisation. Improving staff turnover is therefore multi-factorial. We need to continue our focus on:

Living the NHS values – how we make our social purpose tangible and take time to link

operational priorities and actions to the ‘big picture’ particularly at times when demand, capacity and financial challenges take operational priority. Junior staff in particular need more help to make links between their personal contribution and the difference this is making to society as a whole.

Embedding the Patient First programme and the Patient First Improvement System (PFIS) throughout the organisation through strategy deployment will facilitate this.

Rewarding careers – that are well defined, structured and offer development opportunities and

progression.

Staff leaving have told us we need to do much more in this area. This work has started and within the Core Division, improving the career pathway and opportunities for development has been identified. Through their well-established divisional workforce group, a number of development posts have been agreed. This includes recruitment at band 3 in pathology to progress to a biomedical scientist at band 6. Within physiotherapy extended scope practitioners have been introduced.

Divisions are beginning to develop career pathways that take advantage of the Apprentice Levy.

This includes operational management, associate practitioners, doctors assistants and combined admin/HCA roles.

The development of a nurse rotation programme is in the advanced stages of planning and

could be extended to include a transfer window or an exchange programme. Flexible working – patterns of working that allow staff to achieve a good work life balance,

noting that individuals needs differ flexibly throughout their career. For younger generations this includes exploring innovative ways of working and managing shift patterns to suit the generational difference. Work-life balance is paramount and if work or work related fatigue begins to compromise this, other options of employment will be considered.

Work life balance is cited as the largest single reason why staff resign in the Trust. Staff have

already told us that in some areas there is an unfair allocation of shifts and annual leave, coupled with being moved to wards and unfamiliar teams.

Supervision, mentorship, preceptorship and coaching – this is a key area that staff, particularly

in Generations Y and Z, need and expect to receive. A number of our HCAs, particularly in their first year, are reporting that this needs to be significantly improved.

Value and recognition of achievement – staff need to be valued and their achievements

recognised. There are a series of well-regarded programmes in place across the Trust that demonstrate how we value and recognise staff. This includes employee of the month, annual STARS awards, staff conferences, stories in Headlines, continuous improvement project updates, Patient First in Action stories, Marianne’s message, health and wellbeing initiatives and staff benefits. In PFIS areas, celebrating success and acknowledging good performance is integral to day to day working.

Promoting excellent team working – this is particularly important for Generations Y and Z who

have not been used to working, learning or problem solving in isolation. Promoting good team

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dynamics, regular team meetings and involvement in decision-making is being rolled out as part of the PFIS and strategy deployment of our True North objectives.

5.0 CONCLUSION

• The average number of staff leaving the Trust is circa 550 per annum. • In the last 2 years the number of staff who left by way of voluntary resignation reduced by

75. • The number of staff retiring continues to be a substantial feature of staff turnover,

representing 25% in 2016/17. • The top two reasons for voluntary resignation are work-life balance and relocation for

career progression. • Whilst staff turnover in the organisation compares favourably to other NHS trusts, the loss

of skills and experience undermines the significant efforts to recruit clinical staff in an already competitive labour market where there are national shortages in a number of occupations.

• The number of staff leaving with less than 2 years’ service remains a real concern and particularly for HCAs, with 32% of leavers having less than 12 months’ service. This is a deteriorating position.

• Generational differences impact on staff turnover and there was a higher turnover from Generation Y for HCAs and AHP leavers.

• There is higher turnover at Worthing and specific areas of concern are Medical Imaging, Pharmacy, Physiotherapy, AMU, Emergency Floor, Barrow, Buckingham, Durrington and Chiltington Wards.

• Staff have provided feedback on their experiences or reasons for leaving through staff forums and exit questionnaires; most of which are resolvable at department/ward level.

• Stay interviews are not embedded in the organisation, with little appetite to do so in some areas. Given the turnover of key clinical staff it is clear that the needs and expectations of Generations Y and Z in particular are not being met.

• There is currently no methodology for the collation of themes from stay interviews at directorate and divisional level.

• The Patient First programme, roll out of PFIS and strategy deployment at divisional level is contributing positively to the key strands of our retention strategies.

• We need to do more on helping staff to achieve work-life balance through fair allocation of shifts and annual leave. For ward based staff we must aim to reduce the number of times we move them to other areas where they are working with unfamiliar teams.

• We must aim to significantly improve the supervision, mentorship, preceptorship and coaching for staff.

6.0 PROPOSED ACTIONS

• Improving the retention of staff with less than 2 years’ service needs to be prioritised by

clinical divisions. It is proposed that as part of strategy deployment consideration is given to this being a driver metric.

• A3 problem solving methodology for HCAs turnover should be used to understand the root causes. This will be led by the Workforce Manager for Medicine.

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• A methodology for the collation of themes from Stay interviews should be co-designed with divisional and HR colleagues, led by the HR team.

• Stay interviews should be reintroduced to those staffing groups where turnover is high eg.

registered nurses, HCAs and AHPs.

• A quarterly report of the themes arising from Exit interviews should form part of the workforce reporting at divisional management boards.

• Quarterly new starter forums should be introduced/re-introduced at staff group or divisional

level. These will be replicated at Trust wide level and led by the Directors of Nursing and HR. The themes arising from these engagement events should be captured and responses published in divisional newsletters and on the staff engagement page on StaffNet.

• Continue to offer flexible employment options to staff approaching retirement to retain their

knowledge and skills for longer.

7.0 RECOMMENDATION(S)

The Board is asked to:

NOTE this paper and APPROVE proposed actions.

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Appendix 1

Baby Boomers 1946-1964

The “Post War Children” ambitious workaholics. Driven by career progression • Better educated than my predecessors • Self-reliant, independent and confident • Individualist • Extremely hardworking and a team player • Dedicated and passionate • Adaptable, resourceful, problem solver • Rebellious tendency, not afraid to challenge • Motivated and driven by career progression • Idealistic, competitive and goal-oriented • Define self-worth by work and accomplishments • Live for the here and now and change with time • Embrace challenge and endeavor to make a

difference • Strive to understand developing technology • Imbalance between work and family

Thinks that the ‘gen-next’ lacks work ethics and commitment

Generation X 1965-1979

The “Latch key kids” both parents worked, frequently looked after by friends, family or supervised childcare • Highly educated able to problem solve and multi-task • Prefer structure and direction • Enjoy work life balance and protect “family time” • Practical, independent and self-reliant • Work for self-gratification, own personal

achievements and rewards • Elements of skepticism and cynicism • Generally techno-literate growing up

with the development of PC’s and mobile phone • Entrepreneurial traits, innovative and adapt

well to change • Loyal to careers and employers • Do not respond to micro-management • More accepting of diversity • They are currently approx 40% of the NHS workforce • Value early retirement and quality of life after work Think that the ‘gen-next’ lacks work ethics and commitment

Generation Y 1980-1994

The “Millenials” nurtured by my Baby Boomer parents who have tried to protect me from negative experiences in the world! • Highly educated but expect support to achieve • Ambitious with high career expectations • Career motivated but not company loyal • Team player who requires frequent feedback on progress • Prefers manages to be mentors and coaches • Seek flexibility and work-life balance is paramount • Sense of personal ambition and confidence • Techno-competent: rapidly developing technology has

influenced modes and speed of communication • Friends and social life are important • Social media has enabled friendships to cross continents • My family are my friends • Loyal and embrace diversity • Less well off than previous generations, relying on

parents for financial support Think the “gen-next” lacks work ethics and commitment

Generation Z 1995-2010

The true “Digital native” born into an age of technology, Gen X parents have encouraged more independence • Technology influences everything • Education is more self-directed • Thrive on instant gratification and prefer information

to be delivered in rapid, short bursts or ‘sound’ bites if it is to be understood

• Ambitious but seek more flexibility than previous generations

• Insist on work-life balance • Spend more time changing employment and job hunting • May lack task specific skills • Pragmatic and individualist • Open minded, respectful and tolerant of others

and expect to see diversity around them • Collaborative and creative; they will change the

workplace dramatically in terms of style and expectations • Technological multi-taskers, everything should be

inter-connected • Blurring of social boundaries through social media • Friends and social life important • Struggle with household management, family will

support particularly financially • Personal freedom is non-negotiable

To be continued …

WSHFT WORKFORCE SCORECARD April 2017

Key performance Indicators Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr2017/18

YTDTarget/ Ceiling Amber Limit Trend

1) WORKFORCE CAPACITY NB

Budgeted FTE 6638.6 6650.0 6626.5 6577.0 6585.6 6623.4 6647.5 6697.6 6729.9 6732.2 6734.6 6734.6 6586.4 6586.4 N/A N/A

Total FTE Used 6602.7 6570.1 6566.7 6625.8 6802.6 6689.9 6738.6 6739.9 6733.6 6675.8 6762.9 6778.9 6606.8 6606.8 N/A N/A

Total FTE Used Variance from Budget -35.8 -79.9 -59.8 48.8 217.0 66.5 91.0 42.3 3.7 -56.4 28.4 44.3 20.4 N/A N/A N/A

Total FTE Used Vacancy Factor 0.5% 1.2% 0.9% -0.7% -3.3% -1.0% -1.4% -0.6% -0.1% 0.8% -0.4% -0.7% -0.3% -0.3% N/A N/A

Substantive Contracted FTE 5873.0 5896.5 5915.5 5932.9 6098.5 5998.4 6020.1 6032.1 6049.3 6055.7 6061.5 6064.6 6027.8 6027.8 N/A N/A

Substantive FTE Worked 5773.7 5798.9 5810.9 5826.3 5859.8 5856.0 5865.6 5898.4 5928.3 5886.5 5911.9 5942.2 5913.8 5913.8 N/A N/A

Substantive FTE Used Vacancy Factor 11.5% 11.3% 10.7% 9.8% 7.4% 9.4% 9.4% 9.9% 10.1% 10.0% 10.0% 9.9% 8.5% 8.5% N/A N/A

Bank Usage As % Of Total FTE Used 6.6% 6.2% 6.4% 7.0% 6.8% 6.8% 6.9% 6.6% 6.9% 6.2% 7.2% 7.7% 6.2% 6.2% N/A N/A

Agency Usage As % Of Total FTE Used 4.5% 4.1% 3.5% 3.5% 3.5% 3.5% 3.8% 3.9% 3.3% 3.1% 3.2% 2.8% 2.6% 2.6% N/A N/A

2) WORKFORCE EFFICIENCY NB

Rolling 12 Month Sickness Absence 1 3.9% 3.8% 3.8% 3.8% 3.8% 3.8% 3.8% 3.7% 3.8% 3.8% 3.8% 3.7% N/A 3.3% 3.3%

In Month Sickness Absence % 3.7% 3.4% 3.4% 3.9% 3.7% 3.6% 3.7% 4.0% 4.1% 4.0% 3.8% 3.2% 3.7% 3.3% 3.3%

In Month Maternity Leave % 2.2% 2.1% 2.2% 2.1% 2.1% 2.1% 2.2% 2.3% 2.3% 2.4% 2.4% 2.4% 2.2% N/A N/A

In Month Other Absence % 1.7% 1.7% 1.7% 1.5% 1.2% 1.8% 1.7% 1.9% 1.3% 1.5% 1.7% 1.8% 1.6% N/A N/A

In Month Total Absence % 7.6% 7.3% 7.3% 7.5% 7.0% 7.5% 7.6% 8.3% 7.7% 7.9% 7.8% 7.4% 7.6% N/A N/A

Sickness Episodes 1336 1243 1240 1300 1252 1316 1487 1632 1680 1709 1376 1285 N/A

Maternity Heads 169 161 167 168 172 172 180 182 181 187 190 196 N/A N/A N/A

In Month Long Term Sickness Absence % (28 Days Or More) 1.5% 1.7% 1.6% 1.9% 1.8% 1.6% 1.6% 1.6% 1.7% 1.5% 1.5% 1.4% 1.6% N/A N/A

In Month Short Term Sickness Absence % (<28 days) 2.1% 1.8% 1.8% 2.0% 1.9% 2.0% 2.1% 2.4% 2.4% 2.5% 2.3% 1.8% 2.1% N/A N/A

In Month Stress Related Sickness Absence % 0.5% 0.6% 0.7% 0.7% 0.6% 0.6% 0.5% 0.6% 0.6% 0.5% 0.5% 0.6% 0.6% N/A N/A

In Month Musculo Skeletal Sickness Absence % 0.7% 0.6% 0.6% 0.7% 0.7% 0.6% 0.6% 0.7% 0.7% 0.7% 0.6% 0.6% 0.6% N/A N/A

Number of Staff breaching Management Triggers for sickness absence 988 1002 1022 1009 1026 996 1015 1059 1047 1085 1090 1051 N/A

% of Staff (headcount) 14.3% 14.5% 14.8% 14.5% 14.7% 14.2% 14.4% 15.1% 14.8% 15.4% 15.4% 15.0% N/A

Rolling 12 Month Turnover 8.5% 8.5% 8.4% 8.4% 8.2% 8.1% 7.9% 7.6% 7.9% 8.0% 8.1% 8.0% 8.5% N/A 8.5% 8.5%

3) TRAINING & PERSONAL DEVELOPMENT NB

% Appraisals Up To Date 79.8% 82.2% 81.1% 78.8% 80.9% 82.4% 81.4% 82.5% 84.1% 83.3% 84.0% 83.9% 83.8% N/A 90.0% 80.0%

% In Date - All Mandatory Training 2 81.0% 84.0% 84.0% 81.2% 81.6% 79.2% 78.2% 79.9% 80.3% 82.3% 82.3% 82.5% 81.7% N/A 90.0% 80.0%

% In Date - Fire 89.0% 92.2% 91.1% 87.9% 90.2% 89.0% 89.4% 90.4% 91.1% 92.0% 92.4% 92.2% 91.2% N/A 90.0% 80.0%

% In Date - Infection Control (Role Specific) 88.6% 91.6% 91.1% 87.9% 90.0% 87.7% 87.3% 88.7% 88.5% 89.8% 89.5% 89.9% 89.6% N/A 90.0% 80.0%

% In Date - Back Training (Role Specific) 92.5% 94.1% 94.3% 92.8% 92.8% 91.8% 91.8% 92.2% 92.5% 93.4% 93.2% 92.9% 92.8% N/A 90.0% 80.0%

% In Date - Child Protection (Role Specific) 95.3% 96.3% 96.4% 95.3% 95.3% 94.6% 95.2% 95.6% 95.8% 96.7% 96.6% 96.6% 96.5% N/A 90.0% 80.0%

% In Date - Information Governance 88.1% 91.1% 90.4% 87.7% 88.4% 87.4% 87.6% 88.6% 89.4% 90.4% 90.4% 90.3% 89.7% N/A 90.0% 80.0%

% In Date - Adult Protection 95.6% 97.1% 97.2% 95.0% 94.6% 93.8% 94.3% 94.9% 95.1% 95.4% 95.2% 95.9% 95.9% N/A 90.0% 80.0%

Number of Staff with no mandatory training 8 7 3 5 7 5 4 6 5 2 3 8 6 N/A

Number of Staff > 12 months since any mandatory training 0 0 0 0 0 0 0 0 0 0 0 0 0 N/A

4) REAL-TIME STAFF FEEDBACK NB

Total Respondents To Survey 116 82 81 251 306 267 340 326 210 229 184 266 246 246 N/A N/A

% Respondents who would recommend this trust as a place to work 85.3% 84.1% 75.9% 76.5% 87.2% 87.5% 76.7% 80.3% 85.2% 83.8% 88.3% 83.4% 84.7% 84.7% N/A N/A

% Respondents happy with standard of care if a friend/relative needed treatment 91.4% 96.3% 91.4% 86.1% 93.7% 92.2% 87.8% 92.0% 93.0% 89.5% 95.9% 89.2% 92.9% 92.9% N/A N/A

Overall Staff Engagement Composite Score 3 3.88 4.01 3.98 3.79 3.82 3.81 3.76 4.00 3.76 3.92 N/A 4.20 3.78

Notes:1 Absence data is available one month in arrears.2 An employee is counted as being up to date with all their mandatory training if their Fire, Infection Control, Back, Child Protection and Information Governance training is up to date.3 Overall indicator for staff engagement is a composite score using 3 key finding questions, friend and family recommendation, motivation and making improvements.3 WSHT Total Respondents To Survey is greater than the sum of the divisional Total Respondents To Survey as some staff did not select a division when completing the survey.3 Baseline Data from 2016 Staff Survey, Overall Staff Engagement Score - 3.88


To: Trust Board


Title Financial Performance - April 2017

Presented by

Karen Geoghegan, Director of Finance

Prepared by

Alison Ingoe, Deputy Director of Finance; David Lowe, Assistant Director of Finance

Status

Confidential

Summary of Proposal At the end of April the Trust is reporting a control total deficit, before STF, of £2.3m against a planned deficit of £0.7m. Non Elective activity continued at similar levels to Q4 16/17 and assumed growth has not materialised but the Trust has been unable to achieve a corresponding reduction in capacity and therefore costs. A review of flexing down capacity and cost is underway should activity levels continue to reduce. The financial risk rating has dropped to a '3', which is a consequence of the adverse position in month. The Financial Performance paper provides further detail on the Trust’s financial position. Implications for Quality of Care

Financial planning principles have been established to ensure that expenditure budgets reflect anticipated activity levels and that agreed staffing levels are maintained.

Support for/integration with Corporate Objectives and Strategies

G1. Maintain an acceptable financial risk rating


These are noted within the Financial Performance Report


N/A

Recommendation The Finance and Investment Committee is asked to NOTE the Financial Performance Report for April 2017. Consultation

N/A

Appendices

Financial Performance Report


Finance Report M1 2017/18

Summary

Use of Resources (SOF) A Control Total (exc STF) Surplus £k R Agency Ceiling £k G

Plan Actual / Forecast Plan Actual / Forecast Plan Actual/Forecast

Year to Date 2 3 Year to Date £k (704) (2,337) Year to Date £k 1,584 1,215

Year End Forecast 1 1 Year End Forecast £k 3,350 3,350 Year End Forecast £k 17,249 17,249

Income £k A Operating Costs £k R Agency Expenditure AExpenditure as % of Total

Paybill (monthly) 2015/16 2016/17 2017/18

Plan Actual / Forecast Plan Actual / Forecast Medical 11.7% 5.8% 8.8%

Year to Date £k 34,026 33,630 Year to Date £k (32,327) (33,650) Nursing 6.2% 11.3% 6.0%

Year End Forecast 437,717 437,717 Year End Forecast £k (399,015) (399,015) Other Staff Groups 2.8% 4.4% 0.9%

All Agency 6.6% 7.4% 5.1%

Cash £k A Capital £k G Efficiency and Transformation Programme £k G

Plan Actual Plan Actual / Forecast Plan Actual / Forecast

Year to Date £k 7,336 4,632 Year to Date £k 225 370 Year to Date £k 925 934

Year End Forecast £k 7,306 7,306 Year End Forecast £k 19,003 19,003 Year End Forecast £k 19,949 19,949

Key Risks:

The cash position is behind plan, due to the impact of the adverse operating position

and reduced working capital from not achieving the STF in Q4.

There was capital expenditure of £0.4m in M1, predominantly in IM&T, which was

£0.1m ahead of plan.

The Trust had a small over delivery in April due to over-performance in Medicines

Management and is forecast to be on plan at year end.

1. Agreement and reconciliation of income due for activity undertaken remains a significant risk due to the financial position within the health economy. Outstanding issues from 2016/17 are now progressing to formal mediation. The Trust is working with the CCG

to agree a contract position for 2017/18 that is affordable and sustainable for both parties.

2. Alignment of capacity to non-elective and elective activity levels and responsiveness to changes in levels of demand. A review of capacity levels is underway t and expected to conclude prior to the reporting of the M2 position.

3. Achievement of financial control on a quarterly basis and delivery of access trajectories to secure access to the Sustainability and Transformation Funds. The Trust is behind trajectory in M1 and will need to recover this position in order to achieve STF funding

during the year.

4. Ability to exit premium rate workforce arrangements. The Workforce Transformation Group is overseeing action plans to increase recruitment, redesign workforce roles and manage sickness, rostering and retention issues. Opportunities to move to framework

agencies and reduce rates paid per shift are also being explored.

At the end of April the Trust is reporting a control total deficit, before STF, of £2.3m against a planned deficit of £0.7m. Non Elective activity continued at similar levels to Q4 16/17 and assumed growth has not materialised but the Trust has been unable to achieve

a corresponding reduction in capacity and therefore costs. A review of flexing down capacity and cost is underway should activity levels continue to reduce. The financial risk rating has dropped to a '3', which is a consequence of the adverse position in month.

At the end of April, the Trust has a rating of '3'. The effect of the deficit in month has

caused a reduction in the metrics linked to I&E perfomance. The liquidity metric

remains at a '3'. The Trust is under its agency ceiling trajectory so this particular

metric has improved to a '1'.

The Trust is reporting an adverse variance to plan of £1.6m. Non Elective activity has

continued at the reduced levels seen at the end of last year. Underlying pay

expenditure has marginally decreased from March, however, the reduction has not

been sufficient to offset the reduction in income.

Agency expenditure reduced to £1.2m in April, which is £0.4m below the agency ceiling

for April.

At the end of April income is £0.4m below plan. Non-elective activity and income was

below plan and was the most significant contributor to the adverse variance. This was

offset by over-performance in PbR excluded items, for which there has been a

corresponding increase in expenditure.

Overall pay expenditure is above plan as reduced activity has not led to similar

reduction in capacity. Non Pay is over plan primarily due to over-performance of high

cost drugs, for which additional income is received.

Total agency expenditure in April was £229k lower than reported in March. The

greatest reduction was in Medical agency which reduced by £218k, a slight increase in

Nursing was offset by a reduction in other agency costs.

Documents

Date of Meeting: 25th · 5.4.3 The number of falls in April equates to 5.17 per 1,000 bed days against a national figure of 6.63.3 Of the 34 falls reported as resultingin harm in