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Meeting of the Board of Dire 2010 in the boardroom
Meeting of the Board of Directors
Friday 30th October 2015 at 1.45 pm
Trust Administration meeting room 6
Public Meeting of the Board of Directors Friday 30th October 2015 at 1.45 p.m. in Trust Administration
Agenda
Presentation: Dr. Andrew Wardley, Consultant & Hon. Sen. Lecturer in Medical Oncology – Systemic anti-cancer treatment (SACT) related research
Page Timing 52/15 Standard business
a Apologies Chair
5 mins b Minutes of previous meeting – 25th September 2015 * Chair 3 c Action plan rolling programme, action log & matters arising * CEO 9&11 d Declarations of interest Chair
53/15 Key reports a Chief executive’s report * CEO 13 15 mins b Medical director’s report * EMD 25 10 mins c Integrated performance report */p Exec dirs 29 15 mins
54/15 Other reports a Risk Management Strategy – annual review */p EDoN&Q 99 15 mins b 2016/17 commissioning intentions * EDoF&BD 105 15 mins
55/15 Approvals a Monitor Q2 return * EDoF&BD 113 15 mins
56/15 Board assurance a Corporate Objectives 2015/16 * CEO 120 10 minsb Board Assurance Framework 2015/16 * CEO 141 c Assurance from board committees held in September 2015 * 149 5 mins
57/15 Any other business Chair
5 mins 58/15 Date and time of the next meeting Friday 27th November 2015
* paper attachedv verbal p presentation + separate pack (to follow)
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DRAFT Public minutes of the meeting of the Board of Directors of The Christie NHS Foundation Trust held on Friday 25th September 2015 at 1.30pm in the
trust administration meeting room centre, The Christie NHS Foundation Trust Present: Chris Outram (CO)
Kathryn Riddle (KR) Ron Stout (RS) Kieran Walshe (KW) Roger Spencer (RGS) Jackie Bird (JB) Joanne Fitzpatrick (JF) Chris Harrison (CH) Ann McEvoy (AMc)
Chair Non-Executive Director Interim Non-Executive Director Non-Executive Director Chief executive Executive director of nursing and quality Executive director of finance & business development Executive medical director Director of workforce
In Attendance: Louise Westcott (minutes) Company secretary Stephanie Jenkins (SJ)
Linda Allen Denise Saunt
Deputy COO Matron Matron
Presentation: A patient story – Diane Brookes
DB introduced herself to the board. She explained that she has been a patient for 14 years with genetic breast cancer. Her mum, aunty and grandma all died from breast cancer. This family history was discussed with her doctor after having kids and she then started on annual mammograms. Diane was then diagnosed with breast cancer at 36. In 2001 she underwent a double mastectomy, chemotherapy, radiotherapy and a breast reconstruction. She now knew she was a Bracca 2 carrier. As a preventative measure a full hysterectomy followed. Her 2 sisters, who were also carriers of the gene, also underwent preventative surgery.
In July 2008 Diane had a recurrence and 7 years on she is still here. She described first hearing about parp inhibitors. In September 2010 she met the phase 1 team and started a trial which worked on her 3 tumours and shrank them. 3 years later another lump appeared and she was no longer able to be on that drug. Diane had further hormone injections from 2014. In 2015 she described meeting the tissue viability nurse who helped to deal with the tumour that was now visible on her chest wall. Diane described having 2 phase 1 trials this year. She now had secondary breast cancer in her liver.
Other treatments were discussed with her and were being explored. A phase 1 trial started. This involves chemotherapy and a trial drug infusion. She described how her cancer has shrunk by 45%, the 3rd scan results show good results and the drug will continue.
Diane described the constant changes in the unit for the growing number of trials and described how the staff provide great care. She stressed that Phase 1 trials are unpredictable and that the patients provide great support to each other. She said that she felt very honoured to be part of the opening of the fabulous facilities of the MCRC.
Phase 1 patients undertake trials because they have limited options. It gives incredible opportunities for Christie patients.
Diane described how her kids have watched her go through treatment and that the kids are talked to openly. She described how she felt hopeful that advances in treatment will prevent a similar future to hers for her daughters and nieces.
CO the job is to ensure that we respond to the issues Diane has raised.
Diane talked about the Phase 1 trial accommodation and described it as being a little chaotic. She stressed that we need to keep phase 1 patients together as the mutual support is so important. She said that it would be much better to have a room with a window as it is a long day of treatment in a windowless room.
RGS noted that we are increasing the number of patients in phase 1 trials and there’s a plan in place to do this.
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JB asked if she could put Diane in touch with the matron for phase 1 to talk about the feedback she has.
JF asked if Diane has psychological support. DB responded that she was referred to a psychologist some years ago but that it didn’t work with the first psychologist. She has now found the right person at her local trust in Blackpool and this support is extremely valuable.
CO thanks Diane for a fantastic presentation and for taking the time to come and speak to the board about her experience as a Christie patient.
No Item Action
46/15 Standard business a Apologies
Apologies were received from Jane Maher, Neil Large, Tony Blower & Fiona Noden. CO welcomed Stephanie who is deputising for Fiona. CO also welcomed 2 of our matrons to the meeting, Linda Allen and Denise Saunt.
b Minutes of the previous meeting held on 31st July 2015 The minutes of the meeting held on 31st July 2015 were accepted..
c Action plan rolling programme, action log & matters arising The items on the rolling programme were captured on the agenda. There was one action
on the action log which is on the agenda for the board time out on 15th October 2015.
d Declarations of interest None declared.
47/15 Key reports a Chief executive’s report
• GM devolution – RGS reported that discussions about the devolution programme are
continuing and there is a strong emphasis on establishing governance and decision making structures and the interim financial position across Greater Manchester commissioners and providers. The governance proposals reiterate the principles as set out in the original Memorandum of Understanding, published in March 2015. It also indicates that the governance structures will be in shadow form from October 2015 in preparation for full implementation from April 2016. Draft terms of reference for a Greater Manchester Provider Federation Board have been set out. These describe how this group will oversee service provision and development from a provider perspective. The timeline for the programme shows a detailed strategic plan for Greater Manchester prepared by December 2015. The Christie is feeding into this process. RGS noted that we are party to the new shadow governance structures and are looking to fully participate in GM devolution.
• Manchester Cancer Acute Care Vanguard – RGS described the work done in partnership with a wide range of commissioner and provider organisations to prepare a proposal to take on a leadership role across the Greater Manchester cancer system. He informed board that this vanguard bid has been successful and along with The Royal Marsden and UCLH it has been announced that we will be part of a national cancer vanguard.
• We have had 4 of our activities shortlisted for the HSJ awards – Compassionate Patient Care - this entry is for our patient and public involvement in the development of our Christie quality mark. Rising Star - this entry is an acknowledgement of leadership by Dr Neil Bayman, clinical oncologist and chair of the Greater Manchester lung pathway board, in the development of treatment and services. Specialised Services Redesign - this entry is for the redesigning of chemotherapy services; providing a network of services across Greater Manchester and Cheshire and Staff Engagement - this entry is in acknowledgement of a range of activities summarised in our Christie Commitments.
The winners will be announced at an event in London on the 18th November 2015.
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No Item Action CO noted that it is great to be shortlisted 4 times as it is not easy so this is very impressive.
RS asked if we have had any enquiries about visits whilst the Conservative Party Conference is on in Manchester next week. RGS responded that we haven’t but that this is possible at very short notice.
CH highlighted the item on robotic surgery and noted to board that this presents a very significant role for us as the only compliant service in GM. The progress made with this service should not be underestimated.
CH informed board about the Holts donation event that he attended. This was a great opportunity to meet such a committed group of people who are fundraising for us. RGS added that this represents a big part of our history, with Holts having fundraised for us for over 100 years.
b Medical director’s report • CH highlighted the issue with the Cancer Drug Fund and the response to changes in
the national arrangements. We are preparing a considered response to the proposed change with clinicians. CH noted that our clinicians are involved in national reference groups and that we have good representation. We are leading and influencing where we can.
• CH highlighted that we are now having more Medical students coming through than ever before. This is very important and we have a huge amount to give to training of doctors, not just in oncology.
• CH drew the board’s attention to the fact that John Radford has been invited to be a guest professor at the Memorial Sloan-Kettering Cancer Centre. He will present to their medical oncology Faculty and fellows on latest advances in treating Lymphoma. CH stressed how important it is to bring this to the attention of the board.
• Responsible office annual report – Wendy Makin is the responsible officer – lots of detail of medical revalidation is contained in the report. Board are asked to note it. CH noted that we compare very favourably in comparison to others in this regard.
RS noted that The School of Oncology and education has done a fantastic job in improving the experience of medical students and the results can be seen in the report.
c Integrated performance report JB presented the report for month 5. She drew attention to the additional reports this
month around Emergency preparedness that requires board approval and the letter from Monitor on the Q1 response and the Parliamentary services ombudsmen report.
2 exception reports – cancelled operations and transplant activity
• 99.7% for the patient satisfaction survey • Outpatient 20 min wait – 82.8% (target 80%), Chemotherapy treatment – 86.0% (target
80%), Pharmacy turnaround – 87.2% (target 80%) • CQC IMR band 6 – no associated risks • 0 MRSA reported in August • 2 cases of unavoidable C-Diff reported in August. There have been no lapses in care
this financial year • 2 SUI panels presented in private as still going through Coroners inquests. • 4 executive reviews, 6 complaints, 3 inquests • Safe staffing levels achieved in August • There are no new risks above 15 • Monitor continuity of services rating 4 • Patients treated YTD -1.03% • Objectives are amber • EBITDA surplus £7.882m, £203k below plan • Trading surplus £493k, £76k above plan • I&E surplus £3.053m, £570k below plan - technical issue relating to delay to IPU
project.
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No Item Action • 59.4% CIP achieved recurrently, 71.0% in year • Cash balance £46.9m • Debtor days of 9 • Length of stay 6.55 days – relates to emergency patients, group formed to address
LOS and inpatient pathways. • Sickness absence 3.35% for August • Agency 0.73% of total pay bill • 31 days above target • 18 weeks above target
• 62 day performance 86.3% for August
JB highlighted the Parliamentary services ombudsmen report. The cover letter indicates that this is not about league tables but it has been represented in this way. It shows that we have had 1 enquiry and that this was not accepted for investigation. JB also referred to the complaints presentation that was given at QA committee and that the focus is on everyone taking responsibility to stop complaints.
RGS pointed out that 3 of the top organisations in the Ombudsmen report results are organisations JB has worked with. CH added that there has been a reduction in complaints since JB started.
JB added that staff are very engaged in doing what’s right and lots of work goes into ensuring PALs enquiries do not become complaints.
JB noted that the amber rating for the strategy reflects where we are in the year and that our annual objectives are on course to be achieved.
Board were asked to approve the Pandemic Flu submission. This was approved.
The report was noted.
48/15 Other reports a Compliance with NICE safe staffing guidelines – six month review
JB set out the background to the report in that we are asked to be assured as a board that the staffing we have in place is appropriate and meets the standards of the quality board on safe staffing.
Non-executives asked for a summary on the front in future as this is a long and detailed paper. JB agreed to do this for the next report.
JB thanked the matrons and others that have worked hard on this for their efforts.
In summary, we are compliant with safe staffing levels on our wards.
There was 1 red flag where the number of staff on one ward was not right. Action was taken to move patients to other wards in this instance. This was escalated appropriately, action was taken in a timely way and patients were safe.
JB described ceilings that have been set in agency spend of 3%, our current figure is 0.9% (and this is mainly in critical care).
This is very important work for the nursing staff.
Question’s were invited
RS referred to the recent trouble with Addenbrookes and their CQC inspection where one of the issues was high bed occupancy. He asked if this is an issue here. JB responded that we do have high occupancy on wards 4, 10 and 11 but that we also have safe staffing to reflect this. JB noted that she is assured that matrons escalate when they need to and she has had experience of this working.
JB also noted that other markers of care show that we are staffed safely - pressure ulcers, falls and complaints are all low.
KW asked how much faith we have in the acuity measurement system.
JB responded that we have been using this tool bi-annually since 2010. We have had issues but this has been with the people completing the tool not understanding it fully. There is a way that matrons can give their professional opinion and back that up which is
JB
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No Item Action very helpful. She noted that this is not strictly an oncology tool but that we do find it useful.
KW asked do you feel we would pick up issues using this tool.
SJ responded that on the critical care unit with ratios of 1:1 or 1:2 care, the escalation works. This is through the Matron up through the division to the Director of Nursing.
Board were asked to endorse findings and show assurance.
CH – this is a fundamental and large proportion of CQCs assessment.
RGS – it’s the nurses that decide how many nurse’s they need – this is very important
CO concluded that this is a very good piece of work and provides the board with assurance on staffing. She also noted that it is very pleasing that there is an effective escalation procedure in place.
b Review of productivity
JF presented the report that summarises the preliminary findings from the Carter report.
JF talked about the workflow against workforce and the requirement to give an agency cost report to monitor. JF also referred to the focus on VSM pay and the cap on redundancy pay and off payroll payments.
The report talks about various elements of productivity such as medicines optimisation, use of estate and procurement. JF outlined that of the recommendations in the report, many are part of our CIP programme. There is nothing new for us but we are going through the process to ensure that we are on top of things in terms potential efficiencies.
In terms of treatment indices we are working with the Royal Marsden to look at better reflecting the complexity of oncology. This is key as it may impact on the CQC efficiency marker.
JF asked the board to note the report and receive its updates.
KW asked how this connects with the CQC.
Medical locums will be looked at next and it would have been very helpful to get this implemented at the same time as the nurse requirements but this will now require further work.
AM informed board that we have been looking to set locum rates across GM so this is consistent across the patch for internal and external rates. There is no national interest in this currently. This links with Let-B.
Report noted.
49/15 Board assurance a Board assurance framework
RGS – paper describes changes since the July meeting
It is suggested that following this month’s board meetings that changes are considered for 3 areas - Devo Manc proposal / tariff changes and increasing risk of current proposals / CPP. Board agreed with this suggestion and agreed these will be updated.
50/15 Any other business Board members had a discussion about what should be discussed in the public / private
section of the meetings and whether the current time allocated for the committees on board day is appropriate.
JF suggested that a reduced finance report could be presented in public in future.
CO suggested that further discussion will take place between herself, RGS and LW about the timing of meetings which will include the planned review of the order of the committees.
JB noted that the flu vaccinations have now started and that an appropriate time will be arranged to come and vaccinate board members.
CO/ RGS/ LW
JB
51/15 Date of the next meeting: Friday 30th October 2015
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Agenda item 52/15c
Month From Agenda No Issue Responsible Director
Action To Agenda no
30 October 2015 Annual reporting cycle Corporate objectives & board assurance framework
CEO Interim review 56/15a&b
Annual reporting cycle Q2 Monitor return EDoF&BD 55/15aAnnual reporting cycle Risk Management strategy EDoN&Q Annual review 54/15a
27 November 2015 Annual reporting cycle Integrated performance report COO Monthly report
January 2016 Regulatory Monitor Q3 return EDoF&BD To approveAnnual reporting cycle Integrated performance report COO Monthly report
February 2016 Annual reporting cycle Integrated performance report COO Monthly report
March 2016 Annual reporting cycle Corporate planning (corporate objectives / BAF / financial plans: revenue & capital 2016/17)
Executive directors
Approve next year's annual plan
Annual reporting cycle Letter of representation & independence Chair Directors to signAnnual reporting cycle Register of directors interests Chair Report for approvalAnnual reporting cycle Integrated performance report COO Monthly report
Annual reporting cycle Chair Review
April 2016 Monitor Q4 return EDoF&BD ApproveAnnual reporting cycle Integrated performance report COO Monthly reportAnnual reporting cycle Essential standards for quality & safety /
NHSLAEDoN&Q Declaration / approval
Register of matters approved by the board CEO April 2015 to March 2016Annual reporting cycle Annual plan 2015/16 EDoF&BD Approve
Public Meeting of the Board of Directors - 2015
Action plan rolling programme after September 2015 meeting
December 2015 - no meeting
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Month From Agenda No Issue Responsible Director
Action To Agenda no
May 2016 Annual reporting cycle Integrated performance report COO Monthly reportAnnual reporting cycle Annual reports from audit & quality assurance
committeesCommittee chairs Approve
Annual reporting cycle Annual governance statement Exec direc ApproveAnnual reporting cycle Annual report, financial statements and quality
accounts EDoF&BD Approve
Annual reporting cycle Statement on code of governance ApproveMonitor provider licence Self certification declarations EDoF&BD General condition 6 and
Continuity of Service condition 7 of the NHS Provider Licence
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Action log from the board of directors meeting held on
Friday 25th September 2015
No. Agenda Action By who Progress Board review
1 48/15a Add in summary to the next review of staff staffing EDoN&Q Noted March 2016
2 50/15 Review of the order and timings of the board committees Chair / CEO / Comp sec
Report to board in January following trial of current arrangements January 2016
3 50/15 Set a time to undertake flu vaccinations for board members EDoN&Q Arrangements made for October 30th N/A
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Agenda item 53/15a
Meeting of the Board of Directors Friday 30th October 2015
Report of Chief executive
Paper Prepared By Roger Spencer
Subject/Title Chief executive’s report
Background Papers n/a
Purpose of Paper To keep the board of directors updated on key external developments & relationships
Action/Decision Required The board is asked to note the contents of the paper
Link to:
NHS Strategies and Policy
Link to:
Trust’s Strategic Direction
Corporate Objectives
Achievement of corporate plan and objectives
Impact on resources and risk and assurance profile
You are reminded that resources are broader than finance and also include people, property and information.
You are reminded not to use acronyms or abbreviations wherever possible. However, if they appear in the attached paper, please list them in the adjacent box.
DH - Department of Health
HSJ - Health Service Journal
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Agenda item 53/15a
Meeting of the Board of Directors Friday 30th October 2015
Chief executive’s report
1. Greater Manchester Devolution
The discussions about the devolution programme are continuing and there remains a strong emphasis on governance and decision making structures.
A Greater Manchester submission was made to the Central Spending Review (CSR) to secure circa £500K of transitional funding in order to pump prime service redesign initiatives across Greater Manchester. The outcome of this should be known by December 2015.
At present, the main areas of work have centred on the financial assessments within each of the 10 locality plans. These plans are being compiled by the health and social care partners within each of the 10 geographical localities in Greater Manchester. There will be an 11th ‘Locality’ Plan produced which will be led by a named Senior Responsible Officer (SRO) and will include the financial plans of all providers that are not covered within the 10 geographically based locality plans. It is anticipated that this will only be The Christie and the North West Ambulance Service (NWAS). This plan will however include the strategic narrative around all specialised services and will be led jointly by NHS England and Trafford CCG. To help inform this plan, a number of specialised commissioning workshops are being organised – these will explore the concept of service ‘bundles’ with appropriate co-locations of associated services. The most recent devolution bulletin is appended to this report. http://gmhealthandsocialcaredevo.org.uk/
Strategic Partnership Board Strategic Partnership Board Executive
Provider Federation Board
Joint Commissioning Board Overarching Provider Forum
Joint Commissioning Board Executive
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2. Manchester Cancer - Acute Care Vanguard On 25th September, an announcement was made by NHS England that our GM acute care model proposal had been successful but that Greater Manchester would become part of a single National Cancer Vanguard alongside The Royal Marsden and University College London Hospitals (UCLH). An initial conference with the 2 other provider partners was followed by a meeting in London held on Monday 12th October 2015 with the New Care Models Team (NHS England) and the 3 providers involved to begin to scope and cost the pilot proposal. It was confirmed at this meeting that this will be a single national vanguard spanning a 3 year period and that the focus will be clearly on taking forward the recommendations within the National Cancer Strategy. What are the vanguards set up to do? They are established by the New Care Models Team, part of NHS England, to become vehicles for implementation of Five Year Forward View and other key national strategies. They are tasked with finding new, innovative and potentially radical ways of addressing the pressures facing health and social care in seeking clinical and financial service sustainability.
There are 50 national vanguards in 5 areas:
i. Multispecialty community providers ii. Enhanced health in care homes iii. Integrated primary and acute care collaborations iv. Urgent and emergency care v. Acute Care Collaborations (ACC) – 13 vanguards including
cancer The success of the vanguards will be judged against a number of criteria including
o National replicability o More accessible, responsive, effective health, care and support services o Care closer to home o Improved service coordination and delivery
In order to access the £200m transformation fund, vanguards have to prepare a single business case (‘value proposition’) that describes the strategic context and background, the vision and ambition for change and the specific areas that will be progressed with the pilot. It must indicate the expected benefit to the population as a whole, individual patients and the taxpayer through more cost efficient service delivery. This business case must be submitted by 30th November 2015.
Are the 3 proposals in the national vanguard consistent?
From the initial discussions held with the partners within the cancer vanguard, it is apparent that there is significant synergy in the focus for this work. All 3 have identified the need to focus attention in the early parts of the cancer patient pathway – through public health, primary care and diagnostic initiatives. There are however some differences. The Royal Marsden and The Christie are 2 single speciality cancer centres and both have indicated the intention to progress with a capitated funding approach within the pilot – this would span the entire patient pathway and would result in a single ‘system’ leader managing this capitated budget. This is consistent with recommendation 77 of the National Cancer Strategy. UCLH as a multi-speciality provider has not at this stage indicated this is their intention.
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Next step actions The timescales for progressing this pilot are challenging and must proceed at pace. The table below indicates the overall timeframes for the pilot and the specific actions that will be taken forward over the coming months:
The most immediate action for the Greater Manchester pilot is to establish a Project Management Office (PMO) with dedicated clinical and managerial capacity to lead this programme of change. There is a strong emphasis in this for building on existing workstreams and groups and the early work of the project team will centre on understanding these and aligning work programmes. Further information can be found at @TheChristieNHS@TraffordCCG#vanguardmanchestercancer.org/?p=4053
3. Health Innovation Manchester Health Innovation Manchester (HInM) was launched at NHS Expo on September 2nd, with the vision to ‘transform the health of our population by driving research and innovation into daily practice’. A Memorandum of Understanding was signed by the key partners, comprising Manchester Academic Health Science Centre, Greater Manchester Academic Health Science Network, Greater Manchester CRN, Manchester Science Partnerships and Manchester Growth Company. NHS England Chief Executive Simon Stevens was also present and spoke supporting the importance of the work. Since the launch of HInM, work has progressed with developing plans and business case for HInM. This has included:
- Holding workshops, strategy sessions and individual discussions around the priority areas of clinical trials, precision medicine, health informatics, innovation into practice, ecosystem development and business engagement.
Actions Dates
Greater Manchester cancer workshop / webinar November 2015
National meeting of all acute care collaborationvanguards
13th Nov
Submission of single cancer vanguard business case (‘value proposition’)
30th Nov
GM Vanguard Project Office established December 2015
Pilot established in shadow form By April 2016
Formal notification of any transactional changes Sept 2016
Full implementation of pilot By April 2017
Evaluation and consolidation By April 2018
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- Establishing the interim Executive Group and Steering group that will oversee the work until formal governance arrangements are put in place alongside the wider devolution governance arrangements in 2016.
- Appointing KPMG to assist with the production of the business case and bringing in global learning and benchmarking to the work to ensure that we take the best learning from around the world. It is envisaged that initial priorities will be defined in the coming weeks, with initial business case completion by the year-end. They are likely to include: informatics, clinical trials, precision medicine, innovation into practice and ecosystem development.
In order to keep key partners updated on the work of HInM, it proposed to put in place a regular newsletter containing timely updates on key news and signposting upcoming events of most relevance / importance. It is proposed that this would incorporate the current GM AHSN and MAHSC newsletters as well as any HInM specific material to deliver relevant news covering the entire ecosystem and remove duplication. www.healthinnovationmanchester.com
4. Organisational development – one week all staff
As part of our organisational development strategy and building on the success of our first One Week all Staff event earlier this year, our second One Week All Staff Event took place during the week commencing 28th September across the Trust. Staff were asked what it is like to work at The Christie and what they would change. Postcards with these two questions were attached to the September payslips. The Christie Commitment Champions carried out informal walkabouts to help collate feedback. The information collected is being analysed and will be reported across the Trust in the coming weeks.
5. Nurse and Health Care Assistants Recruitment Open Day On Saturday the 3rd October a very successful recruitment open day was held which saw over 200 people attend the Trust to hear about working at The Christie. Ahead of the event we received over 170 on-line applications. The response to the event was phenomenal and whilst we couldn’t offer a job to everyone we were able to fill all of our existing vacancies, in some areas of higher turnover we over-recruited and we appointed high calibre student nurses who are due to qualify in March 2016.
6. Clatterbridge Cancer Centre visit
On 5th October we hosted a visit of the executive team from Clatterbridge Cancer Centre. We reviewed our respective developments and challenges and progress on joint work including tariff and financial planning, reference costs and the efficiency activities, workforce development plans and our vanguard new care model submissions. Further information on Clatterbridge Cancer Centre can be found at: www.clatterbridgecc.nhs.uk
7. MCRC Steering Board - 06.10.15 On the 6th October the steering board met. They received an update on centre development and forward plans particularly proposals outlining the next phase of development of a new building to house the centre for cancer biomarker sciences. The board also received a presentation from Professor Hughes outlining an Astra Zeneca collaboration called iDecide introducing ‘real time’ data enabled decision making in trials. The board received a further update from the centre director on research and noted that both the centre and ECMC awards are due for renewal in autumn 2016. The renewal submission is in preparation and will focus on four main themes; experimental therapeutics, biomarkers, molecular pathology and radiotherapy related research.
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More information can be found at:- http://www.mcrc.manchester.ac.uk
8. Healthier Together Programme
On the 12th October Greater Manchester NHS Service Transformation received formal notification that ‘Keep Wythenshawe Special Limited’ has lodged an application seeking permission for a Judicial Review challenging the Healthier Together decision. They have named NHS Central Manchester CCG as the lead defendant with the other 11 CCGs as co-defendants. A media statement in response to this notification has been issued and they will continue to provide regular updates to key stakeholders as required. More information can be found at Healthier Together | Best Care For You, Your Family and Your Neighbour. bestcaregm.nhs.uk
9. Future plans and developments On 5th October an event to review our future plans and developments was held in the education centre. It was attended by more than 100 of our clinical staff and reviewed a snapshot of our current strategic plans together with updates on the Greater Manchester cancer vanguard proposals and Biomedical Research centre applications. The event provided considerable feedback in the development of our plans. Further information can be found at Trust Strategy - The Christie
10. Making safety visible (MSV) Members of the board attended the MSV summit event on Wednesday 7th October 2015. We presented the work undertaken as part of the project with Wrightington, Wigan and Leigh and Manchester Cancer around the development of an incident reporting system across the whole pathway for lung cancer. Following the conclusion of the project, this work has become part of the lung pathway work programme in Manchester cancer. More information can be found at Making Safety Visible | Haelo
11. Board of directors’ time out session The board of directors met on 15th October 2015 to review the strategic plan. The board heard from the Greater Manchester devolution chief officer and were updated on the national cancer vanguard. The day also included feedback from the clinical engagement event that took place on 5th October 2015. The review will form part of the next submission of strategic planning.
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Devolution Website Contact us Twitter
Issue 7 - October 2015
What's been happening? It has been a busy three weeks for the Greater Manchester Health and Social Care programme and the pace remains fast as we press on towards some vital key milestones (more in the e-bulletin). The Conservative Party Conference took place in Manchester. Devolution was a key theme at the conference. We are regularly being asked to talk at events and tell people more about what’s happening in GM and the pace stepped up as the conference was in the City. Both national and regional media were keen for interviews and TV shows such as the Andrew Marr Show and the Sunday Politics Show ran interesting and informative pieces. One highlight was that the region’s media joined forces to collectively demand a ‘fair devolution deal’ for Greater Manchester. Partnership working is one of the primary principles of devolution so it was a proud and significant moment for Greater Manchester to see influential titles such as the MEN, Bolton News, Oldham Chronicle and Wigan Evening Post combine. Local support for us taking charge and responsibility of the £6 billion health and social care budget is integral if we are to successfully improve the region’s health outcomes. I’ve talked about this a little more in my blog.
The media’s voice will help bring the devolution messages to the most important audience of all, the general public. We know we must do more to talk to the public and the tens of thousands of staff working across the public sector in GM. We have focussed very much on bringing the partners together, getting our governance in place and launching some significant commitments around access to primary care and others. As we move towards drafting our Strategic Plan – and
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tackling some of the huge challenges in GM - we will have far more tangible things to talk about with people and will be out and about doing just that. Every NHS organisation and every council in GM is part of the Devo programme and we’ve asked them all to contribute their thoughts via their senior teams. Over the coming weeks we’ll share those with you via blogs. Please enjoy reading the rest of this e-bulletin, and we would welcome your feedback on any of the items. Please email [email protected].
Strategic Plan The Strategic Plan will set out how the NHS and local authorities in GM think we may be able to bring the fastest and biggest improvement in health and wellbeing to the people of GM over the next five years. The plan is not just a ‘new’ document. It is the culmination of many years of conversations between the organisations and public of GM – and builds on many successful pieces of work to improve health, wellbeing and services. It will mark the start of many more conversations about the role of the people and the organisations in GM - from the individual to the family, the community, neighbourhoods, the voluntary sector and the public bodies. Devolution gives us the opportunity to bring all this ambition together and the freedom to take charge, together, of the long term future of our city region. The plan will set out how we’re going to work together, the chance to be more involved and some of the pieces of work to take place over the next two years. It will have three building blocks:
• Ten locality plans – these have been developed in the ten GM areas and are the culmination of, in many cases, years of work with partners and the public. They are being developed with local health and wellbeing boards and will reflect our commitment to things being done locally where local people think that’s best
• Big ‘transformation initiatives’ and other GM wide plans – these reflect those areas where we think it makes sense to approach things just once across GM to have the biggest positive impact (though this might not mean delivering services in the same way in every area). This includes, for example, our approach to supporting people with mental health problems
• Plans for how hospital and other services direct to the public can work together more efficiently and effectively.
The plan was one of the pieces of work we agreed to deliver by the end of the year as part of the Memorandum of Understanding in February, to assure NHS England and Government colleagues that we are ready to take on the challenges and opportunities of full devolution. A draft will be ready to share widely in mid-December.
Transformation Initiatives The NHS and councils in GM were asked to team up to submit bold ideas for big pieces of work which would have a positive impact on large parts of GM. The aim is to use these to strengthen our bid to the government for the money we need to really improve health and wellbeing and make sure our Strategic Plan reflects the combined ambitions of GM. Nearly 50 were submitted and these have now been assessed by independent advisors. If we do get the transformation funding we have asked for from the government in November a process will be put in place to use the money to get the plans up and running.
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Governance On October 1st we formally released details of how 38 organisations are going to work together to improve the health and wellbeing of 2.8 million people. The new decision-making structure – with the creation of a new strategic partnership board – provides a once in a lifetime opportunity to map out the future decision making around health and social care in Greater Manchester. The details of what a devolved health and social care system will look like when it comes into full force in April 2016 are still being worked through. This is where we are focussing our efforts right now having worked hard to date to develop a system for governance, which allows us to be fully accountable for our decisions but also gives us the freedom to make changes. With so many stakeholders and interested parties this is no mean feat – and nor should it be – which is why the recent partnership announcement was so important.
HSJ Award It is always nice when hard work is recognised and the Health and Social Care Devolution programme has been shortlisted for a Health Service Journal (HSJ) award for partnership. A small team consisting of Ian Williamson (Chief Officer), Warren Heppolette (Strategic Director) and Steven Pleasant (Chief Executive Tameside Council) spoke with the awards panel last week and outlined the successes of the programme to date with partnership being central to this. We find out on November 18th whether we have been successful but all who have contributed to the programme should take credit for the shortlisting. Many other GM organisations have been shortlisted for the awards showing the strength of GM.
Briefing Event As you can imagine we are getting an increasing number of invitations to talk about health and social care devolution both at a local and national level. It is just not possible to attend each event and we don’t like letting anyone down. Therefore we are planning on holding a briefing style event in the Greater Manchester area for anyone interested in our programme in the next few weeks. Watch this space.
Communications For more information: Sign up to our regular e-bulletin at: www.gmhealthandsocialcaredevo.org.uk/bulletin/ Follow us on Twitter @gmhsc_devo Email us at: [email protected]
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24
Agenda item 53/15b
Meeting of the Board of Directors
Friday 30th October 2015
Report of Medical Director
Paper Prepared By Yvonne Clooney
Subject/Title Executive Medical Director’s report
Background Papers n/a
Purpose of Paper To bring to the attention of the Board of Directors current issues relating to the Trust or external network
Action/Decision Required To note
Link to:
NHS Strategies and Policy Cancer Outcomes Framework
Link to:
Trust’s Strategic Direction
Corporate Objectives
All objectives of the Trust
Impact on resources and risk and assurance profile
You are reminded that resources are broader than finance and also include people, property and information.
Nil
You are reminded not to use acronyms or abbreviations wherever possible. However, if they appear in the attached paper, please list them in the adjacent box.
DNAR – Do not attempt resuscitation PALs – Patient Advice & Liaison Service MHRA – Medicines and Healthcare products Regulatory Agency
25
26
Agenda item 53/15b
Meeting of the Board of Directors
Friday 30th October 2015
Executive Medical Director’s Report
1. Consultant appointments I am pleased to inform you that Ms Eva Myriokefalitaki was recently appointed to the post of Consultant in Gynaecological Surgical Oncology, start date to be confirmed.
2. Development of new 5 year programme for Medical Student A new programme for all year 5 students at Manchester University Medical School has been successfully launched at The Christie. This new programme, developed with the medical School, provides students with the opportunity to work alongside different members of our disease teams, gaining a full understanding of the patient pathway. Feedback from the medical school has been excellent, with students themselves praising the new approach:
“I would like to just say thank you so much for helping to organise our week … I cannot thank you enough for putting together such an informative and useful placement that was so well organised, packed full of different types of clinical exposure and filled with learning opportunities. I felt the week had a good variety of experiences for the right length of time, the sessions worked really well, staff were prepared and able to provide a good overview to their department with relevant information regarding our training. Thank you” A medical Student August 2015
3. Christie launches a new training programme to support staff discussing “Do Not
Attempt Resuscitation” with patients and relatives New national guidelines were recently published on doctors obligations to discuss “do not resuscitation orders” with patients and relatives. This followed a high profile court case, and coincided with work being done at The Christie in the area following a Christie family raising concerns about the issue. As a result The School of Oncology has worked with clinical leaders from Acute Medicine, Clinical and Medical Oncology, Critical Care and Enhanced Supportive Care to develop a 2 hour workshop aimed at senior clinical professionals involved in DNAR conversations. This Christie developed workshop aims to improve professional’s confidence and skills in having these difficult and sensitive conversations. It focusses on clarifying the resuscitation guidance and the legal position on involving patients and relatives in discussions and decision making, and provides an opportunity to consider how these conversations might be approached in different clinical situations.
4. New Christie Positive Patient Experience Programme
The School has worked with leaders in the patient experience committee and the PALs team to develop this unique Christie programme aimed at those staff who don’t have access to communication skills development in their training. The school has supported the development of a faculty of 5-7 to enable the workshop to be delivered on a monthly basis. This 2 hour interactive session has now been delivered to 42 members of front line staff including receptionists, health care assistants, ward clerks, domestic staff,
27
those from medical physics, clinical trials staff, and administrative staff from education. Evaluations have been very positive with 90%+ reporting a greater understanding of those things that contribute to “good experience” and 93%+ reporting they could identify specific things in their own roles that they could do differently. Comment from a delegate:
“Very useful in making people understand the impact of their actions, however small on others. Very informative” …. Course participant October 2015
5. Medicines and Healthcare Products Regulatory Agency
Following the MHRA Inspection in January 2015, the Division of Research developed a comprehensive action plan to address the key findings. This plan was approved by the MHRA on 29th June 2015. Our first quarterly update report was submitted on 28th September 2015 and we have now received feedback. No issues were raised with the progress we have made to date against any of our actions. There were some minor points of clarification requested on work we have already completed, this is purely for their information and understanding. Our next quarterly report is due on 29th January 2016 where we have been asked to update the inspectorate on the transfer of the MAHSC-CTU to the University of Manchester.
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Agenda item 53/15c
Meeting of the Board of Directors Friday 30th October 2015
Integrated performance and quality report for month 6 – September 2015
Report of Executive Directors
Paper Prepared By
Fiona Noden, Chief Operating Officer Anthony Blower, Medical Director Joanne Fitzpatrick, Director of Finance Jackie Bird, Director of Nursing & Quality Ann McEvoy, Director of Workforce Marie Hosey, Head of Performance
Subject/Title Integrated performance and quality report for month 6
Background Papers (if relevant) Balance scorecards
Purpose of Paper The report shows the trust’s performance for strategy, finance, efficiency, workforce, patients’ experience, clinical quality, access and standards
Action/Decision Required To note the content of the report
Link to:
NHS Strategies and Policy
NHS Plan Cancer plan Cancer waiting times NHS planning guidance Payment by results NHS financial regime
Link to:
Trust’s Strategic Direction
Corporate Objectives
Board Assurance Framework 6.1
1. To demonstrate excellent and equitable clinical outcomes and patient safety, patient experience and clinical effectiveness
2. To be an international leader in research and innovation which leads to direct patient benefits
3. To be an international leader in professional and public education for cancer care
4. To integrate our clinical, research and educational activities as an internationally recognised and leading comprehensive cancer centre
5. To provide leadership within the local network of cancer care 6. To maintain excellent operational and financial performance 7. To be an excellent place to work and attract the best staff 8. To play our part in the community
Resource Impact None
You are reminded not to use acronyms or abbreviations wherever possible. However, if they appear in the attached paper, please list them in the adjacent box.
IP – Inpatients DC – Day Case MRI – Magnetic Resonance Imaging CT – Computer Tomography CMPE – Christie Medical Physics Engineers FCE – Finished consultant episode CWT – cancer waiting times IMR – Intelligent monitoring report.
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30
Agenda item 53/15c
Meeting of the Board of Directors Friday 30th October 2015
Month 6 Performance Report Introduction The Integrated Performance and Quality report now includes a summary dashboard that presents an overview of performance. Exception reports set out information about breach of standards highlighted red as well as any other areas of concern within the report, together with action taken and projected performance. Overall Performance In month 6 our overall good performance trend continues. Our length of stay remains slightly above plan. The changes to the national tariff risk has increased in September to a 16. Quality – In September the satisfaction survey results remain high with a 99.1% positive response score. The chemotherapy treatment targets continue to be met and exceeded The Trust remains low risk in the CQC intelligent monitoring assessment. Patient safety – There have been no cases of MRSA bacteraemia and there has been 1 case of unavoidable CDifficile in September Additional reports Tripartite review of cancer improvement plans NIHR Performance in Initiating and Delivering Clinical Research – Q1 2015/16
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1 3 25
Sep-15
Sep-15
0.90%
1.13% 0.69%
AchievedAchieved
87.3%
97.3%h
028h
Patent Safety
62 Day Compliance - Screening
86.3%62 Day Compliance - Post Reallocations
6 Weeks90.0%95.0%92.0%
0
Major Surgery 30 Day Survival Rate
Target / Thresholds
Delayed Transfers Of Care (% of occupied bed days)
Friends & Family Score (Inpatients & Daycases) % Not Recommended
95%Intelligent Monitoring Report
Indicator
Friends & Family Score (Inpatients & Daycases) % Recommended
98.3% 98.5%
Indicator Aug-15 Sep-15
Performance Dashboard - 2015/16
Performance
YTDPerformance
g 44Monitor Continuity of Services Rating 4Target / Thresholds
4
Cancelled Operations On The Day Of Surgery - Rebooked Within 28 Days 100% 100%
Diagnostic Waiting Times - PET/CT/MR 100.0%
18 Weeks Compliance - Non-Admitted Patients 98.7% 98.1%18 Weeks Compliance - Admitted Patients 96.1%
hg
1
100.0%97.5%
Patients Waiting >52 Weeks18 Weeks Compliance - Incomplete Pathways
6.63
10
0 0
0.4%
0
0.9%
6.63
100.0%96.7%98.4%98.5%
0
100%
82.8% 82.9% 84.8%Chemotherapy Waiting Times (% seen within target)
25 25 25gg
6.55
g
85.7%
86% 87%
100.0%85.7%
Cancelled Operations On The Day Of Surgery
99.5% 100.0% 99.7%h
Aug-15 Performance YTD
87.2% 90.3% h 88.4%
4
83.5%
Radiotherapy Waiting Times - Palliative (Days)
Outpatient Waiting Times (% seen within target)
0.7%
10 10
Length Of Stay (Elective & Non-Elective Inpatients - Rolling 12 Months)
31 Day Compliance
87%
Radiotherapy Waiting Times - Radical (Days)
hPharmacy Waiting Times (% seen within target)
80.5%Bed Occupancy (Midnight) <= 82%
ghhh
Sep-15
31 Day Compliance - Subsequent Surgery 95.2% 98.6%31 Day Compliance - Subsequent Radiotherapy 100.0% 99.3%
Friends & Family Response Rate (Inpatients & Daycases)
31 Day Compliance - Subsequent Drug Therapy
40%99.15% 94.42% 97.25%44.70% 43.80% -
Qualty
Indicator Aug-15 Performance YTD
0.57%95.45%1.09%99.70%
0.90%0.30%Patient Satisfaction Score - % Not Recommended
Friends & Family Score (Outpatients) % Not Recommended 1.02%Patient Satisfaction Score - % Recommended 99.10%
Friends & Family Score (Outpatients) % Recommended 93.87%< 4%94%< 4%94%< 4%
95.21%
0 gNumber Of Complaints 6 3
h 1.17%99.10%
0Mixed Sex Accomodation
96.48% -
0
g110
97.52%
g
Performance
0 02 1
Sep-15Aug-15
g89%99%
91%99%
g
YTD
C-Difficile - All Attributable Cases
-
MRSA 0 0
Inpatient Falls Resulting in Harm ( Grade 2 or above) (Year) < 33
Staff Sickness 3.60% 3.36% 3.25%hStaff Training
90.9%Staff PDRs90.8% 90.9% 90.9%h
YTD
100%
89.0% 89.0%
9 17 98
99.7%
Jul-15 YTDPerformance
AchievedHR & Workforce
Never Events 0 0 0
Agency Usage (subject to validation) 0.73%
YTDh -1.18%
h
Overall Trust Activity Vs Plan > 0% -2.17% -2.04%
0.65% 0.76%
< -1%
< 1%
Indicator Aug-15 Performance
37.2Indicator Aug-15
Continuity of Services Risk Rating 4 4 4 g
Sep-15
4
YTDLiquidity - Ratio (days) 42.4 37.2
> 2.53
h -50.5%
CIP Performance - Full Year Impact - Recurrent % 59.4% 62.6%
Indicator Aug-15 Performance YTD
(M6 Target ) > 50% h 62.6%
> 3%
> 90%
Number of Corporate Risks Grade 15 or Above 4 4 g 5Sep-15Target / Thresholds
Safety Thermometer
h
h
0
h
2
VTE Risk Assessments 96.9% 97.8% 96.9%C-Difficile - Attributable Cases Due To Lapse In Care
Clncal Effectveness
Incidents Reported (grade 2 or above)
gSerious Incidents 2
94%
Target / Thresholds0
0(Year) <65
< 3.5%< 6.4 > 6.9
> 90%80.0%80.0%80.0%< 14< 28
85.0%85.0%* 90.0%96.0%98.0%94.0%94.0%
> -2
Actvty
< 3.4%
(Year) < 243
(Year) < 28
(Year) <= 19(Year) <= 12
95%
0
> 94.5% < 84.5%
0100.0%
Target / Thresholds
Target / Thresholds
Cancer Targets
Indicator
100.0% 100.0% g62 Day Compliance - Upgrades
87.5%83.1%96.6%
h
98.9% 97.7% 98.2%
99.7%
h
< -12< 1.25
2
Target / Thresholds
Target / Thresholds
Target / Thresholds
2 19
Fnance
Capital Servicing Capacity
Performance
2.9 3.0 h 3.0
g
Indicator Aug-15 Sep-15
Aug-15
2Number of Pressure Ulcers (Post admission - Grade 2 or above)
Performance
IndicatorPalliative Radiotherapy 30 Day Suvival RateFinal Chemotherapy 30 Day Survival Rate
Key Rsks103.9% 94.3% 94.3%
Income & Expenditure - underspend/overspend against plan - Trading (Rolling YTD) < 0% -18.3% -50.5%
Cash Balance - % of Planned Value < 80%
32
Performance Exception Report
Indicator
Friends & Family Score (Outpatients) % Recommended
Target Performance
94% 93.87%
Issue
• The FFT score for outpatients has dropped slightly below the target performance for the first time since the Friends and Family test was introduced in the outpatient setting in April 2015.
• This is due to a slight increase in the poor responses and the ‘neither likely nor unlikely’ answers, and by an increase in the ‘don’t know’ responses
Proposed Action
• Improvement actions to be led by sisters/charge nurses and matrons learning from areas where response rate is 40% or more
Assessing Improvement
• Weekly monitoring reports from information team
• Improvements to be monitored at Friends and Family Test steering group and Patient Experience Committee
Impact
• Low impact
Expected Date of Performance Delivery
15/11/2015
Executive Lead
Executive Director of Nursing & Quality
33
Performance Exception Report
Indicator
Sickness Target Aug-15 Sep-15 Performance YTD
>3.4% 3.60% 3.36% h 3.25%
Issue
This exception report relates to August sickness following data validation. Overall sickness absence had deteriorated in August.
Proposed Action
Data shows the performance decline is as a result of an increase in short term sickness cases. There are no trends visible across the Trust the sickness covers all departments for a variety of absence reasons.
Regular audits will be undertaken by the division in conjunction with HR to ensure that the Management of Attendance (MOA) policy is being applied appropriately.
Assessing Improvement
Sickness absence continues to be monitored through divisional boards and monthly performance review meetings. A six monthly audits of the application of the MOA policy is and presented to the Capital and Workforce Planning group to ensure sickness is being managed.
Impact
Low. Year to date performance remains within target. Agency use remains below 1% of pay costs.
Expected Date of Performance Delivery
31/10/2015
Executive Lead
Director of HR
34
Performance Exception Report
Indicator
Trust Activity Vs Plan Target Aug-15 Sep-15 Performance YTD
>0% -2.17% -2.04% -1.18%
This exception report focuses on the September performance of Radiotherapy Fractions as these account for the majority of the Trust activity underperformance in September and the year to date.
Issue Activity increased during August however this fell in September and there is still an overall underperformance year to date. The performance team have been asked to reset the planned activity across the three sites. Historically, radiotherapy activity has always fluctuated as consequence of not having a waiting list. Managing capacity and demand has always been a challenge with approximately 8,500 fractions/month being the maximum to match capacity. The activity at the start of the financial year was similar to the previous year but then reduced slightly for the next two months before increasing in July
Proposed Action Activity is being closely monitored but follows the trend of previous years. Work is still on-going to identify any changes in treatment pathways looking at specific disease groups that may account for some of the reduction.
Assessing Improvement
Activity is being closely monitored. There was an improvement in August with activity increasing but this reduced again in September.
Impact
Financial impact on income.
Expected Date of Performance Delivery 31/10/2015
Executive Lead COO
35
Performance Exception Report
Indicator
Inpatient Falls Resulting in Harm (Grade 2+)
Month 6 Cumulative Target
Month 6 Performance
25 17
Issue
The Trust reports all falls and whilst a Quality Improvement workstream is in place the number of patients falling is off trajectory. A number of falls are happening to independent patients who are not triggering as being at risk of falling on the risk assessment.
Proposed Action
The Quality Improvement collaborative has seen good progress on :
• The positive uptake on a focussed staff education programme on falls;
• Introduced “Call don’t Fall” as part of patient education with a focus on independent patients;
• Purchasing of non-slip socks and piloting of TAB system;
• Patient at a glance boards identifying patients at risk of falling;
• Falls risk discussed at safety huddles.
Assessing Improvement
The falls collaborative work was presented to the Quality Assurance Committee and they were assured of the work of the collaborative and the reduction in the number of inpatient falls.
Impact
The quality improvement programme is seeing a reduction in falls
Expected Date of Performance Delivery 31/10/2015
Executive Lead Executive Director of Nursing & Quality
36
Performance Exception Report
Indicator
Number of Pressure Ulcers (Post admission - Grade 2 or above)
Month 6 Cumulative Target
Month 6 Performance
19 16
Issue
The number of patients with hospital acquired grade 2 pressure ulcers is above trajectory.
Proposed Action
The Quality Improvement programme is focussing on the following areas:
• To maintain the position of zero Grade 3 or 4 pressure ulcers;
• Business case is being presented to the Capital & Workforce Planning Group for hybrid mattresses;
• Tissue viability link Nurse scheme has commenced and there has been a significant increase in training;
• Successful change of supplier for TED stockings, NIV masks and NGT tube dressings;
• Safety huddles and intentional rounding taking place on wards
Assessing Improvement
The pressure ulcer collaborative work was presented to the Quality Assurance Committee and they were assured of the work of the collaborative and the reduction in Grade 2 pressure ulcers of which only one was attributed to a lapse in care.
Impact
The quality improvement programme is seeing a reduction in pressure ulcers
Expected Date of Performance Delivery 31/10/2015
Executive Lead Executive Director of Nursing & Quality
37
Performance Exception Report
Indicator
C-Difficile - All Attributable Cases (National Yearly Target 14)
Issue
The Trust has been set by the Department of Health a national trajectory of no more than 14 cases of Clostridium Difficile infections for 2015/16. The Trust has a locally agreed target with NHS England Specialist Commissioners of 19 cases. At month 6 the Trust has had 11 cases, none of which have been attributable to the Trust.
Prior to this financial year the Trust as part of its national contract with commissioners had a locally agreed target and attribution process which is now the national standard for attribution.
Through the attribution process in 2014/15 the Trust accepted cases to the Trust of C.diff infections where it could not be demonstrated that the agreed systems and process had been followed. The process last year led to us declaring 19 cases of C.diff infections on the national data capture system, of which 4 were attributable to the Trust. As the Trust was out with the national system last financial year the maximum number of C.diff infections assigned to the Trust is lower than expected and it was acknowledged that in the 2016/17 financial year this would be resolved.
NHS England Specialist Commissioners have confirmed that they will support the Trust if the nationally trajectory is breached and Monitor have been sighted on this matter over the past years.
Proposed Action
The Trust will maintain the current approach to the management of infection prevention and control and with the aim of continuing to see none of the cases being attributable to the Trust.
Assessing Improvement
The cases will be managed through the monthly infection control meeting dedicated to C.diff and attended by the Director of Nursing for NHSE specialist commissioners where attribution is decided.
Impact
None of the 11 cases of C.diff have been found to be attributable to the Trust and the important message is that the Trust has high standards of infection prevention and control and cleanliness and that unfortunately with the treatment our patients undergo C.diff is sometimes a consequence of their treatment (e.g. chemotherapy, opiates, gut motility drugs, total parental nutrition).
Expected Date of Performance Delivery
31/03/2016
38
1. Patient experience
1.1 Patient Satisfaction Surveys
In April 2015 the 200 inpatient survey scoring methodology was brought in line with the national percentage recommended scoring methodology used in the national friends and family test. The new scoring methodology now focuses on one positive percentage based on responses for strongly agree and agree combined, and one negative percentage based on disagree combined.
Baseline questions are measured regarding a range of issues that may be encountered by patients, carers and relatives. The issues covered are:
Dignity and respect Privacy Pain relief Waiting times
Availability of information Cleanliness Attitude of staff
The table below shows the patient survey performance by month for 2015/16.
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16Recommended % 99.3% 99.2% 98.6% 98.7% 99.7% 99.1%Not Recommended % 0.7% 0.8% 1.4% 1.3% 0.3% 0.9%
Patient Survey % Recommended Scores
The overall performance for patient satisfaction in September is 99.1%.
The table below shows 21 of 2293 responses where patients have given a negative response to one of the 17 questions asked.
39
Questions Strongly Agree Agree Disagree % Rec % Not Rec
Acceptable IP admission waiting time 47 18 3 95.6% 4.4%Acceptable OP treatment waiting time 43 44 6 93.5% 6.5%Acceptable OP test waiting time 5 2 0 100.0% 0.0%Informed of pharmacy waiting time 16 5 0 100.0% 0.0%Informed of medical physics scan waiting time 10 1 0 100.0% 0.0%Acceptable waiting time to be seen by doctor 4 10 4 77.8% 22.2%Treated with respect by staff 177 41 0 100.0% 0.0%Involved in decisions 136 44 2 98.9% 1.1%Given enough privacy 136 44 0 100.0% 0.0%Access to call bell 56 13 0 100.0% 0.0%Member of staff to talk to 137 61 0 100.0% 0.0%Treated with compassion 143 48 0 100.0% 0.0%Received required care 143 50 1 99.5% 0.5%Received necessary information 159 58 2 99.1% 0.9%Received sufficient pain control 124 56 3 98.4% 1.6%High standard of cleanliness 162 57 0 100.0% 0.0%Recommend Christie services 178 44 0 100.0% 0.0%TRUST Score 1676 596 21 99.1% 0.9% Actions are being undertaken to ensure improvements in the areas that have had negative responses.
National Changes to Family and Friends Following a national review, the Net Promoter scoring methodology has been discontinued from 1st April 2015, and has been replaced with an alternative scoring system. The new scoring methodology now focuses on one positive percentage based on responses for extremely likely and likely combined, and one negative percentage based on unlikely and extremely unlikely combined. From April 2015 the day case activity has been included in the inpatients scoring methodology. In addition outpatient data is now reported for new patients referred in for the family and friends test. Inpatient National Family and Friends The family and friends test carried out in September for inpatients and day cases show an excellent response of patients recommending The Christie at 94.9%. For the outpatient areas there has also been an excellent response at 93.8%.
Outlined in the table below are the survey results for each inpatient, day case and outpatient areas.
Inpatients and Day cases
40
1 - Extrem
ely Likely
2 - Likely
3 - Neither likely
nor unlikely
4 - Unlikely
5 - Extrem
ely unlikely
6 - Don't K
now
03 Ward (Dept 48) 45 6 0 0 0 2 61 53 8688.5%
04 Ward (Dept 52) 19 3 0 1 0 0 57 23 4035.1%
10 Ward-Surg Onc Unit (Dept 4) 48 2 1 0 0 1 103 52 5048.5%
11 Ward (Dept 4) 14 2 1 1 0 0 71 18 2535.2%
12 Ward (Dept 4) 20 1 0 0 1 1 73 23 3150.7%
CTU Inpatient Ward (Dept 1) 4 0 0 0 0 0 16 4 2500.0%
Endocrine Ward (Dept 63) 3 0 0 0 0 0 7 3 4285.7%
Haematology Day Unit (Dept 26) 23 3 0 0 0 1 76 27 3552.6%
Medical Assessment Unit (Dept 14) 44 10 1 0 0 0 93 55 5914.0%
Palatine Ward (Dept 27) 19 1 0 0 0 0 64 20 3125.0%
Planned Admission & Transfer Suite (Dept 35) 10 1 3 0 0 2 44 16 3636.4%
Surgical Day Case Unit(Dept 4) 28 1 1 1 0 0 67 31 4626.9%
The BMR Unit (Dept 16) 28 1 0 0 0 0 77 29 3766.2%
Total 305 31 7 3 1 7 809 354 43.8%
Total responses
for each ward
Response rate for each
wardWard name
Total responses in each category for each ward
Total Number of
people eligible to respond
Outpatients
1 - Extrem
ely Likely
2 - Likely
3 - Neither likely
nor unlikely
4 - Unlikely
5 - Extrem
ely unlikely
6 - Don't K
now
Outpatient Locations 515 36 2 2 4 28 587
Total 515 36 2 2 4 28 587
Location
Total responses in each category for each location
Total responses
1.2 Complaints
Three complaints were received in September. High level complaints information is provided contemporaneously to the Board of Directors setting out the main reason for the complaint as described by the complainant. The Trust has set an internal 25 day standard to respond to complaints which it is meeting in more than 95% of responses. A full report and themes of complaints are presented quarterly to the Quality Assurance Committee.
1.3 Number of complaints by primary concern raised by complainant
Complaint Grade Primary Concern
1 3 Disappointed with inability to provide cosmetic surgery to remedy a defect caused at another Trust
2 3 Patient developed drop foot following surgery
3 3 Unhappy with management of treatment
Complaints are graded on receipt and the grading is reviewed on closure of the complaint. The grading matrix used is show below:
41
► Query/suggestion ► Allegation that service received substandard
► Single issue complaints with allegation of lack of appropriate care
► Multiple issue complaints with allegations of lack of care
► Multiple issue, complex complaints
► Verbal concerns resolved by the end of the next working day
► Simple complaints which can be resolved quickly
► Serious complaints containing one issue
► Serious complaints containing more than one issue
► Serious complaint where more than one complaint has been received regarding the same subject from different complainants
► Anonymous comment forms raising concerns
► Simple complaint where more than one complaint has been received regarding the same subject from different
► Risk to organisational reputation
1 2 3 4 5
There were 2 complaints due to be responded to in writing in the month of September
0
2
4
6
8
10
12
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15Total 8 6 1 7 9 4 11 3 2 3 6 3
Total Complaints
Complaints by type
0
2
4
6
8
10
12
14
16
18
20
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15
Chemotherapy
Clinic delays
Communication
Delay in receiving appointment
Delay in referral
Parking
Pharmacy
Operational issues
Radiotherapy
Staff attitude
Transport
Treatment & Care
Total complaints 2014/15 - /16 Oct Nov Dec Jan Feb Mar Apr May June July Aug Sep
Number 8 6 1 7 9 4 11 3 2 3 6 3
Activity (total)* 31900 28048 29189 29585 28515 31758 29362 28081 30788 31826 28515 31154
Complaints as % of total activity 0.03% 0.02% 0.00% 0.02% 0.03% 0.01% 0.04% 0.01% 0.01% 0.01% 0.02% 0.01%
Complaints monthly comparison
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Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar2013/14 3 6 2 8 3 6 4 4 6 9 6 92014/15 6 3 5 4 5 7 8 6 1 7 9 42015/16 11 3 2 3 6 3Baseline 6 6 6 6 6 6 6 6 6 6 6 6
0
2
4
6
8
10
12
12/13, 13/14, 14/15 Monthly Complaints Comparison
1.4 PALS Contacts Patient Advice and Liaison Service (PALS) Contacts by month for the Calendar years 2013, 2014 and 2015. PALS contacts relate to areas such as queries, concerns and compliments.
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec2013 45 70 64 66 76 43 59 63 69 68 52 352014 51 64 46 56 55 68 78 77 84 98 74 582015 78 77 76 77 84 99 84 75 104
0
20
40
60
80
100
120Number of PALS Contacts
1.5 Executive quality walk rounds
The following Executive Walk Rounds have taken place in September 2015.
Date Executive Director Location Outcome
4/09/15 Director of Nursing and
Quality
Pat Seed Department Challenges
• The department is very busy, scanning an average of 75 patients a day and the staff work hard to avoid a ‘conveyor belt’ service.
• The department opens during weekends to try to reduce the waiting list, which is currently 20 days, and this in itself presents a number of challenges due to other services being unavailable and difficulty getting a medical review of patients with incidental PE.
• Another challenge is the availability of porters. The department has its own porters but also relies on the general portering service. Teletracking presents problems for the department as direct communication with the porters is not possible. The system is inflexible; potential safety issues and other important information cannot be entered into the system to help prioritise care.
• Portering issues are exacerbated by time wasted trying to locate chairs and stretchers
• Communication with in-patient areas can present difficulties, however the department will explore the option of utilising the
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Date Executive Director Location Outcome
new boards above patient beds with their own symbol(s) for ward staff to use.
Things to be proud of
• The staff are proud that increasing patient numbers are being managed by dedication and good teamwork.
• Staff have delegated additional roles e.g. co-ordinating CPD sessions for staff
• PE detection training has not only been a CPD opportunity for staff but also enables all scanned patients to be screened. Staff have also undertaken anaphylaxis and extravasation training; and 2 radiography aides are currently undertaking the Christie Care Certificate with more to follow.
• Radiographers are proud of the radiography aides who remain consistently cheerful and enthusiastic with the first patient of the day right through to the last. Each Aide works within 2 diagnostic modalities
• The department has received only 2 complaints in the last year from 17,000 patient episodes
Things to take forward/consider
• The waiting area challenges patient privacy and dignity and consideration of short term solutions is to be discussed with Gill Goodwin.
• The department is showing signs of wear and tear
• A review of teletracking to explore ways of addressing portering issues
• Consider applying for an award for the PE screening work
1.6 Eliminating mix sex accommodation
There were no incidents of mixed sex accommodation in September. There were 33 episodes of mixing for clinical need located in the Critical Care Unit.
2. Patient safety
2.1 Open and Honest Care As a member of the 'Open and Honest care: driving improvement' programme, we continue to work with patients and staff to provide open and honest care, and through implementing quality improvements, further reduce the harm that in-patients sometimes experience when they are in our care.
We have made a commitment to publish a set of patient outcomes; patient experience and staff experience measures so that patients and the public can see how we are performing in these areas.
Detailed below is a summary for our September submission for the Open and Honest Care return.
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Section Measure
Safety Thermometer
Infection Rates - C-Diff (Avoidable + Unavoidable)
Infection Rates - MRSA Bacteraemia
Pressure Ulcers (Grade 2 or above developed post admission)
Pressure Ulcers (Grade 2 or above developed post admission) per 1000 bed days
Inpatient Falls (Grade 3 or above)
Inpatient Falls (Grade 3 or above) per 1000 bed days
% Recommended % Not Recommended
94.90% 1.13%
Patient Experience - Internal survey results % Recommended % Not Recommended
Were you involved as much as you w anted to be in the decisions about your care and treatment? 98.9% 1.1%
If you w ere concerned or anxious about anything w hile you w ere in hospital, did you f ind a member of staff to talk to? 100.0% 0.0%
Were you given enough privacy w hen discussing your condition or treatment? 100.0% 0.0%
During your stay w ere you treated w ith compassion by hospital staff? 100.0% 0.0%
Did you alw ays have access to the call bell w hen you needed it? 100.0% 0.0%
Did you get the care you felt you required w hen you needed it most? 99.5% 0.5%
How likely are you to recommend our w ard/unit to friends and family if they needed similar care or treatment? 100.0% 0.0%
Staff Experience - Internal survey results based on responses from 10 staff on locations w here a harm has occurred % Recommended % Not Recommended
I w ould recommend this w ard/unit as a place to w ork 100.0% 0.0%
I w ould recommend the standard of care on this w ard/unit to a friend or relative if they needed treatment 100.0% 0.0%
I am satisf ied w ith the quality of care I give to the patients, carers and their families 100.0% 0.0%
2. Experience
Patient Experience - Friends & Family Test
Performance / Total
1. Safety
96.48%
1
0
2
0.44
0
0
The Trust Friends and Family test scores are now published on the ward information screens, together with patient comments and improvement stories. Full details of the submission can be found at: http://www.christie.nhs.uk/openandhonest
2.2 Safe Staffing – September 2015
The Christie specialises in cancer treatment, research and education and is the largest cancer centre in Europe. Treating 44,000 patients a year from across the UK, it became the first UK centre to be officially accredited as a comprehensive cancer centre and has its own dedicated hospital charity. The Christie employs 2,750 staff, all of whom are determined to provide the best possible cancer care and patient experience Our organisation is committed to improving quality and delivering safe, effective and personal care, within a culture of learning and continuous service improvement.
Getting the right staff with the right skills to care for our patients all the time is our priority
This report is based on information from September 2015. The information is presented in three key categories: planned vs actual staffing, hospital overview, breakdown by ward and any actions taken. This information is complimented by the bed occupancy of the Trust which enables the senior nurse to make informed decisions on where to place a patient based on patient acuity, clinical speciality and ward staffing levels.
NB: This report should be read in conjunction with the Open and Honest Care - Patient Harms Report for the corresponding month.
Staffing levels Planned vs Actual Hospital Overview Planned staff means the number of staff, both registered nurses and care staff, required for each shift identified within the current funded establishment.
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Actual staff means the number of staff, both registered nurses and care staff, in attendance for each shift.
2675.75Average Fill Rate % 94.1% 95.9%
ALL StaffTotal monthly PLANNED 23080.5 12663
Total monthly ACTUAL
Care StaffTotal monthly PLANNED 6704 2789
Total monthly ACTUAL 6310
22274 11989.25Average Fill Rate % 96.5% 94.7%
DAY NIGHTHours Hours
Registered NursesTotal monthly PLANNED 16376.5 9874
Total monthly ACTUAL 15964 9313.5Average Fill Rate % 97.5% 94.3%
Breakdown By Ward
Critical Care Unit
Admissions Unit
Palatine Trt Centre
10 Ward-Surg Onc Unit
11 Ward
12 Ward
03 Ward
04 Ward
TOTAL
Critical Care Unit
Admissions Unit
Palatine Trt Centre
10 Ward-Surg Onc Unit
11 Ward
12 Ward
03 Ward
04 Ward
TOTAL 6704 6310 94.1% 2789 2675.75 95.9%
1027 1013.5 98.7% 387.75 376 97.0%
442 442 100.0% 293.75 293.75 100.0%
1208 1168 96.7% 376 364.25 96.9%
1061.5 1061.5 100.0% 317.25 352.5 111.1%
1147.5 1091 95.1% 364.25 364.25 100.0%
981.5 767 78.1% 587.5 462.5 78.7%
824 754.5 91.6% 462.5 462.5 100.0%
12.5 12.5 100.0% 0 0 0.0%
Care Staff
DAY NIGHT
Hours Planned Hours Actual % Fill Rate Hours Planned Hours Actual % Fill Rate
16376.5 15964 97.5% 9874 9313.5 94.3%
2376.5 2302.5 96.9% 1257.25 1069.25 85.0%
928 928 100.0% 669.75 669.75 100.0%
2154.5 2106.5 97.8% 1151.5 1116.25 96.9%
1999.5 1884 94.2% 1139.75 1010.5 88.7%
1587 1600.5 100.9% 1045.75 987 94.4%
3308.5 3185 96.3% 2075 1950 94.0%
2346.5 2314.5 98.6% 1125 1112.5 98.9%
1676 1643 98.0% 1410 1398.25 99.2%
DAY NIGHT
Hours Planned Hours Actual % Fill Rate Hours Planned Hours Actual % Fill Rate
Registered Nurses
Action Taken Where actual staff numbers were less than the planned staff numbers the ward team followed an agreed escalation process based on the acuity and dependency of care required and a review of the bed occupancy.
This escalation has included using the hospital bank to support the patient acuity levels. There are twice daily planned staffing reviews as well as a review of the hospitals activity. During this month the ward leaders and Matrons did not escalate any staffing issues to the Director of Nursing & Quality. There has over the month been a fall in staffing numbers in the night time hours. These staffing issues were all escalated in line with the policy to the Matrons and the Matrons have worked across the organisation to look at skill mix, patient acuity to maintain safe staffing
46
levels and this has included warding out of ward nursing staff and using the healthcare assistant bank to provide extra support. The Director of Nursing and Quality has been advised by the Matrons that the staffing levels have been managed appropriately and patient care has not been compromised. The recruitment open day on the 3rd October was well attended and all registered and unregistered vacancies were filled. Bed Occupancy
Ward
BM
RU
04 W
AR
D
11 W
ard
12 W
ard
Pal
atin
e W
ard
MA
U
03 W
ard
10 W
ard
Crit
ical
Car
e
Oct-14 30% 92% 92% 89% 94% 73% 42% 86% 83%Nov-14 30% 90% 91% 93% 92% 81% 54% 79% 60%Dec-14 23% 88% 86% 83% 87% 75% 40% 78% 78%Jan-15 30% 95% 94% 94% 91% 79% 82% 84% 90%Feb-15 29% 92% 91% 93% 94% 78% 82% 91% 93%Mar-15 28% 94% 96% 94% 83% 76% 88% 81% 83%Apr-15 34% 93% 95% 93% 90% 79% 89% 78% 82%May-15 26% 92% 94% 93% 85% 82% 68% 76% 66%Jun-15 37% 91% 93% 92% 83% 79% 83% 74% 80%Jul-15 28% 91% 94% 90% 87% 74% 76% 76% 82%Aug-15 28% 91% 96% 95% 92% 82% 72% 83% 82%Sep-15 39% 94% 93% 93% 92% 84% 40% 69% 60%
*Ward 3 increase in January is due to a transfer of patients from Ward 10 patients whilst refurbishments are taking place.
Efficiency Benchmark = 82%
2.3 MRSA bacteraemia There were no cases of MRSA bacteraemia reported in September
0
1
2
3
No. o
f pati
ents
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
bacteraemia 0 0 0 0 0 0 0 0 0 0 0 0Monitor target 0 0 0 0 0 0 0 0 0 0 0 0
MRSA bacteraemia
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Clostridium Difficile There was 1 case of unavoidable c-diff reported in September
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarAvoidable + Unavoidable 3 6 6 8 10 11Avoidable 0 0 0 0 0 0Avoidable Target (Moni tor) 1 2 3 4 5 6 7 8 9 10 11 12Avoidable + Unavoidable Target (Contract) 2 3 5 6 8 10 11 13 14 16 17 19Avoidable + Unavoidable Target (National) 1 2 4 5 6 7 8 9 11 12 13 14
0
5
10
15
20
Num
ber
of p
atie
nts
Clostridium Difficile (cumulative) against annual target
MSSA There was 1 case of MSSA bacteraemia September
0
1
2
3
4
Numb
er o
f pati
ents
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15MSSA 1 3 1 0 0 1 2 3 2 1 0 1
MSSA bacteraemia
Glycopeptide Resistant Enterococcus (GRE) There was 1 case of GRE bacteraemia in September. Patients who attend Palatine Ward and Ward 12 are routinely screened for GRE as this group of patients are more at risk of infection due to the specific antibiotics received as part of their treatment.
0
2
4
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15Total GRE 1 1 1 1 0 0 0 0 3 0 1 1
Total GRE (bacteraemia)
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Escherichia Coli (E-Coli) There were 6 cases of E-Coli in September. These were found on blood cultures taken from unwell patients. These patients have been found to have the organism occurring naturally on admission. The infections have not been acquired in the hospital.
0
2
4
6
8
10
12
14
Numb
er o
f pati
ents
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15E.Coli 3 5 5 2 4 3 6 3 7 3 8 6
E-Coli
2.4 Clinical incidents
Patient harm There were 17 incidents occurring in September that all resulted in minor patient harm. Clinical incidents are graded using the following matrix; Grade 2 incidents cause the type of harm that can be remedied using first aid measures, whereas grade 3 incidents need professional intervention for example surgery. It is a national requirement that all RIDORR reportable incidents are graded as a 3 (or more if appropriate).
►Minor injury or illness which was remedied with first aid treatment
►Moderate injury or illness requiring professional intervention
►Major injury / long term incapacity / Disability (e.g. loss of limb)
► Fatalities
►Health associated infection which did not result in permanent harm
►No staff attending essential / key training
► >14 days off work ►Multiple permanent injuries or Irreversible health effects
► Affects 1-2 people ►RIDDOR / Agency reportable incident
► Affects 16 – 50 people ►An event affecting >50 people
► 1-3 days off work ► Affects 3-15 people
►
4 / major 5 / catastrophic
Adverse event requiring no/minimal intervention or treatment.
1 / no harm 2 / minor 3 / moderate
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Grade Incident Type Additional Details Location
Pressure ulcer Grade 2 pressure ulcer to sacrum. CCU
Extravasation Extravasation during administration of chemotherapy. Ward 11
Extravasation Extravasation during administration of contrast Radiology
Fall Patient found on f loor by bed, graze to elbow Ward 3
Fall Patient fell, having lost balance Palatine Ward
Extravasation Extravasation during administration of contrast Radiology
Fall Patient fell w hen mobilising to the bathroom Palatine Ward
Medical equipment Oesophageal stent not deployed adequately because of equipment failure during the procedure
Radiology
Extravasation Extravasation during administration of contrast Radiology
Medical equipment Drain tube w as accidentally cut, resulting in patient having to undergo repeat procedure Ward 11
Pressure ulcer Grade 2 pressure ulcer to buttocks Ward 4
Moving and handling Patient’s toe nail came aw ay w hen being assisted to move from kneeling to standing position
Ward 4
Care / monitoring Incorrect management of jejunostomy tube, resulting in need to replace the sutures. OPD
Prescribing Incorrect drug w ith similar sounding name prescribed for patient, resulting in diarrhoea MAU
Extravasation Extravasation during administration of contrast Radiology
Drug administration Patient given Picolax w ithout clear instructions or documentation Ward 3
Extravasation Extravasation during administration of contrast Radiology
2 (Minor)
** extravasation - Accidental leakage into surrounding tissue from the vein
Pressure Ulcers Aim: 10 % reduction in Grade 2 pressure ulcers from the 2014/15 rate of hospital acquired pressure ulcers and no Grade 3 & 4 hospital acquired pressure ulcers. The chart below demonstrates the required reduction of 10% of the previous year’s grade 2 pressure ulcer rate, as set out in the 2013/14 quality accounts. There have been no hospital acquired pressure ulcers of grades 3 and 4 September 2015 shows 2 pressure ulcers which occurred on CCU (1) and Ward 4 (1). The Ward sisters have been given key performance indicators from the Executive Director of Nursing & Quality, one of which is pressure ulcer reduction.
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2014/15 Total 0 4 5 7 8 9 13 13 18 23 24 312015/16 Total 3 9 11 15 17 1915/16 Reduction Tra jectory 5 8 10 12 14 16 18 20 22 24 26 28Incidents as % of IP Spells 0.42% 0.78% 0.24% 0.46% 0.25% 0.26%
0
5
10
15
20
25
30
35
Grade 2+ Pressure ulcers developing after admission (cumulative)
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Patient Falls Aim: To maintain the 25% reduction in falls with harm from the 2013/14 outturn. The number of In-patient falls where harm has been sustained has not continued to maintain at the level achieved during 2013-14. Therefore the target for 2015/16 has been set for a 25% reduction from the 2013/14 outturn. The Ward sisters have been given key performance indicators from the Executive Director of Nursing & Quality one of which is falls reductions.
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2014/15 Total 3 5 9 12 17 22 27 32 34 42 46 482015/16 Total 2 10 16 21 22 2515/16 Reduction Tra jectory 3 6 8 11 14 17 19 22 25 28 30 33Incidents as % of IP Spells 0.28% 1.04% 0.72% 0.57% 0.13% 0.38%
0
10
20
30
40
50
60
Inpatient Falls Resulting in Harm (cumulative)
** This is subject to cases being reviewed at Executive review group, and therefore subject to validation**
Never Events There were no never events in September
2.5 Litigation, claims and inquests
Claims Clinical negligence, employer liability and public liability There were no claims opened, 3 were closed and 1 was repudiated in September.
Payments There were 3 payments made on claims in September Inquests Eight inquests were held in September relating to patients of The Christie.
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Coroner Staff called Verdict
Stockport Yes Natural Causes
Manchester Yes
Named patient, w ho had a past medical history of chronic obstructive pulmonary disease, peripheral vascular disease, and hypertension, w as diagnosed w ith a squamous cell carcinoma of the lung in April 2014 for w hich he w as appropriately treated w ith 5 cycles of radiotherapy 2-12 May 2014 at The Christie. Admitted to North Manchester General Hospital w ith increased breathlessness. Follow ing investigations, he w as treated w ith intravenous steroids and antibiotics but continued to deteriorate and died 12 July 2014 at 5.20 am
Bolton Yes Patient died as a consequence of a rare, but recognised complication of gemcitabine chemotherapy on a background of infection, the cause of w hich cannot be ascertained even on the balance of probability.
Stockport No Aw aiting coroner report
Stockport Yes Patient deliberately took their ow n life
Stockport No Aw aiting coroner report
Bolton Yes Patient developed bladder cancer. The cause of the developing bladder cancer is unclear. The bladder cancer led to the patients death
Warrington Yes Aw aiting coroner report
Police involvement There were 2 episodes of police involvement in September • The police attended following an incident on the Proton building site. This did not involve
Christie staff and was not a health and safety issue. • The police attended a security event to security mark cycles
2.6 Executive reviews
Four executive reviews were held in August, the full detail of which was discussed at the Risk and Quality Governance Committee.
Date of executive
review
Incident Report
Number
Incident Date
Description Root Cause
17/09/15 W23957 27/07/15Chemotherapy prescribed using incorrect weight; no adverse impact for patient.
• Reminder to staff to be vigilant when entering detail into clinical record
Human error; incorrect information entered on prescription chart.
24/09/15 W24318 28/08/15
A patient attended the Trust without an appointment was unwell and this was not recognised by staff
•Flow chart to be developed for the management of walk-in patients, including an escalation process.
No process for managing ‘walk-in’ patients.
Outcome
2.7 SUI panels There were no SUI panels held in September 2.8 IMR - Intelligent Monitoring Report
The latest Intelligent Monitoring Assessment published in May by the Care Quality Commission shows The Christie as rated in the lowest risk band 6, with no elevated risks as outlined below.
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3. Clinical Effectiveness 3.1 Survival Rates
The national cancer outcomes framework produced a number of outcome measures relevant to cancer care. These have not yet been mandated nationally but we have analysed those aspects which are relevant to treatment at The Christie and present the figures in the following tables.
75%
80%
85%
90%
95%
100%
Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15Radical XRT 90 day survival rate 97% 96% 96% 96% 98% 97% 97% 97% 97% 96%Palliative XRT 30 day survival rate 80% 82% 88% 83% 80% 85% 81% 89% 91% 87% 88% 91%Final chemotherapy 30 day survival
rate 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99%
Major surgery 30 day survival rate 100% 100% 98% 100% 100% 100% 100% 100% 100% 100% 100% 99.7%
Treatment survival rates
Data subject to validation
0
20
40
60
80
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15Intrathecal administrat ions 62 49 37 69 59 64 39 24 39 28 15 45Wrong route chemotherapy 0 0 0 0 0 0 0 0 0 0 0 0
Wrong Route Chemotherapy
Data subject to validation.
3.2 Critical Care Outcomes The Trust provides critical care level 2 and also level 3 for selected patients. The data in the tables below shows that our patients have much better survival rates both on leaving critical care and overall than is expected given their condition as measured by the Apache II severity scale. This demonstrates the safety of this service.
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0%
5%
10%
15%
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15Unit mortality 8.0% 8.3% 8.2% 5.2% 5.6% 8.5% 6.4% 4.3% 7.3% 2.1% 8.7% 7.3%Total mortality 10.0% 10.4% 10.2% 12.1% 5.6% 10.2% 6.4% 6.5% 9.1% 2.1% 8.7% 7.3%
CCU Mortality Rates
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15Level 2 - Episodes 44 48 49 57 53 54 47 45 55 46 44 36Level 3 - Episodes 7 2 6 6 3 11 2 5 7 9 5 6Level 2 - Bed days 170 139 148 203 173 171 172 131 162 149 168 102Level 3 - Bed days 31 15 16 18 9 42 15 33 41 37 16 27
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-151 1 0 1 1 2 2 0 1 0 0 10 0 0 0 0 1 1 1 1 1 1 20 0 0 0 0 1 0 0 0 0 0 14 4 4 3 3 5 3 2 3 1 3 31 1 1 4 0 1 0 1 1 0 0 00 0 0 0 0 0 0 0 0 0 0 0
8.0% 8.3% 8.2% 5.2% 5.6% 8.5% 6.4% 4.3% 7.3% 2.1% 8.7% 7.3%10.0% 10.4% 10.2% 12.1% 5.6% 10.2% 6.4% 6.5% 9.1% 2.1% 8.7% 7.3%
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-1520 20 21 19 24 24 20 21 20 23 21 240 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0
Average Apache II Score
Admissions for central line infections
Levels of Care
Unit mortality Total mortality
Readmissions (within same month)Patients transferred out Patients repatriated to CCUPatients died in CCUPatients died in hospital after CCUPatients died in other ICU
Central Line Infections Aquired on Unit
3.3 Christie Inpatient Deaths
All deaths that occur within The Christie are screened against clinical criteria. One or more of these triggers a detailed case note review. A three-monthly meeting is held with the medical and deputy medical directors, clinical directors, a senior nurse and clinical audit to discuss the findings. Following this a report is sent each quarter to the Patient Safety Committee.
Elective/planned admission 5
Non Elective/emergency admission 18
TOTAL 23
Deaths on CCU 3
deaths within 30 days of surgery undertaken at The Christie* 1
Deaths within 30 days SACT* 3
Deaths reported to coroner (*includes the above): 4
Deaths associated with a serious untoward incident: 0Deaths associated with triggers other than the above:Clinical or radiological documentation of pulmonary embolus (1)Sepsis (1)
2
TOTAL 9
Sep-15
Number of NHS Christie Inpatient deaths
Number of deaths that have triggered case note review (Each death can have more
than one trigger)
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3.4 Clinical Outcomes Unit
Bladder Cancer The following report includes clinical outcomes data on bladder cancer based on analyses of new cases January 2014 to October 2015 who are referred to Clinical Oncology for primary treatment. Survival estimates include patients diagnosed from 2013. onwards. As with all outcomes data, care should be taken when comparing The Christie outcomes data with published regional and national survival figures as The Christie endometrial cancer patient population is not entirely representative of the UK or England cancer population as a whole. As our dataset grows, and as national data improves, particularly with regard to stage and grade data, we will be able to undertake much more fine-tuned analysis that will take into account age at diagnosis, performance status, comorbidities and disease sub-type as well as stage and treatment, to provide more informative comparative data. This report and other cancer specific reports produced by the Christie’s Clinical Outcomes Unit can be downloaded from: http://www.christie.nhs.uk/our-standards/clinical-outcomes/the-christie-outcomes/cancer-specific-reports.aspx
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56
57
Estimating Patient Prognosis
High quality structured patient data such as that collected at the Christie enables us to build algorithms (often called nomograms) to estimate the prognosis of an individual patient. This report demonstrates how a prognostic nomogram is built using a sample of 344 non-small cell lung cancer patients given radiotherapy with curative intent, having had no previous treatment.
This report and other cancer specific reports produced by the Christie’s Clinical Outcomes Unit can be downloaded from:
http://www.christie.nhs.uk/our-standards/clinical-outcomes/the-christie-outcomes/cancer-specific-reports.aspx
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4. Top Risks 4.1 Top corporate and financial risks
Ris
k N
umbe
r
Risk
Cur
rent
risk
sc
ore
Targ
et d
ate
for
redu
ctio
n of
ris
k sc
ore
Control measures
1
Changes to national tariff and commissioning intentions may adversely impact on Trust income in 2016-17.
16 31st Mar 2016
The Deputy Director of Finance is a member of Monitor's Specialised Complex Tariff group.
Trust is identified as NHSE test site for chemo tariff development.
Director of Pharmacy is a member of the Medicine Optimisation CRG.
Draft tariff implication has been modelled and consultation feedback submitted to Monitor.
2
Park and ride schemes do not currently meet the Trust requirements to meet sustainable travel requirements.
15 31st March 2016
S106 residential parking restrictions in operation and monitored via MCC
The park and ride pilot scheme commenced in June 2015. Usage is currently low, however continual promotion and permit reviews via eligibility group
Park & Ride pilot will be extended whilst pilot evaluated. A business case to be developed for further off site Park & Ride services currently under review
3
Potential adverse impact on service delivery should aging plant and equipment need repair or replacement, complicated by the presence of loose asbestos and excessive heat in Plant room 26
15 31st July 2016
Funding approved to relocate and replace the plant and equipment located in plant room 26, however re-engineering is being applied due to excessive cost returns
Safe working practices are in place should emergency repair be necessary and confined space controls apply to cover the current risk situation.
Asbestos management protocols restrict access to the plant-room and mitigate the risk of exposure to any asbestos containing materials.
A project will be developed to remove and encapsulate asbestos in plant room 26 following removal of the heating, chlorinators & DHW.
4
2015/16 Recurrent Trust Wide Cost Improvement Programme not achieved.
15 31st Mar 2016
Seven workstreams have been agreed for 2015/16.
Targets for delivery and identification of savings have been approved. Q2 targets have been met.
Transformation Board monitors progress.
PMO is to formally report through the performance management structure.
61
5. Activity 5.1 Key trends and forecasts
Following transition from local to national tariff the activity against plan is being closely monitored and valued at a component level.
The Trust has consistently delivered the commissioner activity plan within 1% of the contract value. Fluctuations in income associated with under and over performance are contained without the risk share agreement with NHS England. Point of Delivery Plan Actual VarianceDay Cases 846 939 10.97%Elective 459 460 0.15%Non Elective Emergency 311 305 -1.78%Non Elective Non Emergency 14 15 3.99%OP First Attendances 1278 1318 3.16%OP Followup Attendances 8074 7954 -1.48%OP Followup Attendances Chemotherapy Review 3438 4027 17.15%OP Followup Attendances Radiotherapy Review 1535 1341 -12.65%Supportive Care Hormonal Drug Review 292 308 5.63%OP Procedures 485 515 6.23%AHP Attendances 640 501 -21.74%Chemotherapy Delivery 5201 5084 -2.25%Radiotherapy Treatment 9230 8387 -9.13%Month 6 Total Activity 31801 31154 -2.04%Month 6 Cumulative Total Activity 181870 179726 -1.18% A significant proportion of our activity is delivered at outreach centres. This currently results in a short delay in adding this activity. As a consequence a retrospective improvement in activity against plan occurs. This is set out in the table below.
Core/Unbundled Point of Delivery High Level Total Plan Total Activity Variance % Variance Total Plan £ Total Actual £ Variance £Day Cases 4846 5037 191 3.93% £3,195,464 £3,344,899 £149,434Elective 2631 2752 121 4.59% £12,328,131 £11,654,612 -£673,519Non Elective Emergency 1894 1884 -10 -0.54% £4,502,306 £4,580,468 £78,162Non Elective Non Emergency 88 128 40 45.47% £358,676 £495,295 £136,619OP First Attendances 7318 7536 219 2.99% £1,444,151 £1,487,040 £42,890OP Followup Attendances 46241 44647 -1594 -3.45% £4,486,444 £4,319,574 -£166,870OP Followup Attendances Chemotherapy Review 19533 23676 4143 21.21% £1,922,716 £2,326,138 £403,422OP Followup Attendances Radiotherapy Review 8792 7875 -917 -10.44% £862,975 £772,923 -£90,052Supportive Care Hormonal Drug Review 1670 1811 141 8.44% £177,155 £187,328 £10,173OP Procedures 2777 2842 65 2.35% £542,302 £571,215 £28,913AHP Attendances 3667 2718 -949 -25.87% £258,280 £221,706 -£36,573Chemotherapy Delivery 29552 29667 115 0.39% £8,247,778 £8,148,922 -£98,856Radiotherapy Treatment 52862 49153 -3709 -7.02% £7,124,351 £6,838,890 -£285,461
181,870 179,726 -2,144 -1.18% £45,450,728 £44,949,009 -£501,718
Unbundled
Grand Total
Apr - Sep
Core
1st Cut of Data Actual Refreshed Actual 1st Cut of Data VarianceRefreshed Variance
Month 1 total activity 29146 29362 0.77% 1.45%Month 2 total activity 27796 28081 0.37% 1.31%Month 3 total activity 31029 30788 -2.27% -1.98%Month 4 total activity 31782 31826 -3.25% -2.99%Month 5 total activity 28431 28515 -2.46% -2.17%Month 6 total activity 31154 -2.04%
62
6. Finance 6.1 Summary Month 4 Financial Performance: Variance Analysis
Wei
ght
Gre
en =
Ambe
r =
Red
=
Curr
ent M
onth
Dat
a
Mon
itor r
isk
ratin
g
July
201
5
Augu
st 2
015
Sept
embe
r 201
5
Continuity of servcies Balance sheet sustainabiity - Capital service cover (times)
25% 2.5 1.75 1.25 3.0 4 u u p
Continuity of servcies Liequtiity - Liquidity (days) 25% -2 -7 -12 37.2 4 q q qFinancial Efficiency Underlying performance - I&E margin (%) 25% 1% 0% -1% 2.9% 4 qFinancial Efficiency Variance from plan - I&E margin variance (%) 25% 0% -1% -2% -0.6% 3 qOverall Monitor Risk Rating Financial Sustainability Risk Rating 4 3 2 4 u u u
Income & Expenditure: YTD Overall financial position variance (%) - (underspend)/overspend against plan - bottom line
<0% <0 to 3% >3% 18.9% p q q
Income & Expenditure: YTD Overall financial position variance (%) - (underspend)/overspend against plan - trading
<0% <0 to 3% >3% -50.5% q p p
CIP Performance Underperformance against target - In year to current month (%) excluding reserves mitigation
<50% <50 to 70% >70% 25.7% p p p
CIP Performance Underperformance against target - Full year impact - in year (%)
<50% <50 to 70% >70% 26.6% p p p
CIP Performance Underperformance against target - Full year impact - recurrent (%)
<50% <50 to 70% >70% 37.4% p p p
Capital Expenditure Exchequer Capital Spend to date (£'000) £26,842kCash Balance Current balance to date (£'000) £41,153kCash Balance Percentage of planned value >90% 80-90% <80% 94.3% q q q
Principal purpose cap Income derived from principal purpose exceeds income derived from other purposes
<50% <50% to 99% >100% 23.6% q q p
Debtor Days Average length of time debt is outstanding <12 <15 >16 8 p p pPublic Sector Payment Policy Trade creditors paid cumulatively within 30 days (%) >95% 90-94% <90% 96.3% p q qPublic Sector Payment Policy Trade creditors paid cumulatively within 10 days (%) >80% 65-80% <65% 76.9% p p q
M6 Target
Trust Objective Themes & Performance Indicators
Tolerances Indicator
6.2 I&E
The month 6 EBITDA position has a surplus of £9,164k (£538k below plan). The month 6 trading surplus is £752k (£252k above plan). The month 6 I&E surplus is £3,525k (£824k below plan). The financial sustainability risk rating is 4. CIP delivery is better than the planned recurrent trajectory, standing at 62.6% recurrently and 73.4% in year.
6.3 Balance sheet / liquidity
Cash balances stand at £41.2m (94.3% of plan). Debtor days stand at 8 in line with quarterly trend in relation to the NHS Agreement of Balances exercise and the raising of quarterly invoices. Capital expenditure stands at 88.3% of plan
6.4 Other TCC distributable profits of £8,544k for the 2015 year to date, sufficient to generate a share of excess profits to the Trust.
0
3000
6000
9000
£000
's
Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16Actual 767 1539 1982 2808 3053 3525Plan 725 1450 2174 2899 3624 4349 5073 5798 6523 7248 7972 8697
Overall Trust Position
63
£0
£10,000,000
£20,000,000
£30,000,000
£40,000,000
£50,000,000
£60,000,000
Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16
Exchequer Cash Balances 2015/16
0
1000
2000
3000
4000
5000
£000
's
Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16Actual 0 0 369 836 1293 1714Plan 341 681 1022 1362 1703 2043 2384 2724 3065 3406 3746 4087
The Christie Clinic Performance
64
7. Access Standards & Efficiency 7.1 Cancer waiting time standards Performance against each standard to date is outlined below.
Existing Standards Operational Standard September Q2
14 day standard (2WW) 93% n/a n/a
62 day with reallocations 85% 87.3% 88.3%
31 day standard 96% 97.9% 98.3%
62 day screening standard 90% 100% 100%
62 day consultant upgrade standard No National Standard Set 83.1% 85.6%
31 day drug standard 98% 100% 99.6%
31 day surgery standard 94% 98.6% 97.9%
31 day radiotherapy standard 94% 99.3% 99.7%
Breast 14 day symptomatic 93% n/a n/a Subject to validation and breach reallocations. Data Accurate as of 12.10.15
94%
96%
98%
100%
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-1531 day 97.5% 98.5% 98.6% 97.7% 98.6% 98.7% 98.9% 98.7% 97.1% 98.5% 98.9% 97.7%
31 sub (drug) 100.0% 99.3% 100.0% 100.0% 100.0% 100.0% 99.5% 100.0% 100.0% 99.3% 99.5% 100.0%
31 sub (XRT) 100.0% 99.3% 98.3% 99.3% 100.0% 100.0% 100.0% 99.5% 99.6% 99.7% 100.0% 99.3%
31 sub (surgery) 99.4% 100.0% 96.8% 98.5% 98.3% 97.5% 95.1% 97.7% 97.2% 100.0% 95.2% 98.6%
31 day performance
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15 Jul-15 Aug-
15Sep-15
62 day CWT 64.7% 65.5% 70.3% 62.2% 61.3% 70.2% 71.1% 62.6% 59.6% 71.5% 64.7% 68.9%62 day (adjusted) 88.6% 85.4% 85.7% 86.0% 91.3% 92.2% 88.6% 85.2% 85.7% 91.5% 86.3% 87.3%62 day target 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85%
0%
20%
40%
60%
80%
100%62 day performance
Q3 14/15 Q4 14/15 Q1 15/16 Q2 15/16Qtr % CWT 67.0% 64.7% 64.2% 68.4%Qtr % Local Policy 86.7% 89.9% 86.5% 88.3%Standard 85% 85% 85% 85%
0%
20%
40%
60%
80%
100%
62 day performance
65
Improving and sustaining cancer performance As per the letter from Monitor regarding reporting of the 62 day standard performance by tumour groups, the charts below show the month on month position for 62 days, both pre and post reallocation by tumour group.
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15
Brain / Central Nervous SystemCWT position Adjusted position National Standard DH Suggested Standard
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
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
Compliances
Breaches
Christie breaches
Total treats
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15
BreastCWT position Adjusted position National Standard DH Suggested Standard
6 13 6 5 3 7 9 10 10 9 11 11 22
6 12 6 5 3 7 9 10 10 9 11 10 20
0 1 0 0 0 0 0 0 0 0 0 1 2
0 0 0 0 0 0 0 0 0 0 0 1 1
Total treats
Compliances
Breaches
Christie breaches
66
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15
GynaecologicalCWT position Adjusted position National Standard DH Suggested Standard
11 13 20 14 14 14 16 22 18 13 12 15 22
9 12 12 12 11 12 11 14 16 9 11 12 13
2 1 8 2 3 2 5 8 2 4 1 3 9
1 1 0 1 2 1 1 3 1 1 1 0 2
Total treats
Compliances
Breaches
Christie breaches
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15
Haematological (Excluding Acute Leukaemia)CWT position Adjusted position National Standard DH Suggested Standard
5 5 6 2 5 7 2 4 2 4 3 8 5
1 4 4 1 2 4 2 2 2 0 0 5 3
4 1 2 1 3 3 0 2 0 4 3 3 2
1 0 1 0 0 0 0 0 0 0 1 0 0
Total treats
Compliances
Breaches
Christie breaches
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15
Head & NeckCWT position Adjusted position National Standard DH Suggested Standard
9 10 12 14 16 13 10 11 13 7 8 10 5
4 6 7 9 11 11 5 7 8 4 4 7 4
5 4 5 5 5 2 5 4 5 3 4 3 1
3 0 0 1 1 0 0 0 0 0 1 0 0
Breaches
Christie breaches
Total treats
Compliances
67
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15
Lower GastrointestinalCWT position Adjusted position National Standard DH Suggested Standard
13 19 13 15 16 19 33 12 21 20 11 16 11
8 11 12 9 9 9 19 10 8 12 6 10 6
5 8 1 6 7 10 14 2 13 8 5 6 5
0 2 0 1 2 0 2 1 4 0 2 2 1
Compliances
Breaches
Christie breaches
Total treats
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15
LungCWT position Adjusted position National Standard DH Suggested Standard
32 35 32 24 36 24 35 36 40 53 50 45 50
24 28 24 17 32 18 25 29 30 37 31 38 33
8 7 8 7 4 6 10 7 10 16 19 7 17
3 0 0 0 1 1 2 0 0 2 2 1 0
Total treats
Compliances
Breaches
Christie breaches
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15
OtherCWT position Adjusted position National Standard DH Suggested Standard
3 2 2 4 6 3 3 0 5 3 6 5 2
1 1 0 1 3 3 0 0 2 2 1 1 0
2 1 2 3 3 0 3 0 3 1 5 4 2
1 0 0 0 0 0 0 0 0 0 0 0 0
Total treats
Compliances
Breaches
Christie breaches 68
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15
SarcomaCWT position Adjusted position National Standard DH Suggested Standard
1 5 4 1 2 3 4 3 2 2 4 7 1
1 3 3 1 2 0 1 2 1 1 3 2 1
0 2 1 0 0 3 3 1 1 1 1 5 0
0 0 0 0 0 0 1 0 1 0 0 2 0Christie breaches
Total treats
Compliances
Breaches
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15
SkinCWT position Adjusted position National Standard DH Suggested Standard
9 14 17 10 10 4 10 20 9 9 15 12 7
7 13 11 7 8 3 9 19 6 9 11 12 7
2 1 6 3 2 1 1 1 3 0 4 0 0
1 0 3 1 1 0 0 0 1 0 1 0 0
Total treats
Compliances
Breaches
Christie breaches
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15
Upper GastrointestinalCWT position Adjusted position National Standard DH Suggested Standard
18 19 22 14 21 17 16 21 15 9 25 14 24
9 7 7 7 12 4 7 14 5 5 9 8 13
9 12 15 7 9 13 9 7 10 4 16 6 11
0 1 3 2 1 1 0 0 2 0 2 0 3
Total treats
Compliances
Breaches
Christie breaches 69
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15
Urological (Excluding Testicular)CWT position Adjusted position National Standard DH Suggested Standard
9 11 15 12 9 15 15 9 16 16 9 13 12
5 5 9 6 5 7 8 3 11 7 5 6 7
4 6 6 6 4 8 7 6 5 9 4 7 5
0 0 0 1 0 1 0 0 1 1 0 0 0Christie breaches
Total treats
Compliances
Breaches
80%
85%
90%
95%
100%
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15Internal 31 day 98.4% 89.7% 89.7% 86.8% 93.6% 94.2% 93.0% 91.2% 87.6% 90.1% 92.9% 91.5%31 day internal target 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85%
Internal performance - referral receipt to FDT in 31 days
18 weeks
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15
Incomplete 97.4% 97.6% 97.0% 99.2% 99.0% 98.9% 98.7% 98.8% 98.6% 98.7% 98.3% 98.5%Admitted 97.1% 93.8% 97.0% 94.9% 97.2% 96.1% 93.3% 98.3% 97.5% 97.2% 97.5% 96.1%Non-admitted 98.3% 97.3% 97.3% 98.1% 98.5% 99.2% 98.1% 98.3% 98.6% 98.8% 98.7% 98.1%Known clock start 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
90%
92%
94%
96%
98%
100%
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15Incomplete 97.4% 97.6% 97.0% 99.2% 99.0% 98.9% 98.7% 98.8% 98.6% 98.7% 98.3% 98.5%Admitted 97.1% 93.8% 97.0% 94.9% 97.2% 96.1% 93.3% 98.3% 97.5% 97.2% 97.5% 96.1%Non-admitted 98.3% 97.3% 97.3% 98.1% 98.5% 99.2% 98.1% 98.3% 98.6% 98.8% 98.7% 98.1%
18 weeks performance
70
Radiotherapy
0
5
10
15
20
25
30
Wait
ing D
ays
Oct-14 Nov-1 4 Dec-1 4 Jan-15 Fe b-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-1 5 Sep-1 5Palliative average 9 10 10 10 10 11 10 10 10 10 10 10
Palliative ta rget 14 14 14 14 14 14 14 14 14 14 14 14
Radical a verage 23 26 25 26 26 25 26 26 25 24 25 25
Radical t arget 28 28 28 28 28 28 28 28 28 28 28 28
Waiting Days Summary - RTSD
7.2 Waiting times on the day
Outpatients
40%
60%
80%
100%
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15target 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80%compliance 88.2% 81.3% 83.0% 83.6% 80.9% 80.8% 92.8% 85.2% 85.0% 80.2% 82.8% 82.9%
Progress against 20 minute wait - Outpatients
Pharmacy
50%
60%
70%
80%
90%
100%
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15Target 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80%combined
compliance 85.5% 87.1% 91.0% 87.1% 91.0% 87.2% 92.7% 85.0% 87.0% 88.6% 85.5% 90.3%
Pharmacy waits
Chemotherapy
70%
75%
80%
85%
90%
95%
100%
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15Target (all patients) 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80%Compliance (all patients) 89% 84% 88% 89% 85% 88% 87% 87% 86% 87% 86% 87%Target (2 day treats) 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%Compliance (2 day treats) 93% 92% 93% 93% 93% 95% 94% 95% 93% 94% 93% 93%
Patients receiving chemotherapy within one hour
71
7.3 Commissioning for quality and innovation (CQUINS) 2015/16 The 2015/16 CQUIN indicators have been agreed with Commissioners, these are highlighted below and will be reported quarterly, all thresholds for Q2 and September have been met.
Providers to screen for sepsis all those patients for whom sepsis screening is appropriate, and
to rapidly initiate intravenous antibiotics within 1 hour of presentation, for those patients who
have suspected severe sepsis, Red Flag Sepsis or septic shock.
The CQUIN requires an established local protocol that defines which emergency patients require
sepsis screening.
Assessment of the baseline in line with calculation derived from local protocol.
Specification of requirements for e-forms to be developed.
Acute Kidney Care
The assessment of patients admitted with Acute Kidney Injury (AKI) to determine if earlier
interventions could have prevented the admission. To identify the elements of NICE
guidance (CG169) applicable to patients undergoing chemotherapy and where
appropriate make recommendations for changes in practise to reduce the risk of
patients developing AKI.
Form to be developed for collection of data on sample of patients admitted with AKI.
Tissue Viability and Wound Care
To improve the management and use of wound care products at The Christie and how we communicate with the wider healthcare
community about their use.
To develop a wound care formulary for the trust and to rationalise the products used ensuring that this
mirrors practise within the GM area.
Medication Changes
To clearly identify on discharge summaries all medication changes. Where no changes have
been made to a patients’ treatment a statement to this effect will be included on the discharge
summary.
Include on the trust electronic discharge summary statements to clearly indicate whether changes
have been made to a patients medication.Baseline to be agreed.
Ready For DischargeDevelop a local procedure/protocol to ensure
patients are clinically ready to be discharged in the AM.
Develop a local procedure/protocol to ensure patients are clinically ready to be discharged by
the am with the following
Next appointment (if appropriate)Take home medication
Onward referral arranged
Christie Portal Improve the quality and content of the GP portal increasing its value within the GP community
Effective discharge planning can decrease the chances that a patient is readmitted to the
hospital, help in recovery, ensure medications are prescribed and given correctly, and adequately prepare you for community, home or self-care.
Planning for discharge with clear dates and times reduces:
• Patient's length of stay • Emergency readmissions • Pressure on hospital beds
This CQUIN is a two year implementation of an electronic patient diary for a tablet/smartphone
providing patients the following ability:
- View upcoming clinical appointment dates and detail
- View/update patient demographic details- Carer Profiles - view information on Christie
staff supporting their care- Hospital Information (Maps, important
numbers etc.)- Chemotherapy symptom diary
- Specific side effects to monitor related to their specific treatment
Test the implemented system with patient user group
Prostate
Thyroid
Lymphoma Monitoring of progress with 'Adapted' cohort (I.e. Patients on active surveillance).
Implementation of improved prescribing practice aimed at achieving reduction in the level of Oral
SACT that is prescribed but not taken by patients.
The provider is to provide a compliance report against the (draft) NHS England Policy on
Management of Oral Formulations of Systemic Anticancer Therapy (SACT) specifically
highlighting the following: : - Prescribing & Treatment Initiation,
- Verification of Prescriptions,- Patient Education and Information,
- Pre-Treatment Consultation and Consent, - Dispensing and Supply, Original Pack
Dispensing,- Access to 24 house Specialist Oncology Advice,- Monitoring/On-Treatment assessment and Follow-
up
The provider is to submit an improvement plan to the commissioner showing remedial actions plans for any areas of non-compliance, data collection and reporting arrangements and a monthly waste
reduction trajectory
Achieved
Management of Oral Formulation of Systematic Anticancer Therapy (SACT) Achieved
Monitoring of current clinics and plan for further roll out.
Shadow monitoring of local tariff for charging of remote clinic activity.
Q2
Achieved
Achieved
Achieved
Achieved
Achieved
Achieved
Achieved
Achieved
Achieved
INDICATOR Brief Description Q1 Target / Deliverables Apr May Jun SepJul Aug
Q1
Safer Hospital Discharge
Achieved
Achieved
Achieved
Medicines Optimisation
Achieved
Achieved
Anti-biotic Door to Needle Bundle Achieved
Patient Held Information Achieved
Reducing Long Term Follow Ups
Reducing the number of patients on long-term follow-up following specialised cancer treatment within an NHS Specialised service (i.e. where the responsibility for follow-up post treatment
lies with the specialised cancer MDT).
72
7.4 Length of stay (LOS) Average rolling LOS is 6.6 in September against a standard of 6.4.
Reporting month Total EL NEL
Oct-14 6.44 5.43 7.85Nov-14 6.43 5.37 7.89Dec-14 6.48 5.36 8.06Jan-15 6.5 5.36 8.18Feb-15 6.58 5.42 8.32Mar-15 6.64 5.48 8.38Apr-15 6.62 5.47 8.36May-15 6.66 5.45 8.55Jun-15 6.64 5.44 8.53Jul-15 6.53 5.36 8.36Aug-15 6.55 5.37 8.39Sep-15 6.63 5.40 8.58
6.0
6.2
6.4
6.6
6.8
7.0
No o
f day
s
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15Annual 6.44 6.43 6.48 6.50 6.58 6.64 6.62 6.66 6.64 6.53 6.55 6.63
12 month rolling average LOS - Trust level
7.5 Theatre Utilisation
0
1
2
3
4
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Cancelled 0 0 0 3 1 0 1 0 1 1 1 0Re-Booked in 28 days 0 0 0 3 1 0 1 0 1 1 1 0
Cancelled operations on the day for non-clinical reasons
0
100
200
300
400
500
600
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15Total 491 453 441 485 465 489 396 424 484 475 413 468
Number of Surgical Operations
73
7.6 Diagnostic utilisation High utilisation continues for MRI and CT.
50%
60%
70%
80%
90%
100%
%
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-156 weeks 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%4 weeks 86.4% 81.8% 82.2% 88.7% 85.4% 80.3% 81.7% 84.0% 88.9% 91.5% 99.7% 99.8%2 weeks 70.2% 70.6% 67.5% 78.5% 69.3% 69.8% 69.8% 72.8% 76.1% 84.2% 94.7% 84.7%
CT waiting times
40%
50%
60%
70%
80%
90%
100%
%
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-156 weeks 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%4 weeks 99.0% 95.5% 97.6% 88.5% 93.4% 95.5% 82.7% 72.1% 75.4% 92.5% 99.5% 100.0%2 weeks 55.6% 62.9% 67.3% 74.3% 67.6% 68.8% 62.4% 56.9% 64.3% 72.8% 79.5% 88.1%
MRI waiting times
0
100
200
300
400
500
600
700
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15PET scans 566 513 470 497 521 600 643 610 647 643 572 624
Clinical PET scanner - studies per month
74
7.7 Efficiency programme
75
The annual target for CIP in 2015-16 is £5.46m. As at month 6, £3.4m has been achieved and removed from budget recurrently and £4.0m has been achieved in year.
Within month 6 – Six new PIDs have been submitted; of the one hundred and twenty-six schemes a further 5 schemes completed in month to release £130K in year savings and £171K recurrently. There are 66 active schemes which are anticipated to deliver a further £2.04m of recurrent savings and £488K in year. The Trust achieved its Q2 Target at the end of Month 4 for 50% of recurrent CIP to be transacted, focus within the divisions is now on moving towards the Q3 target. The table below demonstrate predicated and actual performance against the quarterly targets agreed at the beginning of the year.
Quarter Target Actual Actual + Risk assessed value of schemes
Q1 30% 47.1% 50.5%
Q2 50% 62.6% 73.4%
Q3 88% 62.6% 88%
Q4 100% 62.6% 100%
76
8. Workforce 8.1 Employees in post The table shows performance in whole time equivalents (WTEs) against workforce plan for
2015/16
2100
2200
2300
2400
2500
2600
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15Total Headcount 2496 2504 2489 2500 2494 2505 2508 2518 2502 2509 2531 2557Total FTE 2278 2279 2266 2278 2271 2285 2286 2297 2284 2292 2311 2335Forecast FTE plan for year end 2415 2415 2415 2415 2320 2320 2320 2320 2320 2320 2320 2320
Total Headcount & FTE
8.2 Use of bank and agency
Agency costs are at 0.65% of the total pay bill in September. The table below shows actual agency spend for 2015/16.
Apr May Jun Jul Aug SeptCancer Centre Services £58,262 £38,515 £36,106 £43,200 £32,848 £30,221Cancer Networked Services £18,037 £14,807 £12,063 £14,800 £17,827 £19,772Finance & Business Development £3,101 £1,550 £0 £0 £4,885 £0Estates & FacilitiesHuman ResourcesMedical PhysicsCharityResearch & Development
£79,400 £54,872 £48,169 £58,000 £55,560 £49,993
Cumulative Actual % of Total Pay Bill (Target) 1% 1% 1% 1% 1% 1%% of Total Pay Bill (Actual) 1% 0.72% 0.64% 0.77% 0.73% 0.65%
Q1Division
TOTAL Actual £182,441
Agency Spend
Q2
£163,553£345,994
8.3 Sickness absence
The trust sickness absence rate is at 3.36% for September against a standard of 3.4%. Sickness absence continues to be monitored at divisional board meetings and performance reviews
2%
3%
4%
5%
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15target 3.2% 3.2% 3.2% 3.2% 3.2% 3.2% 3.4% 3.4% 3.4% 3.4% 3.4% 3.4%Trust total 3.63% 3.33% 3.41% 3.77% 3.84% 4.00% 3.44% 3.21% 2.61% 3.29% 3.60% 3.36%
Trust Level - Absence Rates
Subject to validation
77
Division Sep-15 YTD (From Apr-15)
Cancer Centre Services 4.26% 3.65%Christie Medical Physics and Engineering 1.19% 2.19%Clinical Networked Services 3.75% 2.99%Corporate Services ** 0.76% 1.64%Estates & Facilities 4.80% 6.54%Finance & Business Devlp 2.26% 2.41%Research and Development (Medical Internal) 3.23% 2.67%Grand Total 3.36% 3.25%RAG Rating (>=Apr-15): <=3.4 GREEN; >3.4 RED** This includes Corporate Development, Education, Performance, Quality and Standards, Trust Admin and Workforce Subject to validation
8.4 Personal development reviews (PDR)
Performance in September is 88.9% compliance against a 95% standard. PDR compliance continues to be closely monitored through Performance Review meetings and divisional board meetings. Division Sep-15Cancer Centre Services 89.12%Christie Medical Physics and Engineering 86.10%Clinical Networked Services 93.12%Corporate Services 85.50%Estates & Facilities 88.89%Finance & Business Devlp 83.87%Research and Development (Medical Internal) 87.92%Grand Total 88.99%RAG Rating (>=June-15): >=94.5% GREEN; 85<>94.5 AMBER; <=84.5 RED
8.5 Essential Training
Essential Training in September is at 90.4% against the 95% standard. Monitoring of compliance continues at performance review meetings and through the risk committee on a monthly basis.
Division Sep-15Cancer Centre Services 91.04%Christie Medical Physics and Engineering 92.67%Clinical Networked Services 88.44%Corporate Services 93.60%Estates & Facilities 92.95%Finance & Business Devlp 95.51%Research and Development (Medical Internal) 93.18%Grand Total 90.94%RAG Rating (>=June-15): >=94.5% GREEN; 85<>94.5 AMBER; <=84.5 RED 78
9. Research and development 9.1 Clinical trials / studies
In the 2011 budget the government announced the transformation of incentives at local level for initiation and delivery of research. Benchmarks, to set-up a clinical trial within 70 days (from receipt of a valid research application to recruitment of the first patient) and to deliver commercial contract clinical trials to time and target were written into the NIHR contracts from April 2012. The Trust is required to provide, on a quarterly basis, information on recruitment to clinical trials in two key areas:
• Initiating Research- the 70 day target (this looks at how quickly studies are set up and first patient is recruited)
• Delivering Research- time and target (this looks at whether or not we’ve recruited the agreed target number of patients within the agreed timeframe)
In February 2014, for the first time, the NIHR report shows 70-day performance taking into account where providers have explained clearly that a delay was outside their control. It is intended to inform discussion about what this shows, and how data should be presented and used, before the NIHR starts to hold providers to account for performance
Target 01/04/14 – 31/03/15
Initiating Clinical Research (70 day target)
82.8%
0
100
200
300
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15Patients 187 152 137 162 156 139 148 133 129 141 116 141Target 114 114 114 114 114 114 114 114 114 114 115 115
New patients recruited to clinical studies
500
520
540
560
580
600
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15Trials 554 536 531 538 549 560 571 578 584 586 587 589
Number of studies/trials currently open
79
372337
298286
259232
218190189
177171
156154154
147121
1049392
8775
7271
6866
6363
595858
5555
494644
3939393838
2420
10987664333333111
0 50 100 150 200 250 300 350 400
Barts Health NHSTThe Christie NHSFT
Guys and St Thomas NHSFTThe Royal Marsden NHSFT
Kings College Hospital NHSFTUniversity Hospital Southampton NHSFT
Nottingham University Hospitals NHSTUniversity Hospitals Of Leicester NHSTCambridge University Hospitals NHSFT
Oxford University Hospitals NHSTThe Newcastle Upon Tyne Hospitals NHSFT
Central Manchester University Hospitals NHSFTLeeds Teaching Hospitals NHST
Sheffield Teaching Hospitals NHSFTImperial College Healthcare NHST
University College London Hospitals NHSFTSt Georges Healthcare NHST
Norfolk and Norwich University Hospitals NHSFTUniversity Hospitals Bristol NHSFT
Royal Liverpool and Broadgreen University Hospitals NHSFTSalford Royal NHSFT
Royal Surrey County Hospital NHSFTBrighton and Sussex University Hospitals NHST
Great Ormond Street Hospital for Children NHSFTBradford Teaching Hospitals NHSFT
Royal Cornwall Hospitals NHSTRoyal Devon and Exeter NHSFT
Royal Brompton & Harefield NHSFTUniversity Hospitals Birmingham NHSFT
University Hospitals Coventry and Warwickshire NHSTHeart of England NHSFT
South Tees Hospitals NHSFTUniversity Hospital Of North Staffordshire NHST
Moorfields Eye Hospital NHSFTNorth Bristol NHST
Alder Hey Childrens NHSFTChelsea and Westminster Hospital NHSFT
University Hospital Of South Manchester NHSFTBirmingham Children's Hospital NHSFT
Sandwell and West Birmingham Hospitals NHSTSouth London and Maudsley NHSFT
Northumbria Healthcare NHSFTOxford Health NHSFT
Blackpool Teaching Hospitals NHSFTBirmingham and Solihull Mental Health NHSFT
Berkshire Healthcare NHSFTManchester Mental Health and Social Care Trust
Northumberland Tyne and Wear NHSFTHertfordshire Partnership University NHSFT
Devon Partnership NHSTHomerton University Hospital NHSFTLeeds Community Healthcare NHST
Nottinghamshire Healthcare NHSTQueen Victoria Hospital NHSFT
West Hertfordshire Hospitals NHSTCambridgeshire and Peterborough NHSFT
Camden and Islington NHSFTCumbria Partnership NHSFT
Number of Reported Commercial Trials Delivered from All Providers
80
100.00%
100.00%
100.00%
100.00%
97.10%
92.30%
92.20%
91.20%
90.90%
90.90%
87.50%
87.50%
83.90%
81.00%
80.00%
80.00%
78.90%
77.80%
74.00%
71.40%
71.40%
71.20%
70.70%
70.30%
69.00%
67.30%
66.70%
66.70%
66.70%
66.40%
65.60%
64.80%
62.00%
59.10%
57.90%
57.30%
53.30%
51.40%
50.60%
50.00%
50.00%
50.00%
43.40%
40.90%
38.70%
37.70%
30.40%
0.00%
0.00%
0.00%
0.00% 20.00% 40.00% 60.00% 80.00% 100.00%
Northumberland Tyne and Wear NHS Foundation TrustOxford Health NHS Foundation Trust
Queen Victoria Hospital NHS Foundation TrustRoyal Brompton and Harefield NHS Foundation Trust
The Royal Marsden NHS Foundation TrustRoyal Devon and Exeter NHS Foundation Trust
Sheffield Teaching Hospitals NHS Foundation TrustUniversity Hospital Of North Staffordshire NHS Trust
Solent NHS TrustSouth London and Maudsley NHS Foundation Trust
Alder Hey Childrens NHS Foundation TrustNorth Bristol NHS Trust
University Hospital Of South Manchester NHS Foundation TrustThe Christie NHS Foundation Trust
Moorfields Eye Hospital NHS Foundation TrustNorthumbria Healthcare NHS Foundation Trust
Bradford Teaching Hospitals NHS Foundation TrustGreat Ormond Street Hospital for Children NHS Foundation Trust
Guys and St Thomas NHS Foundation TrustRoyal Liverpool and Broadgreen University Hospitals NHS Trust
University Hospitals Bristol NHS Foundation TrustCentral Manchester University Hospitals NHS Foundation Trust
St Georges Healthcare NHS TrustCambridge University Hospitals NHS Foundation Trust
Nottingham University Hospitals NHS TrustUniversity Hospitals Birmingham NHS Foundation Trust
Leeds Community Healthcare NHS TrustManchester Mental Health and Social Care Trust
Nottinghamshire Healthcare NHS TrustALL PROVIDERS
Barts Health NHS TrustThe Newcastle Upon Tyne Hospitals NHS Foundation Trust
Leeds Teaching Hospitals NHS TrustKings College Hospital NHS Foundation Trust
Royal Cornwall Hospitals NHS TrustUniversity College London Hospitals NHS Foundation Trust
Oxford University Hospitals NHS TrustSouth Tees Hospitals NHS Foundation Trust
Imperial College Healthcare NHS TrustBrighton and Sussex University Hospitals NHS Trust
Camden and Islington NHS Foundation TrustPennine Care NHS Foundation Trust
University Hospitals Of Leicester NHS TrustRoyal Surrey County Hospital NHS Foundation Trust
Salford Royal NHS Foundation TrustUniversity Hospital Southampton NHS Foundation Trust
University Hospitals Coventry and Warwickshire NHS TrustCumbria Partnership NHS Foundation Trust
Hertfordshire Partnership NHS Foundation TrustHomerton University Hospital NHS Foundation Trust
% of Trials Meeting the 70 Day Target
81
10. Sustainable development management 10.1 Sustainability
• The sustainable development management committee review progress of overall actions on a quarterly basis, against the SDM plan (SDMP).
• The current status of all elements of the NHS sustainable development unit (SDU) guidance, are reported by individual leads, via key issue reports. In turn pertinent issues are escalated to the capital workforce planning group (CWPG).
10.2 Good corporate citizenship – DH toolkit (www.corporatecitizen.nhs.uk) Graphs indicate performance progress, via self assessment with detailed evidence, for each of the six good corporate citizenship elements with an overall trust rating.
10.3 Energy and the carbon reduction commitment (CRC)
The graph indicates the percentage compliance against the target set out by the trust of 10%:- • The annual reduction in consumption average for 2015/16 is currently 28.4% • Meetings arranged to review proposals for phase 3 of energy reduction programme • Gas procurement services framework agreement renewed - Flexible Energy Management
(FEM). • Solar PV cells output will reduce the trust imported electricity. • The government is proposing to scrap CRC, maintaining the revenue by reviewing the
Climate Change Levy. This is still a consultation only and our CRC liabilities have not changed.
• 175k of CRC allowance for 2015/16 has been applied to the Trust’s account at the reduced rate
• The Trust’s CRC emissions in Year 5 were down by 4% over Year 4 to 9,092 tCO2. • Display Energy Certificate (DEC) renewal - Schneider and Veolia assisting with data
collation • Veolia to produce expansion proposal report re current boiler capacity / limitations.
05
10152025303540
%
Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15Target 10 10 10 10 10 10 10 10 10 10 10 10Energy 29.16 30.21 37.66 30.79 26.42 34.57 24.67 32.36 34.47 30.80 32.86 28.38
Energy reduction monthly performance
10.4 Food Waste (and sustainable catering)
The graph indicates percentage compliance against the trust year on year of 10% target. • The Catering department works together with the Cooperate screening group to see how we
can improve ordering system for patient’s food from ward level in electronic version. This would reduce a significant amount of paper, a better audit trail and potential a further reduction in waste.
• The online system for ordering refreshments and functions is now in the final stage.
82
0
2
4
6
8
10
12
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15Target 10 10 10 10 10 10 10 10 10 10 10 10Actual food waste 4.74 4.96 7.10 5.32 4.95 4.46 5.08 5.29 5.65 5.44 5.42 4.85
Food waste following ERIC criteria
10.5 Low carbon travel Green travel plan (GTP) target set at 60% of staff to use sustainable travel by 2030 • Meeting with MCC took place to review progress on GTP. Focus was on cycling and walking
i.e. 40% modal shift target for this year. • “Brompton bikes” fold up bike pilot launched (8 bikes for 8 weeks, Sep-15 & Oct-15) • TfGM installed a public bicycle pump at the Christie. • New 20 space cycle compound (close to MSCP) under construction. • Living Streets’ Walk Challenge (28th October – 2nd November) promoted including stand in
the dining room on the 28th October to provide advice on walking routes and benefits. • Parking permits eligibility consultation group required to implement new controls for
December. 10.6 Carbon emissions from clinical waste
• The graph continues to indicate an increase in clinical waste produced. However, the trend line through July, August and Sept indicate tonnage rates are reducing
• An implementation action plan is under development, with the clinical waste contractor SITA UK (December 2015), for orange (bagged) infectious waste stream, in line with HTM 07-01 safe management of healthcare waste guidance. Reduction in carbon emissions is due to treatment process permitted for orange waste stream
0.00.20.40.60.81.01.21.41.61.8
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15target 1.22 1.22 1.22 1.22 1.22 1.22 1.22 1.22 1.22 1.22 1.22 1.22savings 1.47 1.52 1.38 1.53 1.51 1.44 1.49 1.52 1.45 1.33 1.28 1.21
Carbon emmissions from waste
11. Recommendation
The board is asked to note performance for month 6
83
DATA APPENDICES
Month 6 2015/16
Section
1
Patient safety
2
Activity
3
Finance
4
Workforce
5
Additional Reports
84
1. Patient Safety
1.1 Issue • Litigation and claims
Indicator • Number of outstanding claims • Trend and forecast of amount paid out
Source • Datix system Standard • Internal performance standard
0
4
8
12
16
20
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15Clinical Negligence 9 9 9 8 9 9 9 9 9 10 9 8Employer Liability 19 19 19 18 18 17 16 17 16 14 13 11Public Liability 2 2 2 2 2 2 1 1 1 1 1 1
Litigation and Claims - number of live claims
£0£5,000
£10,000£15,000£20,000£25,000£30,000£35,000£40,000£45,000
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15Payments £0 £0 £0 £939 £0 £26,750 £0 £40,809 £14,435 £21,100 £0 £10,223
Payments relating to claims
85
2. Activity
2.1 Issue • Market and business development Indicator • Trust external referral rates Source • Referrals received by Trust from EPR Standard • Commissioner plan
Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug SepExternal Referrals (13-14) 1448 1291 1293 1468 1284 1772 1366 1397 1647 1583 1311 1524External Referrals (14-15) 1554 1350 1497 1389 1387 1540 1451 1382 1653 1804 1447 1685
0
400
800
1200
1600
2000External Referrals
2.2 Issue • Key trends and forecasts
Indicator • Activity against plan by delivery & treatment type • CoSR Forecast 5 years
Source • Finance ledger Standard • Monitor – Continuity of Service Rating (CoSR)
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarACTUAL 718 768 838 875 785 780PLAN 743 733 784 816 754 784 795 763 774 754 742 774
100200300400500600700800900
Spells
Inpatient Spells Against Plan
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarACTUAL 769 791 914 886 738 939PLAN 769 731 846 885 769 846 846 808 808 769 808 808
0100200300400500600700800900
Episo
des
Daycase Episodes Against Plan
86
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarACTUAL 1164 1143 1406 1314 1191 1318PLAN 1162 1103 1278 1336 1162 1278 1278 1220 1220 1162 1220 1220
0200400600800
1000120014001600
Atten
danc
esOP First Attendances Against Plan
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarACTUAL 7310 6780 7884 7681 7038 7954PLAN 7340 6973 8074 8440 7340 8074 8074 7707 7707 7340 7707 7707
0100020003000400050006000700080009000
10000
Atten
danc
es
OP FollowUp Attendances Against Plan
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarACTUAL 5064 4815 4904 5164 4636 5084PLAN 4729 4610 4965 5201 4847 5201 5201 4965 5083 4729 4965 5083
0
1000
2000
3000
4000
5000
6000
Delive
ries
Chemotherapy Deliveries (Treatments) Against Plan
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarACTUAL 8064 7751 7978 8857 8116 8387PLAN 8391 7972 9230 9649 8391 9230 9230 8810 8810 8391 8810 8810
0
2000
4000
6000
8000
10000
Delive
ries
Radiotherapy Deliveries (Fractions) Against Plan
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarACTUAL 490 439 486 499 413 515PLAN 441 419 485 507 441 485 485 463 463 441 463 463
0
100
200
300
400
500
600
Proce
dures
OP Procedures Against Plan
87
3. Finance
0
3,000
6,000
9,000
£000
s
Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16Actual 767 1,539 1,982 2,808 3,053 3,525Trust Plan 725 1,450 2,174 2,899 3,624 4,349 5,073 5,798 6,523 7,248 7,972 8,697
Trust performance against budgets
20.0
30.0
40.0
50.0
60.0
70.0
80.0
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15Actual 70.8 73.6 71.8 72.1 75.5 68.9 74.4 69.7 61.4 49.4 42.4 37.2
Plan 55.6 55.6 55.6 55.6 55.6 55.6 37.2 37.2 37.2 37.2 37.2 37.2
Liquidity (Days)
`
0123456789
1011
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15
Millio
ns
Aged Debt
>180 Days
90-180 Days
61-90 Days
31-60 Days
0-30 Days
3.1 Issue • Income and expenditure Indicator • Performance against budgets Source • Finance ledger Standard • Monitor – Continuity of Service Rating (CoSR)
3.2 Issue • Liquidity days Indicator • Total cash flow Source • Finance ledger Standard • Monitor – Continuity of Service Rating (CoSR)
3.3 Issue • Debtors Indicator • Value of 30, 60 and 90 day debtors Source • Finance ledger
88
4. Workforce
Staff Group FTE Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15Add Prof Scientific and Technic 75 77 77 77 76 78 75 77 77 75 76 78 78 79Additional Clinical Services 233 243 233 227 222 219 223 225 222 223 227 229 229 241Administrative and Clerical 687 685 691 695 686 693 693 694 693 696 692 696 702 707Allied Health Professionals 205 205 205 206 203 205 204 207 209 212 210 209 209 210Estates and Ancillary 208 209 210 209 209 209 209 210 212 214 212 212 216 215Healthcare Scientists 152 159 158 160 161 161 162 163 165 164 162 159 162 165Medical and Dental 158 158 157 160 159 158 153 154 152 156 157 156 157 162Nursing and Midwifery Registered 531 536 547 545 550 556 551 555 557 556 547 551 558 556Students 3 0 0 0 0 0 0 0 0 1 1 1 1 1Grand Total 2250 2272 2278 2279 2266 2278 2271 2285 2286 2297 2284 2292 2311 2335 Staff Group Headcount Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15Add Prof Scientific and Technic 81 83 83 83 81 83 81 83 83 80 81 83 83 84Additional Clinical Services 256 266 257 250 246 241 246 248 245 247 250 253 254 269Administrative and Clerical 754 751 757 763 752 761 763 763 762 765 761 762 768 773Allied Health Professionals 224 225 225 227 224 225 224 227 229 232 231 230 230 230Estates and Ancillary 236 238 238 239 239 240 239 239 242 245 242 243 247 245Healthcare Scientists 158 165 164 167 168 168 169 169 171 170 169 166 169 172Medical and Dental 173 173 172 175 174 172 167 168 167 171 171 171 172 177Nursing and Midwifery Registered 582 586 600 600 605 610 605 608 609 607 596 600 607 606Students 3 0 0 0 0 0 0 0 0 1 1 1 1 1Grand Total 2467 2487 2496 2504 2489 2500 2494 2505 2,508 2,518 2,502 2,509 2,531 2,557
0%
5%
10%
15%
20%
25%
30%
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15Medical staf f 27.0% 27.7% 26.5% 26.1% 28.1% 26.4% 26.5% 25.9% 25.5% 27.1% 26.3% 26.7%Nurse staff 20.5% 20.9% 21.5% 21.6% 21.0% 20.9% 20.9% 21.1% 21.3% 20.4% 20.9% 20.3%Clinical staff 23.6% 23.8% 24.3% 23.9% 23.6% 24.9% 24.8% 24.9% 25.4% 24.7% 24.8% 25.0%Non clinical staff 28.1% 27.1% 27.1% 27.6% 26.3% 26.8% 26.8% 27.4% 27.2% 27.0% 27.3% 27.3%Total agency/other 0.73% 0.54% 0.68% 0.78% 0.99% 0.99% 1.05% 0.72% 0.64% 0.77% 0.73% 0.65%
% of cost - clinical to non-clinical
5.1 Issue • Staff Profile
Indicator • Total headcount and FTE • Staff Group by headcount and FTE • % cost - clinical / non-clinical
Source
• Finance ledger • Electronic Staff Record
Standard • Internal performance monitoring
89
5.2 Issue • Use of agency and bank Indicator • Total cost per month by division Source • Finance ledger Standard • NHS Better Care, Better Value Indicators
£0
£10,000
£20,000
£30,000
£40,000
£50,000
£60,000
£70,000
Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15Networked Services £12,255 £8,698 £8,290 £7,584 £27,000 £14,339 £18,037 £14,807 £12,063 £14,800 £17,827 £19,772Cancer Centre Services £43,472 £32,610 £44,290 £54,672 £66,073 £54,375 £58,262 £38,515 £36,106 £43,200 £32,848 £30,221Estates & Facilities £0 £0 £0 £4,908 £3,721 £381 £3,101 £1,550 £0 £0 £4,885 £0
Agency Costs by Division
5.3 Issue • Staff Turnover
Indicator • Number of leavers by leaving reason • 12 month turnover (headcount) • Gender and employee split
Source • Integrated personnel system
Standard • Internal performance monitoring • NHS Better Care, Better Value Indicators
Leavers Headcount Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15Dismissal 1 0 1 2 0 0 0 0 0 0 0 0 0 2End of Fixed Term Contract 2 3 3 1 2 0 2 1 3 3 5 3 2 3Mutually Agreed Resignation 0 0 0 0 0 0 0 0 0 0 0 0 0 0Redundancy 0 0 0 0 1 0 0 0 0 0 3 0 1 1Retirement 3 3 1 2 3 3 2 3 1 11 5 3 4 2TUPE 1 0 0 1 1 0 2 1 0 0 2 0 1 1Voluntary Resignation 17 12 12 22 14 11 14 24 9 20 18 22 17 0Others 0 1 0 0 0 0 1 0 0 0 0 0 0 1Grand Total 24 19 17 28 21 14 21 29 13 34 33 28 25 2112 Month Turnover % Headcount 13.05% 12.63% 12.78% 13.62% 14.06% 13.88% 13.87% 13.29% 12.72% 10.33% 10.83% 10.08% 11.14% 11.11%Adjusted 12 month Turnover %* 8.19% 7.84% 7.45% 7.51% 8.44% 8.68% 8.78% 8.66% 8.41% 9.02% 9.19% 9.57% 9.52% 9.74%* Turnover based on substantive leaving reasons only (Dismissal, M.A.R.S, Redundancy, Retirement, Voluntary Resignation, Other)
0
200
400
600
800
1000
1200
1400
1600
1800
2000
Female Male
Gender and Employee Category Splitas at 30th September 2015
Full Time Part Time 90
5. Additional Reports
5.1 Tripartite review of cancer improvement plans
91
92
5.2 NIHR Performance in Initiating and Delivering Clinical Research – Q1 2015/16
Performance in Delivery
NHS provider (# quarter submitted) # Trials Analysed # Closed Trials# Trials Meeting
Target# Closed Trials Meeting Target
# Trials where Meeting the Target
is N/A
% Closed Trials Meeting Target out of Closed Trials PP
% Closed Trials Meeting Target out
of Closed Trials Meeting Target PL
% Closed Trials Meeting Target out
of Closed Trials Meeting Target All
Providers
Rank of % Closed Trials Meeting Target PP, Per
League
Rank of % Closed Trials Meeting
Target All ProvidersTOTAL TOTAL TOTAL TOTAL TOTAL TOTAL
All providers 7238 3086 2093 1551 3375 50.3
Barts Health NHS Trust 474 106 110 71 303 67.0 7.1 4.6 4 16 Guys and St Thomas NHS Foundation Trust 301 136 72 48 130 35.3 4.8 3.1 19 66 The Royal Marsden NHS Foundation Trust 291 155 95 93 135 60.0 9.3 6.0 5 23 The Christie NHS Foundation Trust 283 176 120 94 83 53.4 9.4 6.1 11 37 Nottingham University Hospitals NHS Trust 228 140 96 96 88 68.6 9.6 6.2 3 14 University Hospital Southampton NHS Foundation Trust 225 114 84 66 93 57.9 6.6 4.3 8 29 Kings College Hospital NHS Foundation Trust 223 82 62 33 77 40.2 3.3 2.1 17 58 Oxford University Hospitals NHS Trust 205 101 89 59 63 58.4 5.9 3.8 7 26 Cambridge University Hospitals NHS Foundation Trust 192 94 61 40 57 42.6 4.0 2.6 16 56 Royal Free London NHS Foundation Trust 182 119 65 58 61 48.7 5.8 3.7 12 42 The Newcastle Upon Tyne Hospitals NHS Foundation Trust 176 79 62 62 89 78.5 6.2 4.0 1 9 University College London Hospitals NHS Foundation Trust 163 58 23 23 105 39.7 2.3 1.5 18 63 Central Manchester University Hospitals NHS Foundation Trust 161 72 64 34 35 47.2 3.4 2.2 14 45 Leeds Teaching Hospitals NHS Trust 159 74 42 42 85 56.8 4.2 2.7 9 31 Imperial College Healthcare NHS Trust 158 85 65 50 61 58.8 5.0 3.2 6 25 Sheffield Teaching Hospitals NHS Foundation Trust 155 108 62 48 34 44.4 4.8 3.1 15 47 University Hospitals Of Leicester NHS Trust 142 85 25 13 6 15.3 1.3 0.8 20 83 Norfolk and Norwich University Hospitals NHS Foundation Trust 110 50 35 28 53 56.0 2.8 1.8 10 33 Salford Royal NHS Foundation Trust 108 18 15 13 87 72.2 1.3 0.8 2 12 St Georges Healthcare NHS Foundation Trust 100 62 37 30 32 48.4 3.0 1.9 13 44
TOTAL TOTAL TOTAL TOTAL TOTAL MEAN MEAN MEAN4036 1914 1284 1001 1677 52.5 5.0 3.2
Ashford and St. Peters Hospitals NHS Foundation Trust 89 37 22 18 49 48.6 6.6 1.2 12 43 Great Ormond Street Hospital for Children NHS Foundation Trust 88 38 37 26 39 68.4 9.6 1.7 2 15 Royal Liverpool and Broadgreen University Hospitals NHS Trust 86 39 12 9 44 23.1 3.3 0.6 18 79 University Hospitals Bristol NHS Foundation Trust 83 30 19 19 43 63.3 7.0 1.2 4 19 Brighton and Sussex University Hospitals NHS Trust 78 48 33 25 21 52.1 9.2 1.6 11 39 Royal Surrey County Hospital NHS Foundation Trust 77 41 18 14 30 34.1 5.2 0.9 15 68 Mid Essex Hospital Services NHS Trust 76 15 31 11 39 73.3 4.1 0.7 1 11 University Hospitals of North Midlands NHS Trust 72 37 16 15 32 40.5 5.5 1.0 14 57 Bradford Teaching Hospitals NHS Foundation Trust 71 40 22 22 31 55.0 8.1 1.4 9 35 East and North Hertfordshire NHS Trust 71 30 25 19 32 63.3 7.0 1.2 4 19 Heart of England NHS Foundation Trust 67 24 24 14 27 58.3 5.2 0.9 7 27 South Tees Hospitals NHS Foundation Trust 66 39 29 23 20 59.0 8.5 1.5 6 24 Shrewsbury and Telford Hospital NHS Trust 62 11 7 7 51 63.6 2.6 0.5 3 18 Plymouth Hospitals NHS Trust 61 3 7 1 51 33.3 0.4 0.1 16 69 University Hospitals Birmingham NHS Foundation Trust 58 1 11 0 44 0.0 0.0 0.0 19 86 Royal Brompton & Harefield NHS Foundation Trust 57 28 16 15 28 53.6 5.5 1.0 10 36 The Royal Bournemouth and Christchurch Hospitals NHS Foundatio 57 7 7 0 38 0.0 0.0 0.0 19 86 University Hospitals Coventry and Warwickshire NHS Trust 57 39 19 17 16 43.6 6.3 1.1 13 53 East Kent Hospitals University NHS Foundation Trust 52 16 6 4 28 25.0 1.5 0.3 17 75 Portsmouth Hospitals NHS Trust 50 21 21 12 19 57.1 4.4 0.8 8 30
TOTAL TOTAL TOTAL TOTAL TOTAL MEAN MEAN MEAN1378 544 382 271 682 45.8 5.0 0.9
93
Performance in Delivery
NHS provider (# quarter submitted) # Trials Analysed # Closed Trials# Trials Meeting
Target# Closed Trials Meeting Target
# Trials where Meeting the Target
is N/A
% Closed Trials Meeting Target out of Closed Trials PP
% Closed Trials Meeting Target out
of Closed Trials Meeting Target PL
% Closed Trials Meeting Target out
of Closed Trials Meeting Target All
Providers
Rank of % Closed Trials Meeting Target PP, Per
League
Rank of % Closed Trials Meeting
Target All ProvidersTOTAL TOTAL TOTAL TOTAL TOTAL TOTAL
All providers 7238 3086 2093 1551 3375 50.3
University Hospital Of South Manchester NHS Foundation Trust 49 25 15 11 19 44.0 6.1 0.7 17 51 North Bristol NHS Trust 47 16 9 9 27 56.3 5.0 0.6 10 32 Barking Havering and Redbridge University Hospitals NHS Trust 46 2 2 2 44 100.0 1.1 0.1 1 1 Chelsea and Westminster Hospital NHS Foundation Trust 42 28 12 12 13 42.9 6.7 0.8 19 54 Countess Of Chester Hospital NHS Foundation Trust 42 12 9 6 29 50.0 3.4 0.4 13 40 Hull and East Yorkshire Hospitals NHS Trust 42 0 1 0 36 N/A 0.0 0.0 N/A N/A Harrogate and District NHS Foundation Trust 41 11 4 3 28 27.3 1.7 0.2 25 73 London North West Healthcare NHS Trust 41 16 8 7 23 43.8 3.9 0.5 18 52 Sandwell and West Birmingham Hospitals NHS Trust 41 30 12 11 8 36.7 6.1 0.7 22 64 Moorfields Eye Hospital NHS Foundation Trust 38 21 20 17 14 81.0 9.5 1.1 4 7 Northampton General Hospital NHS Trust 37 6 10 5 23 83.3 2.8 0.3 3 6 Royal Cornwall Hospitals NHS Trust 36 10 15 4 15 40.0 2.2 0.3 20 59 Royal United Hospitals Bath NHS Foundation Trust 35 22 9 8 12 36.4 4.5 0.5 23 65 Papworth Hospital NHS Foundation Trust 29 9 8 4 11 44.4 2.2 0.3 14 47 South Devon Healthcare NHS Foundation Trust 29 18 8 8 11 44.4 4.5 0.5 14 47 The Clatterbridge Cancer Centre NHS Foundation Trust 29 7 1 1 22 14.3 0.6 0.1 28 84 The Royal Wolverhampton NHS Trust 29 5 0 0 24 0.0 0.0 0.0 29 86 Great Western Hospitals NHS Foundation Trust 28 1 1 1 27 100.0 0.6 0.1 1 1 South London and Maudsley NHS Foundation Trust 28 15 4 4 14 26.7 2.2 0.3 26 74 Alder Hey Childrens NHS Foundation Trust 27 2 10 0 16 0.0 0.0 0.0 29 86 Aintree University Hospital NHS Foundation Trust 26 8 10 5 15 62.5 2.8 0.3 7 21 Buckinghamshire Healthcare NHS Trust 26 3 16 1 5 33.3 0.6 0.1 24 69 York Teaching Hospital NHS Foundation Trust 26 3 0 0 21 0.0 0.0 0.0 29 86 Frimley Health NHS Foundation Trust 25 18 8 8 11 44.4 4.5 0.5 14 47 Lancashire Teaching Hospitals NHS Foundation Trust 25 8 8 5 14 62.5 2.8 0.3 7 21 Northumbria Healthcare NHS Foundation Trust 25 12 9 7 10 58.3 3.9 0.5 9 27 Doncaster and Bassetlaw Hospitals NHS Foundation Trust 24 18 10 10 6 55.6 5.6 0.6 11 34 Pennine Acute Hospitals NHS Trust 24 7 5 5 17 71.4 2.8 0.3 6 13 Royal Devon and Exeter NHS Foundation Trust 24 23 12 12 0 52.2 6.7 0.8 12 38 Dartford and Gravesham NHS Trust 23 0 2 0 21 N/A 0.0 0.0 N/A N/A Sheffield Children's NHS Foundation Trust 21 6 1 1 13 16.7 0.6 0.1 27 81 The Walton Centre NHS Foundation Trust 21 7 0 0 21 0.0 0.0 0.0 29 86 Wrightington Wigan and Leigh NHS Foundation Trust 21 0 1 0 19 N/A 0.0 0.0 N/A N/A County Durham and Darlington NHS Foundation Trust 20 13 13 10 3 76.9 5.6 0.6 5 10 West Suffolk NHS Foundation Trust 20 5 10 2 6 40.0 1.1 0.1 20 59
TOTAL TOTAL TOTAL TOTAL TOTAL MEAN MEAN MEAN1087 387 263 179 598 45.2 2.9 0.3
94
Performance in Delivery
NHS provider (# quarter submitted) # Trials Analysed # Closed Trials# Trials Meeting
Target# Closed Trials Meeting Target
# Trials where Meeting the Target
is N/A
% Closed Trials Meeting Target out of Closed Trials PP
% Closed Trials Meeting Target out
of Closed Trials Meeting Target PL
% Closed Trials Meeting Target out
of Closed Trials Meeting Target All
Providers
Rank of % Closed Trials Meeting Target PP, Per
League
Rank of % Closed Trials Meeting
Target All ProvidersTOTAL TOTAL TOTAL TOTAL TOTAL TOTAL
All providers 7238 3086 2093 1551 3375 50.3
Colchester Hospital University NHS Foundation Trust 19 1 1 1 18 100.0 2.3 0.1 1 1 Derby Teaching Hospitals NHS Foundation Trust 19 17 6 6 3 35.3 13.6 0.4 11 66 Liverpool Heart and Chest Hospital NHS Foundation Trust 18 5 2 2 13 40.0 4.5 0.1 9 59 Dorset County Hospital NHS Foundation Trust 17 7 4 3 9 42.9 6.8 0.2 8 54 Gloucestershire Hospitals NHS Foundation Trust 17 4 3 1 11 25.0 2.3 0.1 14 75 North Tees and Hartlepool NHS Foundation Trust 17 7 2 1 11 14.3 2.3 0.1 19 84 The Dudley Group NHS Foundation Trust 17 0 0 0 17 N/A 0.0 0.0 N/A N/A The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Founda 17 3 2 2 15 66.7 4.5 0.1 5 17 Blackpool Teaching Hospitals NHS Foundation Trust 16 4 0 0 13 0.0 0.0 0.0 20 86 Milton Keynes Hospital NHS Foundation Trust 16 0 8 0 0 N/A 0.0 0.0 N/A N/A Birmingham and Solihull Mental Health NHS Foundation Trust 15 3 2 1 11 33.3 2.3 0.1 12 69 Mid Yorkshire Hospitals NHS Trust 15 9 3 2 5 22.2 4.5 0.1 17 80 Lancashire Care NHS Foundation Trust 14 10 8 8 4 80.0 18.2 0.5 4 8 Poole Hospital NHS Foundation Trust 14 4 2 1 5 25.0 2.3 0.1 14 75 East Sussex Healthcare NHS Trust 13 3 2 1 9 33.3 2.3 0.1 12 69 Western Sussex Hospitals NHS Foundation Trust 13 11 5 5 2 45.5 11.4 0.3 7 46 Barnsley Hospital NHS Foundation Trust 12 6 0 0 7 0.0 0.0 0.0 20 86 Avon and Wiltshire Mental Health Partnership NHS Trust 11 0 2 0 8 N/A 0.0 0.0 N/A N/A Northern Devon Healthcare NHS Trust 11 5 4 2 4 40.0 4.5 0.1 9 59 Oxford Health NHS Foundation Trust 11 6 1 1 4 16.7 2.3 0.1 18 81 The Hil l ingdon Hospitals NHS Foundation Trust 11 2 3 2 8 100.0 4.5 0.1 1 1 Worcestershire Acute Hospitals NHS Trust 11 4 3 2 8 50.0 4.5 0.1 6 40 Berkshire Healthcare NHS Foundation Trust 10 1 3 0 6 0.0 0.0 0.0 20 86 Hampshire Hospitals NHS Foundation Trust 10 2 2 2 7 100.0 4.5 0.1 1 1 Surrey and Sussex Healthcare NHS Trust 10 4 2 1 4 25.0 2.3 0.1 14 75 The Princess Alexandra Hospital NHS Trust 10 1 0 0 10 0.0 0.0 0.0 20 86
TOTAL TOTAL TOTAL TOTAL TOTAL MEAN MEAN MEAN364 119 70 44 212 38.9 3.8 0.1
95
Performance in Delivery
NHS provider (# quarter submitted) # Trials Analysed # Closed Trials# Trials Meeting
Target# Closed Trials Meeting Target
# Trials where Meeting the Target
is N/A
% Closed Trials Meeting Target out of Closed Trials PP
% Closed Trials Meeting Target out
of Closed Trials Meeting Target PL
% Closed Trials Meeting Target out
of Closed Trials Meeting Target All
Providers
Rank of % Closed Trials Meeting Target PP, Per
League
Rank of % Closed Trials Meeting
Target All ProvidersTOTAL TOTAL TOTAL TOTAL TOTAL TOTAL
All providers 7238 3086 2093 1551 3375 50.3
James Paget University Hospitals NHS Foundation Trust 9 1 0 0 7 0.0 0.0 0.0 33 99 South Essex Partnership University NHS Foundation Trust 9 2 1 1 6 50.0 1.8 0.1 17 51 The Rotherham NHS Foundation Trust 9 3 3 3 6 100.0 5.4 0.2 1 1 Bolton NHS Foundation Trust 8 5 6 5 2 100.0 8.9 0.3 1 1 East Lancashire Hospitals NHS Trust 8 4 3 3 4 75.0 5.4 0.2 12 18 George Eliot Hospital NHS Trust 8 5 3 2 2 40.0 3.6 0.1 28 78 Leicestershire Partnership NHS Trust 8 0 2 0 5 N/A 0.0 0.0 N/A N/A Medway NHS Foundation Trust 8 0 2 0 6 N/A 0.0 0.0 N/A N/A Northern Lincolnshire and Goole NHS Foundation Trust 8 0 0 0 1 N/A 0.0 0.0 N/A N/A Northumberland Tyne and Wear NHS Foundation Trust 8 5 4 2 1 40.0 3.6 0.1 28 78 Salisbury NHS Foundation Trust 8 4 0 0 4 0.0 0.0 0.0 33 99 Somerset Partnership NHS Foundation Trust 8 0 0 0 8 N/A 0.0 0.0 N/A N/A Taunton and Somerset NHS Foundation Trust 8 1 1 0 6 0.0 0.0 0.0 33 99 United Lincolnshire Hospitals NHS Trust 8 1 2 1 6 100.0 1.8 0.1 1 1 5 Boroughs Partnership NHS Foundation Trust 7 4 2 2 4 50.0 3.6 0.1 17 51 Basildon and Thurrock University Hospitals NHS Foundation Trust 7 0 1 0 6 N/A 0.0 0.0 N/A N/A City Hospitals Sunderland NHS Foundation Trust 7 0 2 0 5 N/A 0.0 0.0 N/A N/A Epsom and St Helier University Hospitals NHS Trust 7 2 0 0 7 0.0 0.0 0.0 33 99 Liverpool Womens NHS Foundation Trust 7 4 2 2 3 50.0 3.6 0.1 17 51 Peterborough and Stamford Hospitals NHS Foundation Trust 7 2 1 1 5 50.0 1.8 0.1 17 51 Sussex Partnership NHS Foundation Trust 7 3 2 2 4 66.7 3.6 0.1 14 26 The Whittington Hospital NHS Trust 7 3 3 2 3 66.7 3.6 0.1 14 26 University Hospitals Of Morecambe Bay NHS Foundation Trust 7 2 1 1 5 50.0 1.8 0.1 17 51 Weston Area Health NHS Trust 7 0 0 0 7 N/A 0.0 0.0 N/A N/A Homerton University Hospital NHS Foundation Trust 6 1 1 1 5 100.0 1.8 0.1 1 1 Ipswich Hospital NHS Trust 6 2 3 1 2 50.0 1.8 0.1 17 51 Manchester Mental Health and Social Care Trust 6 0 3 0 2 N/A 0.0 0.0 N/A N/A Sherwood Forest Hospitals NHS Foundation Trust 6 0 0 0 6 N/A 0.0 0.0 N/A N/A St Helens and Knowsley Hospitals NHS Trust 6 4 3 3 2 75.0 5.4 0.2 12 18 Stockport NHS Foundation Trust 6 6 3 3 0 50.0 5.4 0.2 17 51 Yeovil District Hospital NHS Foundation Trust 6 2 2 1 4 50.0 1.8 0.1 17 51 Birmingham Womens NHS Foundation Trust 5 2 1 0 0 0.0 0.0 0.0 33 99 Central and North West London NHS Foundation Trust 5 0 1 0 4 N/A 0.0 0.0 N/A N/A Coventry and Warwickshire Partnership NHS Trust 5 3 4 3 1 100.0 5.4 0.2 1 1 East Cheshire NHS Trust 5 5 1 1 0 20.0 1.8 0.1 32 95 Maidstone and Tunbridge Wells NHS Trust 5 1 0 0 5 0.0 0.0 0.0 33 99 Nottinghamshire Healthcare NHS Foundation Trust 5 3 1 1 2 33.3 1.8 0.1 30 87 Sheffield Health & Social Care NHS Foundation Trust 5 0 0 0 5 N/A 0.0 0.0 N/A N/A The Queen Elizabeth Hospital Kings Lynn NHS Foundation Trust 5 3 0 0 2 0.0 0.0 0.0 33 99
96
Performance in Delivery
NHS provider (# quarter submitted) # Trials Analysed # Closed Trials# Trials Meeting
Target# Closed Trials Meeting Target
# Trials where Meeting the Target
is N/A
% Closed Trials Meeting Target out of Closed Trials PP
% Closed Trials Meeting Target out
of Closed Trials Meeting Target PL
% Closed Trials Meeting Target out
of Closed Trials Meeting Target All
Providers
Rank of % Closed Trials Meeting Target PP, Per
League
Rank of % Closed Trials Meeting
Target All ProvidersTOTAL TOTAL TOTAL TOTAL TOTAL TOTAL
All providers 7238 3086 2093 1551 3375 50.3
Warrington and Halton Hospitals NHS Foundation Trust 5 0 1 0 3 N/A 0.0 0.0 N/A N/A Hinchingbrooke Health Care NHS Trust 4 1 3 0 0 0.0 0.0 0.0 33 99 Kettering General Hospital NHS Foundation Trust 4 2 0 0 2 0.0 0.0 0.0 33 99 Leeds Community Healthcare NHS Trust 4 4 1 1 3 25.0 1.8 0.1 31 92 Luton and Dunstable University Hospital NHS Foundation Trust 4 2 0 0 2 0.0 0.0 0.0 33 99 Mid Cheshire Hospitals NHS Foundation Trust 4 0 0 0 4 N/A 0.0 0.0 N/A N/A Norfolk and Suffolk NHS Foundation Trust 4 3 2 2 1 66.7 3.6 0.1 14 26 North Cumbria University Hospitals NHS Trust 4 0 0 0 4 N/A 0.0 0.0 N/A N/A South Tyneside NHS Foundation Trust 4 0 0 0 3 N/A 0.0 0.0 N/A N/A West Hertfordshire Hospitals NHS Trust 4 2 2 1 2 50.0 1.8 0.1 17 51 Wirral University Teaching Hospital NHS Foundation Trust 4 1 0 0 3 0.0 0.0 0.0 33 99 Bedford Hospital NHS Trust 3 1 1 1 2 100.0 1.8 0.1 1 1 Cambridgeshire and Peterborough NHS Foundation Trust 3 1 0 0 1 0.0 0.0 0.0 33 99 Devon Partnership NHS Trust 3 2 0 0 1 0.0 0.0 0.0 33 99 Hertfordshire Partnership University NHS Foundation Trust 3 0 1 0 2 N/A 0.0 0.0 N/A N/A Lewisham and Greenwich NHS Trust 3 0 0 0 3 N/A 0.0 0.0 N/A N/A Lincolnshire Partnership NHS Foundation Trust 3 2 3 2 0 100.0 3.6 0.1 1 1 North East Ambulance Service NHS Foundation Trust 3 0 1 0 2 N/A 0.0 0.0 N/A N/A North Essex Partnership University NHS Foundation Trust 3 2 2 2 1 100.0 3.6 0.1 1 1 Queen Victoria Hospital NHS Foundation Trust 3 2 1 1 1 50.0 1.8 0.1 17 51 Southern Health NHS Foundation Trust 3 1 0 0 2 0.0 0.0 0.0 33 99 Surrey and Borders Partnership NHS Foundation Trust 3 0 0 0 3 N/A 0.0 0.0 N/A N/A Cornwall Partnership NHS Foundation Trust 2 2 2 2 0 100.0 3.6 0.1 1 1 Gateshead Health NHS Foundation Trust 2 0 2 0 0 N/A 0.0 0.0 N/A N/A Solent NHS Trust 2 1 2 1 0 100.0 1.8 0.1 1 1 South Staffordshire and Shropshire Healthcare NHS Foundation Tru 2 1 1 0 1 0.0 0.0 0.0 33 99 West Middlesex University Hospital NHS Trust 2 2 1 1 0 50.0 1.8 0.1 17 51 Airedale NHS Foundation Trust 1 1 0 0 1 0.0 0.0 0.0 33 99 Burton Hospitals NHS Foundation Trust 1 0 0 0 1 N/A 0.0 0.0 N/A N/A Cheshire and Wirral Partnership NHS Foundation Trust 1 0 0 0 1 N/A 0.0 0.0 N/A N/A Cumbria Partnership NHS Foundation Trust 1 0 1 0 0 N/A 0.0 0.0 N/A N/A Derbyshire Healthcare NHS Foundation Trust 1 1 0 0 0 0.0 0.0 0.0 33 99 Dorset Healthcare University NHS Foundation Trust 1 1 0 0 0 0.0 0.0 0.0 33 99 Isle of Wight NHS Trust 1 0 0 0 0 N/A 0.0 0.0 N/A N/A Mersey Care NHS Trust 1 1 0 0 0 0.0 0.0 0.0 33 99 Norfolk Community Health and Care NHS Trust 1 0 0 0 1 N/A 0.0 0.0 N/A N/A North East London NHS Foundation Trust 1 0 0 0 1 N/A 0.0 0.0 N/A N/A North Staffordshire Combined Healthcare NHS Trust 1 0 0 0 1 N/A 0.0 0.0 N/A N/A South West Yorkshire Partnership NHS Foundation Trust 1 1 0 0 0 0.0 0.0 0.0 33 99 Tameside Hospital NHS Foundation Trust 1 0 0 0 0 N/A 0.0 0.0 N/A N/A Tees Esk and Wear Valleys NHS Foundation Trust 1 1 1 1 0 100.0 1.8 0.1 1 1 The Royal Orthopaedic Hospital NHS Foundation Trust 1 0 0 0 1 N/A 0.0 0.0 N/A N/A Walsall Healthcare NHS Trust 1 0 1 0 0 N/A 0.0 0.0 N/A N/A West London Mental Health NHS Trust 1 0 1 0 0 N/A 0.0 0.0 N/A N/A Wye Valley NHS Trust 1 1 0 0 0 0.0 0.0 0.0 33 99
TOTAL TOTAL TOTAL TOTAL TOTAL MEAN MEAN MEAN373 122 94 56 206 40.7 1.2 0.0
97
98
Agenda Item: 54/15a
Meeting of the Board of Directors
Friday 30th October 2015
Report of Executive Director of Nursing and Quality
Paper prepared by Head of Safety & Risk
Subject/Title Review of Year 1 progress of the 2014-17 Risk Management Strategy
Background papers
Risk Management Strategy 2014-17
Health Foundation; Framework for Measuring and Monitoring Safety 2014
Board and committee papers
Internal Audit reports
Purpose of paper • To present the Year One review of the effectiveness of the 2014-2017 risk management strategy
Action/Decision required • To approve the Year One outcomes of the Risk
Management Strategy and confirm year 2 milestones continue to meet the Trust’s requirements.
Link to:
NHS Strategies and Policy
Monitor’s Governance Framework
CQC Outcomes Framework
Link to:
Trust’s Strategic Direction
Corporate Objectives
Christie Commitment
Christie Five Year Strategy
Corporate Objective (1); to demonstrate excellent and equitable clinical outcomes and patient safety, patient experience and clinical effectiveness.
Impact on resources and risk and assurance profile
You are reminded that resources are broader than finance and also include people, property and information.
None
You are reminded not to use acronyms or abbreviations wherever possible. However, if they appear in the attached paper, please list them in the adjacent box.
DRC; Document Ratification Committee
Q&S; Quality and Standards
R&QGC – Risk and Quality Governance Committee
RAG; Red, Amber, Green
RCA; root cause analysis
99
100
Agenda Item: 54/15a
Meeting of the Board of Directors Friday 30th October 2015
1. Introduction 1.1 The 2014-2017 risk management strategy was ratified at the September 2014 Board of
Directors meeting and reaffirmed the Trust’s commitment to implementing the principles of high quality governance, supported by an effective risk management system designed to deliver improvements in patient safety and care as well as the safety of its staff, patients and visitors.
1.2 The strategy provided a structured approach to the management of financial, organisational, reputational, clinical and projects risks. It was tested during the PWC review of the ‘Well Led’ domain and during the Monitor CQC preparatory review and no concerns were raised with regarding risk management.
1.3 The Strategy was developed using the five elements of the Health Foundation’s 2014 Framework for measuring and monitoring safety. Each of the five elements have key milestones in place in order to:
a) Ascertain whether it has been safe for patients, staff and others in the past; b) Identify whether our systems and processes are reliable; c) Ensure sensitivity to operations so that we are safe in the present; d) Anticipate and prepare to ensure that we will be safe in the future; e) Integration and learning to ensure we are responding and learning as appropriate.
1.4 The initial scoping of the status of the Trust against these five elements was carried out by
the Quality and Standards team working with divisional colleagues.
1.5 Following the review the trust’s systems and processes for risk management were re-defined and very good progress has been made in year one. Key achievements to highlight are:
• The real engagement of staff in the Trust wide safety culture survey and the following diagnostic work in the divisions; 101
• The input into the development of a ‘Never @The Christie Event’ list;
• The introduction of Human Factors work within the Trust.
• The joined up cross divisional working of the Quality Managers and the Quality and Standards team as a ‘Governance Leads Forum’ where issues are discussed and solutions developed.
1.6 During the year the Board has had development as part of a Greater Manchester wide programme of Making Safety Visible. As part of the pre-development of the course we were reviewed by Jane Carthey a human factors consultant and co-author of the Health Foundation model used for the Risk Management Strategy and she advised that we were at the stage of anticipation and preparedness based on the information she had reviewed.
2. Milestones to achieve in Year One of the 2014-2017 risk management strategy.
2.1 A number of key milestones were identified for year one implementation of the strategy; by the end of year one the intention was to have:
1. Designed and implemented communication systems to ensure that both reactive and proactive messages about safety reach all areas of the Trust;
2. Undertaken a gap analysis to assess the extent to which human factors methodology is a part the Trust’s risk management systems and processes and to have introduced Human Factors Training;
3. Implemented formal patient safety and Quality walkrounds at Executive level; 4. All risks of grade 10 and above underpinned by a risk assessment that has been
approved at departmental level and all grade 12 and above at divisional level and are managed using the Datix database risk register module;
5. Been actively involved in the sign up for safety campaign; 6. Risks identified during clinical audit managed using Trust risk management processes
and monitored by parent committees and managed at departmental levels; 7. Undertaken diagnostic work at divisional level on the outcome of the staff safety culture
survey.
3. Evaluation of Year One of the 2014-2017 risk management strategy. 3.1 The following table gives examples indicating how the individual milestones have been
achieved.
Milestone Progress
Designed and implemented communication systems to ensure that both reactive and proactive messages about safety reach all areas of the Trust;
• A ‘Safety Matters’ section has been included in team brief to cascade key messages;
• A monthly ‘Governance Leads Forum’ has been established, attended by Q&S Division and those people working in governance or standards roles within the other divisions;
• The Library Manager has developed a 2 page ‘safety newsletter’ for cascading information about a particular issue;
• The ‘Grand Round’ has been used to cascade incident investigation reports and other governance information, for example Duty of candour as part of Trust wide learning:
• Toolbox talks (facilities) and safety huddles (clinical areas) have been established;
• There is a proposal that DRC should receive key highlights of policy & which staff groups should be informed as part of process.
Undertaken a gap analysis to assess the extent to which human factors methodology is a part the Trust’s risk
• An independent consultant spent time with The Head of Safety & Risk and also gave a Grand Round presentation;
• Human Factors training has been written and piloted; The July meeting of the E&TC approved its inclusion in the Trust 102
Milestone Progress
management systems and processes and introduced Human Factors Training;
Training Prospectus and the first session will be open to all Trust staff in October 2015.
Implemented formal patient safety & Quality walkrounds at Executive level;
• Walk-rounds have been implemented, with 36 being undertaken within year one of this strategy. They are well received by staff. Examples of actions implemented as a result of the walk-round: - Different wheel chairs for patients who parked in the multi-
story car park as the standard ones are difficult to push over uneven ground
- Additional TV screens for the out-patient department - Consideration of implementing blister packs for take home
medication to facilitate speedier discharge.
All risks of grade 10 and above underpinned by a risk assessment that has been approved at departmental level and all grade 12 and above at divisional level and are managed using the Datix database risk register module;
The source of evidence used to assess progress against this milestone was the Datix database. Four risks from each divisional risk register were randomly selected; all the grade 15 risks were reviewed, together with a mix of grade 12s and 10s.
It has been difficult to assure progress against this milestone; only two of the divisions with risks of grade 12 and above had risk assessments uploaded to Datix. Previous audits undertaken for the NHSLA Level 3 assessment found good compliance with the requirement to undertake risk assessments.
Key to this milestone was that risks were assessed and the risk assessment uploaded to Datix. Hence, further work is needed to assure that this particular Y1 milestone has been met.
Been actively involved in the sign up for safety campaign;
Two ‘Sign up to Safety’ projects have commenced 1. Assessment tool to be designed when treating older people
with chemotherapy 2. Sepsis six project
Both teams are undertaking ISA4C (Improvement Skills for Academics) training.
Risks identified during clinical audit managed using Trust risk management processes and monitored by parent committees and managed at departmental levels;
• The Trust has implemented a new software system (HealthAssure) which has a clinical audit module. This module includes a RAG rating for audit outcomes and is therefore now flagging poor outcomes in red,
• The RAG outcomes are being included in quarterly programme updates and annual report and the clinical audit team are rolling out access to dashboards and views with RAG project status and RAG outcomes;
• A risk section has been added to the clinical audit report template; if a risk is identified, it prompts the next steps;
• Audits are being identified or triangulated via ERG action plans; e.g. management of patients commenced on steroids in OP clinics;
• Risks are identified when the quarterly ‘Patient Safety and Experience Report’ is written;
• Examples of risks added to the risk register include - Extravasation audit - Maintenance of Consent Competence Databases;
• A major piece of work has been undertaken by the Clinical Audit team, working with colleagues across the trust, to reduce the number of audits open beyond their deadline.
Undertaken diagnostic work • The diagnostic work completed & approved at Patient Safety 103
Milestone Progress
at divisional level on the outcome of the staff safety culture survey.
Committee; this has been to feedback outcomes of incident investigations to local levels.
• Recent survey of progress regarding this feedback has identified some excellent examples of practice and work is on-going to embed this across all areas of the Trust and the action to deliver this was discussed at the July Governance leads forum.
• A hierarchy of incident types has been set up for two of the non-clinical divisions who did not have a speciality specific incident hierarchy.
• A ‘TalkSafety’ pilot is being undertaken in September with the trainee doctors. The intention is to eventually roll this out to trainees in all professional groups. A key area being explored in the pilot is around escalation of concerns.
4. Conclusion 4.1 This report forms the year one review of the 2014-17 Risk Management Strategy and
indicates that good progress has been achieved in reaching the Year One milestones.
4.2 Our year two milestones are as follows:
• To ensure risk assessments underpin the grade 10+ risks and to audit this again in January 2016;
• To implement and embed Trust wide training in human factors methodology as appropriate;
• Establish a system for safety champions at departmental level; • A risk assessment library populated to facilitate the production of risk assessments; • Implement a set of internal ‘Never @ Christie Events’; • Scope where we need to invite, or improve, patient and carer involvement in safety &
risk systems; • Introduce two awareness weeks per year around safety & risk issues; • Participate as a key player in patch-wide and peer group safety and risk networks;
4.3 In addition to this and as a result of the Board development programme during Making Safety Visible, a programme of work in partnership with Manchester Cancer will be undertaken to scope near miss and incident reporting across cancer pathways.
4.4 This strategy update has been presented to the Risk & Quality Governance Committee and Management Board. Both committees are supportive of the year 2 milestones and were positive about the achievements of year 1 milestones. Both committees agreed the importance of ensuring risk assessments for all grade 10+ risks.
5. Recommendation 5.1 The Board of Directors is asked to approve the Year One outcomes of the Risk
Management Strategy and confirm the year 2 milestones continue to meet the Trust’s requirements.
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Agenda item 54/15b
Meeting of the Board of Directors Friday 30th October 2015
Report of Executive Director of Finance & Business
Development
Paper prepared by Suzanne Robinson, Deputy Director of Finance
Liesl Hacker, Assistant Director of Finance Strategy
Subject/Title 2016/17 Commissioning Intentions
Background papers Improving Value for patients from Specialised Care – Commissioning Intentions 2016-17 for Prescribed Specialised Services
Purpose of Paper To update the Board of Directors
Action/Decision required The Board of Directors is asked to; Note the content of this report
Receive regular updates in the run up to
contract signing for 2016-17 as part of the finance report
Link to:
NHS strategies and policy
National Tariff Document 2015-16
NHS Planning Guidance
Monitor Compliance framework
Link to:
Trust’s Strategic Direction
Corporate objectives
To provide leadership within the local network of cancer care
To maintain excellent operational and financial performance.
Resource impact Nil
Risk rating 16
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You are reminded not to use acronyms or abbreviations wherever possible. However, if they appear in the attached paper, please list them in the adjacent box.
IR- Information Rules
PSS – Prescribed Specialised Services
CCG – Clinical Commissioning Group
PET-CT - Positron Emission Tomography and Computerised Tomography imaging
CDF – Cancer Drugs Fund
POC – Programme of Care
IFR - Individual Funding Request
FT – Foundation Trust
Linac – Linear Accelerator
BMT – Blood and Marrow Transplants
IOG – Improving Outcomes Guidance
PHE – Public Health England
CUR – Clinical Utilisation Review
CRG – Clinical Reference Group
CCP – Clinical Commissioning Policy
QST – Quality Surveillance Team
NICE – National Institute for Health and Care Excellence
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Agenda item 54/15b
Meeting of the Board of Directors Friday 30th October 2015
2016-17 Commissioning Intentions
1. Background NHS England published its commissioning intentions for 2016-17 on 30 September 2015. These respond to the Five Year Forward View and build on progress to deliver sustainable consistent care standards within constrained funding.
The Specialised Services focus in 2016-17 is centred around a number of key principles;
Supporting new models of care through cluster/lead provider based commissioning, commissioning
around major centres and around service bundles, not providers, to provide long-term sustainable service models.
Collaborative commissioning with CCGs to commission full end-to-end service pathways within service bundles.
Shaping provision of services through service reviews and competitive process.
Strengthening quality assurance, intelligence and analytics to ensure quality and to ensure commissioning for value, via improved dashboards, the National Quality Surveillance Team visits and self-assessments.
2. Introduction The Trust has received 2 documents in relation to Commissioning Intentions;
Specialised Commissioning Team Commissioning Intentions 2016-17 (Local)
Commissioning Intentions 2016-17 for Prescribed Services (National) 3. Local Commissioning Intentions
These outline the Commissioning Intentions specific to our Trust. They are to be read in conjunction with the National Commissioning Intentions to ensure there are clear plans from a local and national perspective.
The specific items for noting include;
The Specialised Commissioning hub team are working closely with the Devolution Manchester team
to fully understand the impact of devolution on the Specialised Commissioning portfolio. Once this is clarified this will be discussed with the trust. This could potentially lead to changes in the way in which the services are contracted and managed in 2016-17.
Impact: We are working closely with Manchester Devolution to develop the 11th locality plan which will include all specialised services.
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Attention is drawn to the consistent application of the Identification Rules as detailed in the National Specialised Commissioning Intentions. As a result of this review NHSE will wish to revisit the decision that Specialised Commissioning are responsible for 100% of services in the Christie contract; as the direction of travel is that Specialised Commissioning should commission services consistent with the Identification Rules.
Impact: A significant number of our services will be co-commissioned by NHSE and Trafford CCG from April 2016. Contract negotiations will also take place on this basis.
NHSE note that The Christie have been awarded Vanguard Status, in conjunction with Trafford
CCG, and will work with us to identify to identify the implications of this. Impact: The Vanguard model could see a different commissioning and pricing approach.
4. National Commissioning Intentions
Key areas impacting on the Trust are:
Strengthening Commissioning Where improvements in quality and efficiency could occur, NHSE will explore three year, rather than annual, contracts. This could provide stability for the Trust through a period of service transformation. Service Reviews, Transformation and Competitive Processes NHSE will ensure that services are commissioned from the most capable providers in an open and transparent way through a published Strategic Services Review Programme. They expect there to be more networks of specialist providers and greater re-shaping of supply models and contracting approaches to integrated care around patients. Service reviews will also provide opportunity for providers to propose sustainable solutions in line with clinically developed requirements. Where the relationship between quality, value and patient volumes is strong NHSE expect there will be a consolidation of some services as a consequence of undertaking reviews. Reviews currently underway with a transformational impact, which may impact the Trust, in 2016-17 include;
Stereotactic radiosurgery/radiotherapy PET-CT Genomic Laboratories Drugs and devices Proton beam therapy
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Specialist Endocrinology - Co-commissioning opportunities and links with national priorities on obesity and diabetes are proposed with a co-ordinated development approach. Adult Critical Care (ACC) – It is anticipated that ACC service specifications will be implemented and put into Provider contracts in the autumn of 2015. Stereotactic radiosurgery/radiotherapy – A competitive procurement process is likely. PET-CT services – A competitive procurement process is likely. Cytoreductive Surgery with HIPEC for peritoneal carcinomatosis – A decision will be made on the approach to commissioning of services to meet the national caseload. Further Commissioning through Evaluation (CtE) will be considered for some renal and HPB services, although it isn’t stated whether these would relate to cancer or not. Specifically in the North;
• A plan will be agreed to achieve NICE Improving Outcomes Guidance (IOG) compliant Oesophago-
Gastric and Urology cancer services in Greater Manchester.
• There will be further development of a strategic partnership between Mid-Cheshire NHS FT and University Hospitals North Midlands Trust [Stronger Together] to provide better cancer services for South Cheshire populations; gynaecology cancer and possibly urology noted. This is area where the trust needs to pay close attention to fully understand the impact and risk to our service.
• There is proposed further development of a community model for the delivery of chemotherapy to
low risk cancer patients in Greater Manchester.
Improving Quality The improving quality work programme will be delivered by the newly established Quality Surveillance Team (QST), supported by improvements in the specialised commissioning quality dashboards. Services previously covered by the national Peer Review Team will continue to be monitored by the QST with targeted visits of Head and Neck, Urology and Upper-Gastro Intestinal cancer services. Providers will be required to complete self-declarations of compliance with service standards and identify derogations. Implementation of National Cancer Taskforce Findings NHSE will be working with partners to implement the findings of the Cancer Taskforce; which set out an ambitious 5 year programme of change for cancer services in the NHS to improve survival and patient experience. During 2016-17 NHSE will be seeking to work with providers and other stakeholders to implement a range of recommendations contained within the strategy. One specific focus will be on the enabling and improving population based commissioning and supply side innovation. They will be seeking, through a vanguard approach, partners to pilot;
Commissioning of the entire cancer pathway in a least 1 area – diagnosis, treatment and living with
and beyond cancer and end of life care. The pilot will test a fully devolved budget for that population, to be delivered over multiple years and which may involve the introduction of population based payments model based on pre-specified set of clinical and patient outcomes.
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Supply side innovation through the introduction of a lead provider approach to manage secondary/tertiary cancer treatment services. The lead would manage the entire budget.
The Trust’s successful Vanguard bid will provide a vehicle to be at the forefront of the delivery of many of the National Taskforce recommended developments.
Chemotherapy It is proposed that a suite of chemotherapy algorithms detailing routinely available chemotherapy treatments will be developed. Treatments outside of these algorithms would require Individual Funding Request (IFR) approval. This is not considered to be a significant concern for the Trust. Roll-out of dose standardisation in chemotherapy is expected in 2016-17. The Christie’s pharmacy team is intrinsically involved in the national project and implementation plans. NHSE intends to pay on a drug specific procurement basis and not on chemotherapy procurement bands. There is a risk that Christie pharmacy and other associated costs would not be appropriately reimbursed under this approach. Radiotherapy A Clinical Commissioning Policy (CCP) will be published for rapid implementation of the changes in clinical practice for prostate radiotherapy recommended by the CHHIP trial. As this is already in operation at the Christie, there would be no operational impact, but there is a need for NHS England to consider appropriate reimbursement of providers adopting this amended clinical practice.
Consideration is being given to a review of radiotherapy tariffs to support the replacement of aging Linear Accelerators. This would be positive for the Trust and we are actively involved in the groups taking this forward from a payment perspective.
Value for Money and Consistency BMT currency - It is proposed that a consistent currency will be developed for the reimbursement of BMT, with a view to shadow monitoring in 2016-17. This will be followed in future years by national mandatory tariffs. High Cost Drugs - The high cost excluded drugs covered by Blueteq, requiring prior approval, will be expanded to all high cost excluded drugs where an NHS England commissioning policy or NICE Technical Appraisal exists. This could lead to a significant administrative burden on the Contracting Team. Clinical Utilisation Review (CUR) - CUR would be mandated for the Christie. This would be implemented at the Trust’s expense, supported by CQUIN funding. The Trust has an in-house developed Electronic Patient Record (EPR) system that supports some of the objectives of the CUR currently and our development roadmap will address the remaining objectives over the coming years. A challenge is being lodged in relation to this given the duplication with existing system and strategy. National Tariff Development - As a result of the implementation of HRG4+ and proposed amended top-ups, NHS England doesn’t propose to make payments above mandatory national tariff. The Trust currently has a number of local tariffs where nationally mandated tariffs exist. The refresh of the concept of specialist top ups is expected to reward the trust for a number of service lines. The details are current being worked through.
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5. Next Steps
The Trust will formally respond to NHS England’s commissioning intentions by the end of this October 2015 and will discussed in detail with commissioners during the 2016-17 contract negotiation process, which will commence in earnest in December 2015-January 2016. Updates will be included within the monthly finance report to the Board of Directors.
The full impact of the IR will be modelled in October which will confirm the commissioning arrangements for 2016-17. This will need to be considered in line with the Vanguard model and Manchester Devolution.
6. Recommendations
The Board of Directors is asked to: Note the content of this report
Receive regular updates in the run up to contract signing for 2016-17
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Agenda item 55/15a
Meeting of the Board of Directors Friday 30th October 2015
Report of
Executive director of finance & business development Chief operating officer Executive director of nursing and quality
Paper prepared by Deputy director of finance Assistant director of finance Head of performance Executive director of nursing and quality Company secretary
Subject/Title
Monitor declaration for quarter 2 submission
Background papers (if relevant)
Purpose of Paper
To present the draft narrative that will be submitted to Monitor together with the Board of Directors’ declaration
Action/Decision required To approve the submission
Link to: NHS strategies and policy
Monitor’s Risk Assessment Framework
Link to: Trust’s Strategic Direction Corporate objectives
Strategic objective 1. NHS Services – Continue to meet the overarching financial and quality requirements of the Care Quality Commission, Department of Health and Monitor.
Resource impact None
You are reminded not to use acronyms or abbreviations wherever possible. However, if they appear in the attached paper, please list them in the adjacent box.
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Agenda item 55/15a
Meeting of the Board of Directors
Friday 30th October 2015
Monitor Declaration for Quarter 2 submission
1. Introduction The Risk Assessment Framework sets out the approach Monitor will take to monitoring risks to foundation trusts' compliance with their financial and governance licence conditions and for triggering further investigation when necessary. The basic principle is one of self-regulation with trusts being required to report in-year on a quarterly basis and more frequently as required by Monitor should risks emerge. The form of reporting is a linked spreadsheet displaying the income and expenditure, balance sheet and cash flow actuals against the annual plan. There is also an analysis on significant financial variances and other exceptional issues, a governance report which certified compliance against key performance targets, a governance statement and a self-assessment table against a number of measures which give early warnings of the potential for a trust to have financial failings. Details of any elections held are also included in this return. There are four declarations/board statements to be signed: Finance Declaration - The board anticipates that the trust will continue to maintain a Continuity of Service risk rating of at least 3 over the next 12 months. The Board anticipates that the trust's capital expenditure for the remainder of the financial year will not materially differ from the amended forecast in this financial return. Governance Declaration - The board is satisfied that plans in place are sufficient to ensure: ongoing compliance with all existing targets (after the application of thresholds) as set out in Appendix A of the Risk Assessment Framework; and a commitment to comply with all known targets going forwards. Otherwise - The board confirms that there are no matters arising in the quarter requiring an exception report to Monitor (per the Risk Assessment Framework page 22, Diagram 6) which have not already been reported. The contents of these declarations were specified in Monitor's Risk Assessment Framework. In the event than an NHS foundation trust is unable to confirm these statements it should not select 'Confirmed’ in the relevant box. It must provide a response explaining the reasons for the absence of a full certification and the action it proposes to take to address it. This may include any significant prospective risks and concerns the foundation trust has in respect of delivering quality services and effective quality governance. Monitor may adjust the relevant risk rating if there are significant issues arising and this may increase the frequency and intensity of monitoring for the NHS foundation trust. In addition, the board is asked to declare the number of subsidiaries included in the finances of the return, whilst ensuring the results of any NHS charitable funds are not included.
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2. Narrative report and declarations
The narrative that will be submitted to Monitor is attached at Appendix A together with the four declarations at Appendix B. All four declarations will be submitted as confirmed. The number of subsidiaries is declared as nil.
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Appendix A
Monitor Declaration for Quarter 2 submission 1. Finance 1.1 Income & expenditure
We are reporting an income and expenditure surplus for the half year to 30th September 2015 of £3.525m, which is £0.824m below plan. Our trading surplus, which excludes technical adjustments for impairments and charitably funded capital donations, is £0.752m, £0.252m above plan. EBITDA (as defined by Monitor) is £0.538m better than plan. NHS clinical income is £0.506m above the plan for the half year. Donations received of cash to buy PPE & intangible assets are below plan by £1.076m due to the planned timing of charitably funded capital expenditure against the evenly phased income target. This is expected to return to plan by the end of the financial year. Increases in other income include commercial income and income from service agreement trading with The Christie Clinic and The Christie Pathology Partnership. Our expenditure to date includes the costs required to deliver the additional activity in these areas. The Charity contribution is below plan and matches expenditure. Research income is below plan, matched to reduced expenditure reflecting the timings of a significant CRUK major centre grant. Pay costs are below plan for the half year by £0.395m. This includes a favourable variance of £0.630m on charitably funded posts (matched by income), offset by an adverse variance of £0.037m on agency costs. This position reflects planned vacancies as part of our medium term measures to control costs and reducing agency usage. Drug expenditure is below plan by £0.294m, with drugs (excluding pass through costs) being below plan by £0.054m, and pass through drugs being £0.240m below plan and therefore offset by reduced income. Expenditure on pass through costs accounted on a gross basis are below plan by £0.240. Interest receivable, depreciation, impairments, dividend costs and interest payable are in line with plan. The Christie Clinic joint venture continues to perform well and is ahead of its business plan, driven by patient activity and volumes. The Trust’s share of private patient income from the equity accounted joint venture is below our straight line plan by £0.329m. In line with the contractual arrangements, the Trust is due the first £2.087m generated by TCC in the 2015 financial year. The Trust received its allocation of distributable profits for the 2015 calendar year in the 2014-15 Trust financial year. However, TCC has generated sufficient profits in 2015 to trigger additional distributable profits in excess of contractual levels to the Trust of £1.714m as at September 2015.
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1.1.1 CIP As reported through the annual plan, the transformation board and Programme Management Office (PMO) we invested in in January 2012 continues to have a significant positive effect on efficiency programme. As at Q2, 100.0% of in-year CIP (£2.730m) has been removed from budgets through both recurrent schemes and non-recurrent schemes (including revenue generation), with the requirement for mitigation from reserves being less than plan. Full year, 62.6% of CIP (£3.417m) has been removed recurrently from budgets. The Trust has identified 100% of the recurrent target through risk-assessed schemes. Work is therefore progressing on these further schemes, which are subject to quality impact assessment and confirmation of key milestones. In total our transformational programme is designed to deliver a risk assessed value of £5.460m recurrently. Q2 programme milestones have been achieved (50% recurrent CIP achieved), and we are on track to deliver Q3 milestones (88%) within our PMO. Action plans are developed to mitigate and recover any slippage against the overall plan, with the transformational board and its sub-committees monitoring progress.
1.2 Cash flow
The exchequer cash balance, excluding current asset investments, at the end of September stands at £41.154m, which is £2.479m below plan. This is predominantly due to below plan PDC drawdown in relation to the Proton Beam Therapy project aligned to the slippage on the programme, offset by the improved EBITDA and improvements in working balances and capital creditors, along with reduced capital expenditure.
1.3 Balance sheet
Non current assets are below the Q2 plan by £1.501m. This position reflects capital expenditure slippage, partially offset by above plan JV investment as a result of a slippage in the planned cash distribution from the private patient joint venture. Net current assets are £13.246m below plan. This reflects:
• the below plan cash position of £2.479m • below plan stock of £0.021m • above plan debtors/accrued income/prepayments of £0.603m • above plan capital creditors of £6.310m • above plan creditors/liabilities of £5.038m
Debtor days are 8 against our internal target of 12 days, in line with quarterly and year-end trend. Debt within 30 days accounts for 48% of total debt, whilst debt over 90 days accounts for 11%. Performance against the 30 day and 10 day public sector payment policies are:
• 30 days policy 96.3% against a target of 95% • 10 days policy 76.9% against a target of 80%
There have been no revisions of the investment in Kaupthing, Singer and Friedlander in Q2. Therefore as at 30th September 2015, the Trust’s investment remains at £25k.
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1.4 Strategic Capital Projects
The Trust has a number of capital projects as identified within the annual plan, and these are continuing to progress to programme, with the exception of the externally managed Manchester Cancer Research Centre and Maggie’s Centre projects. A brief update on each is set out below. Manchester Cancer Research Centre (MCRC) Following previously reported delays in the completion of the MCRC, the centre has now been completed and handed over to the University of Manchester for fit out, which is underway. The building is due to be fully operational by the end of 2015. The Christie has been allocated space on the 2nd floor of the building and research and development services from disparate accommodation around the Trust have now moved into the building. This will enable greater integration with both the University of Manchester and CRUK. Proton Beam Therapy The Department of Health have announced a £250m investment for a national proton beam therapy service from 2 centres – one at The Christie and one at University College London Hospitals (UCLH). Contract Stage 4 (Construction phase) of the project has commenced with the agreed Target Cost figure of £67.8m. The scheme is progressing against Revision 2 of the Construction Programme. The Enabling Works have concluded with the completion of the reduced level dig, King Post retaining wall and piling mat installation. Main piling works commenced on 18th August 2015 and are due to continue for 9 weeks. These works are progressing to programme. Outpatients and Inpatient reorganisation Design options are being developed for new facilities for outpatient and inpatient accommodation to replace the existing areas which are within our older estate and include nightingale ward facilities, as part of the Trust’s wider estates strategy. Integrated Procedures Unit This facility will co-locate 5 ambulatory services currently situated in disparate locations. Following indications from market testing that the final GMP would be in excess of original estimates, a further round of detailed design and cost reviews, including external moderation, has been undertaken. A revised business case is progressing through the Trust’s governance structure in October, and subject to approval, the project is now expected to start on site in February 2016. Maggie’s Caring Centre Maggie's is recognised as a high quality, award-winning and innovative organisation providing support to anyone with cancer. The Maggie's@Christie scheme is currently under construction by Sir Robert McAlpine, project managed by Foster + Partners, and is progressing well. The current forecast construction completion date has slipped from January 2016 to late February/early March 2016.
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MRI Development Further to the development of the Trust’s MR strategy, the scope of the project is to provide accommodation for two replacement 1.5t MRI scanners and a new 3t MRI scanner, with potential for further expansion for a fourth scanner. The main contractor has been appointed and work on site has commenced. The project is due to be completed March 2016.
1.6 Capital expenditure reforecast trigger The Trust has not breached the capital expenditure reforecast trigger, which has a +/- 15% tolerance. Capital expenditure stands at 88.3% of plan, due to the timing of expenditure on schemes, predominantly on the Proton Beam Therapy project.
1.7 Financial Sustainability Risk Rating
The quarter 2 return shows we have a Financial Sustainability Risk Rating (FSRR) of 4, in line with a plan of 3.
1.8 Validation Checks
There are no validation checks within the linked spreadsheets the Trust is asked to explain.
1.9 Forecast
The Trust is forecast to be on plan for both its income and expenditure surplus, and its capital expenditure.
2. Performance 2.1 Core standards
We are compliant with core standards in Quarter 2 and have signed the governance declaration as confirmed.
2.2 Areas of compliance 2.2.1 62 day referral to treatment indicator
Month Total number of patients
Performance with no
reallocations
Performance with
reallocations
Jul-15 151 71.5% 91.5%
Aug-15 156 64.7% 86.3%
Sep-15 190 68.9% 87.3%
Q2 497 68.4% 88.3%
The Christie - 62 day performance
The Christie is compliant with both the local and national performance thresholds for this indicator when the Greater Manchester and Cheshire Cancer Network breach reallocation policy is applied. Following the recent tripartite review of 62 Day Cancer Improvement Plans, The Christie has been issued with a confirmation letter (Attachment 1) stating that our Cancer Improvement Plan has received a rating of assured.
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Improving and sustaining cancer performance The Christie has raised concerns with our relationship manager regarding the weekly collection of 62 day target information which is to be uploaded to unify. The process will be even further away from representing actual performance than the monthly CWT data, as this will be pre reallocations. It may also perpetuate the overall communication of performance problems that we have seen recently within GM.
2.2.2 Referrals to the Christie
Referral times to The Christie from other providers has slightly increased in Q2 with 60.5% of referrals coming in before day 42.
Q2 CaRPs 60.5% received before day 42
0 - 38 39 - 42 43 - 62 63 + TotalTotal 310 66 164 82 622
Q2 CaRP receipt time-bands
2.3 Areas of compliance 2.3.1 CWT targets for quarter 2 2015/16 (subject to validation)
The table below shows the Q2 performance against the access targets
Operational Standard Q2
93% N/A
85% 88.3%
96% 98.3%
Not yet set 85.6%
90% 100.0%
98% 99.6%
94% 97.9%
94% 99.7%
93% N/A
31 day drug standard
31 day surgery standard
31 day radiotherapy standard
Breast 14 day symptomatic standard
Existing Standards
14 day standard (2WW)
62 day standard
31 day standard
62 day consultant upgrade standard
62 day screening standard
2.3.2 18 week milestones We have been compliant with the milestones for this target each month since March
2008. Our current Q2 position is 96.9% performance for admitted patients, 98.5% for non-admitted patients and we have achieved 98.5% against the 92% target for incomplete pathways. We have obtained 100% of clock start dates for all patients referred to us.
2.3.3 Infection rates MRSA We have had 0 MRSA bacteraemia in Q2. 2.3.4 Clostridium difficile
As of Q2 we have had a total of 11 non avoidable cases against our full year trajectory of no more than 14. None of the 11 cases have been due to a lapse in care and no cases are under review.
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3. Quality The Trust on a quarterly basis holds a Quality Assurance Committee which is a formal sub-committee of the Board and is wholly non-executive director led. The purpose of the meeting is to hold the executive directors of the Trust to account with regards Quality Governance and this is achieved through receiving assurance of quality systems across the Trust and through a formal internal audit plan looking at quality outcomes. During Quarter 2 of 2015-16 the following reports were discussed and assurance obtained at the Quality Assurance Committee:
• The committee received the annual complaints report with a focus in the
presentation on the lessons learned over the past year; the work done with a patient focus group with regards to complaint responses and the outcome of post complaint questionnaires. The committee also received the annual clinical audit report;
• The committee received a clinical audit presentation on Acute Kidney Injury
and there was agreement to review how we could have a system leadership impact on ensuring that the learning from the audit is enacted across the clinical pathways;
• The committee received and were assured of the comprehensive data provided and actions being taken in the quarterly patient safety and experience quarterly report for April to June 2015 which identified themes and trends of complaints, claims and incidents;
• The committee had requested to receive an update on the Quality
Improvement work on pressure ulcers and falls as the improvement targets set were off trajectory. The committee were assured that there had been no grade 3 or 4 pressure ulcers. The committee were also advised that all but one of the grade 2 pressure ulcers were unavoidable and that the quality improvement interventions were starting to reap dividends. The falls quality improvement programme also showed a reduction in grade 2 minor falls. The committee asked that they have a further in-depth review in March 2016 and that exception reports are continued to be provided within the Integrated Quality and Performance Report;
• An overview of the work of the Risk & Quality Governance Committee over the
quarter and assurance that this is providing the links to corporate and divisional risks and operational assurances;
• The committee received significant assurance internal audit reports on bed
management and discharge planning review and serious and moderate incident review;
The Board of Directors have also been assured of the following quality performance:
• The quality performance of the organisation as set out in the monthly
integrated performance report against local and national targets and indicators;
• Achieving the requirements of the Quarter 1 CQuIN scheme and being on trajectory to meet quality targets identified in Quarter 2 2015-16;
• There have been no never events; • There have been no significant risks to quality identified as the Trust delivers
its annual plan.
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4. Non Financial Information 4.1 Membership
As at the end of September 2015 we had 33,698 members, against a target of 30,000. Of these 30,840 are public members, 2,557 are staff, and 301 are volunteers.
4.2 Mandatory services There are no issues in regard to Continuity of Service that would trigger a variation to our terms of authorisation or impact on our license. In addition there has been no disposal of assets used in the provision of Commissioner Requested Services.
4.3 Council of governors The governor election process concluded at the end of July and the results of the elections are as follows:
• Allen Leitch-Whittaker was appointed uncontested as public governor for Stockport
• Nick Coghlan was appointed uncontested as public governor for Wigan • Christine Mathewson was re-elected as public governor for Rochdale • Alex Davidson was re-elected as public governor for Cheshire
Their 3 year terms of office commenced following our Annual Members’ meeting on 16th July 2015. It was also agreed at the Annual Members meeting that we will no longer have a staff governor: volunteers and that the volunteers will now be represented by the staff governor: non clinical. This reduces the overall number of governors from 29 to 28.
4.4 Board update
The composition of the board has changed during Q2 2015-16. Since the Q1 report Kieran Walshe has taken up his post as non-executive (from 1st July 2015), Neil Large, who was an interim non-executive director, has been appointed to a substantive non-executive post (from 15th July 2015), and Jane Maher has taken up her role as non-executive director (from 1st September 2015). Fiona Noden was appointed as Chief Operating Officer in Q1 and started in post from 1st August 2015, replacing Jason Dawson who was in an interim post. Dr. Anthony Blower, Executive Medical Director, reduced his hours to part time (16 hours per week) from 2nd October 2015, and Professor Chris Harrison was appointed as Executive Medical Director on an honorary contract (1 day a week) from August 2015 (they share 1 vote on the board).
4.5 Incidents and Complaints 4.5.1 Incidents
One serious incident was reported to our commissioners in Quarter 2. This pertained to a patient who committed suicide 12 days after being discharged following a long inpatient stay. The outcome of the serious incident panel chaired by the Senior Independent Director was that nothing could have been done to prevent this patient’s death.
4.5.2 Complaints
The quarterly complaints total for 1st July to 30th September 2015 was 12. This is 4 fewer than Q1 and 4 fewer for the same quarter last year. All complaints are reviewed weekly by the executive directors and all new complaints are triaged through an executive review process so that there is a triangulation between incidents, claims and complaints.
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The learning from complaints is captured through the quarterly integrated patient safety and experience report and this report is reviewed in detail by the patient safety and patient experience committees and any issues are escalated to the risk and quality governance committee. The committees ask for a more in-depth response from divisions when trends are identified. This report is also discussed at the quality assurance committee as part of the Board’s assurance processes. A monthly report on complaint actions is presented at the patient experience committee. All complaints are graded from 1-5 using the following matrix: 1 2 3 4 5
►Query/suggestion ►Verbal concerns resolved by the end of the next working day ►Anonymous comment forms raising concerns
►Allegation that service received substandard ►Simple complaints which can be resolved quickly
►Single issue complaints with allegation of lack of appropriate care ►Serious complaints containing one issue ►Simple complaint where more than one complaint has been received regarding the same subject from different complainants
►Multiple issue complaints with allegations of lack of care ►Serious complaints containing more than one issue
►Multiple issue, complex complaints ►Serious complaint where more than one complaint has been received regarding the same subject from different complainants ►Risk to organisational reputation
For quarter 2 the scoring of the 12 complaints using the risk management scoring methodology is as follows:
Table 2: Risk scores assigned to complaints prior to investigation
Quarter 2 2015-16 Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 July 0 0 2 1 0 August 0 0 6 0 0 September 0 0 3 0 0
Table 3: Risk Scores for Complaints following conclusion of investigation Quarter 2 2015-16
Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 July 1 2 0 0 0 August 0 2 2 0 0 September 0 1 0 0 0 The investigation process is not completed for all complaints hence the figures in tables (2) and (3) do not correlate.
4.6 Data validation It should be noted that the Trust’s monitoring template submission will include a flag against the completion of the Targets and Indicators checks. This relates to an error in the monitoring template supplied by Monitor, and the Trust has been advised to submit the template with the flag in place. Joanne Fitzpatrick Executive director of finance and business development
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Attachment 1
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Appendix B
In Year Governance Statement from the Board of The Christie NHS Foundation Trust
The board are required to respond "Confirmed" or "Not confirmed" to the following statements (see notes below) Board Response
For finance, that:
Confirmed
Confirmed
For governance, that:
Confirmed
Otherwise:
Confirmed
Consolidated subsidiaries:
0
Signed on behalf of the board of directors
Signature Signature
Name Chris Outram Name Roger Spencer
Capacity Chair Capacity Chief Executive
Date Date
Responses still to complete: 0
A
B
C
The board is unable to make one of more of the confirmations in the section above on this page and accordingly responds:
Notes: Monitor will accept either 1) electronic signatures pasted into this worksheet or 2) hand written signatures on a paper printout of this declaration posted to Monitor to arrive by the submission deadline.In the event than an NHS foundation trust is unable to confirm these statements it should NOT select 'Confirmed’ in the relevant box. It must provide a response (using the section below) explaining the reasons for the absence of a full certification and the action it proposes to take to address it. This may include any significant prospective risks and concerns the foundation trust has in respect of delivering quality services and effective quality governance.Monitor may adjust the relevant risk rating if there are significant issues arising and this may increase the frequency and intensity of monitoring for the NHS foundation trust.
The board anticipates that the trust will continue to maintain a financial sustainability risk rating of at least 3 over the next 12 months.
The Board anticipates that the trust's capital expenditure for the remainder of the financial year will not materially differ from the amended forecast in this financial return.
The board is satisfied that plans in place are sufficient to ensure: ongoing compliance with all existing targets (after the application of thresholds) as set out in Appendix A of the Risk Assessment Framework; and a commitment to comply with all known targets going forwards.
The board confirms that there are no matters arising in the quarter requiring an exception report to Monitor (per the Risk Assessment Framework, Table 3) which have not already been reported.
Number of subsidiaries included in the finances of this return. This template should not include the results of your NHS charitable funds.
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Agenda item 56/15a Meeting of the Board of Directors
Friday 30th October 2015
Report of Chief executive
Paper Prepared By Company secretary
Subject/Title Corporate objectives 2015/16
Background Papers Agenda item 15/15a - Corporate planning
Purpose of Paper To review the draft corporate objectives 2015/16
Action/Decision Required To note progress against the corporate objectives 2015/16
Link to: • NHS Strategies and Policy
• NHS Cancer Reform Strategy
• NHS Financial Regime, NHS Planning Guidance, Payment by Results Monitor Compliance framework
Link to: • Trust’s Strategic Direction • Corporate Objectives
• Trust’s strategic direction • Divisional implementation plans
• Key stakeholder relationships
Impact on resources and risk and assurance profile You are reminded that resources are broader than finance and also include people, property and information.
You are reminded not to use acronyms or abbreviations wherever possible. However, if they appear in the attached paper, please list them in the adjacent box.
COO – chief operating officer
EDoN&Q – executive director of nursing & quality
EDoF&BD – executive director of finance & business development
DoW – director of workforce
EMD – executive medical director
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Agenda item 56/15a
Meeting of the Board of Directors Friday 30th October 2015
Corporate objectives 2015/16
1. Introduction This paper provides an interim review to board on the corporate objectives for 2015/16. 2. Background Our strategy for 2020 has been developed through a structured process. The corporate
plan for 2015/16 reflects the work undertaken through the 2020 Vision development process, through extensive consultation with the divisions and through the development of the 5 year strategy.
As in previous years we have used a single corporate planning process that
incorporates all of the forward looking elements of the annual plan into one single product. This allows for a simpler and more efficient planning process for the organisation that includes the corporate objectives, board assurance framework and revenue and capital plans. The board of directors considered the corporate objectives at its meeting in March 2015.
Monitoring of the objectives has been through the performance report and quarterly
consolidated updates to the board. Assurance is managed through the board assurance framework.
3. Summary There are no risks associated with the annual objectives that score above 12. There are
no gaps in assurance or gaps in control seen in the interim review. 4. Recommendation
The board of directors is asked to note progress against the corporate objectives.
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Corporate Objectives 2015-16
1. To demonstrate excellent and equitable clinical outcomes and patient safety, patient experience and clinical effectiveness
Annual objective Measure Timescale Director Progress
1.1 Increase access to the latest imaging and treatment
Commence relocation and expansion of MR scanning service
31.3.16 COO Building work commenced following board approval
Identify options for more local delivery in PET / CT 31.12.15 COO Option appraisal paper in development
1.2 Widen access for patients to supporting services
Progress development of Maggie’s Centre in line with milestones 31.3.16 EDoF&BD On track
1.3 Improving the patient experience of the outpatient environment
Deliver of business case for redevelopment and relocation of service for the patient benefit 30.9.15 COO
Review commenced
1.4 Develop standards for patient and public experience
Implement The Christie Experience quality mark for patient and public experience, and monitor effectiveness 31.3.16 EDoN&Q
Christie Quality Mark accreditation achieved in three organisations
1.5 To support the divisions in the delivery of the Quality Strategy
To realise the year 2 goals and ambitions of the Quality Strategy 31.3.16 EDoN&Q
Year 2 Quality Strategy being delivered within timescales
1.6 To identify and develop plans to deliver Improving Outcomes Guidance requirements for cancer care
Maintain Peer Review standards and undertake self-assessment of IOG and Quality Standards for cancer. 31.3.16 EDoN&Q On track
1.7 To ensure that the legislative requirements set out in The Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 are embedded into the organisation
Through the process of mock inspections and embedding of requirements to meet CQC inspection standards the Trust will continue to review and update evidence.
31.3.16 EDoN&Q
Mock inspections continue to show the meeting of CQC outcomes and adherence with The Health & Social Care Act 2008 (Regulated Activities) Regulations 2014
1.8 Develop plan to deliver the new integrated procedures unit
Commence build of the new integrated procedures unit 31.3.16 EDoF&BD Business case going to October board for approval
1.9 To lead the development of a bespoke ward accreditation scheme
To have an agreed to plan and to have begun implementation of a ward accreditation scheme (full implementation by 31st March 2017). 31.3.16 EDoN&Q
The benchmarking for The Christie CODE has nearly completed and the first ward will be assessed in December 2015.
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1.10 To introduce a development project to deliver end to end pathways of care (primary care through secondary to tertiary) for gynaecology and lung patients in partnership with another acute provider
Improved understanding and capability for measuring and monitoring safety within the Board team, and; Improved measuring and monitoring of safety within the organisation with measurable benefits for patients on pathways of care between the Trust and the provider
31.3.16 EDoN&Q
Through the Board development of Making Safety Visible the project was redefined. The focus is now on the lung pathway with Wigan & Manchester Cancer. Baseline audit has been carried out and outcome and further work plan will be handed over to the Manchester Cancer lung pathway group.
2. To be an international leader in research and innovation which leads to direct patient benefits
Annual objective Measure Timescale Director Progress
2.1 Work alongside MAHSC to deliver agreed strategy and increase research capabilities
Implement plan for BRC application 31.3.16 EMD Plan in place and on track
Progression of Academic Expansion Plan 31.3.16 EMD On track
2.2 Implement early trial phase strategy Increase recruitment capacity in line with strategy 31.3.16 EMD Plan in place and progressing well
3. To be an international leader in professional education for cancer care
Annual objective Measure Timescale Director Progress
3.1 To increase the provision and range of education and training
To develop strategic approach to the delivery of educational services in areas of Christie clinical expertise
31.3.16 EMD
Expanded breadth of educational activity for cancer care professionals internally and externally. Notably new proton therapy, cancer pharmacology, immunotherapy, acute oncology brachytherapy and peritoneal surgery. Increased opportunities for GP and primary care staff. Embedded cancer into GP
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training curriculum. Led strategic development of Cancer Education Manchester to ensure collaboration and partnership working across GM. AML partnership -leadership, research co-ordination and educational aspects of PET-CT contract.
Increase the level of commercial activity of the School of Oncology
31.3.16 EMD
School has maintained its commercial activity level. Maguire Communication Unit continues to be commercially successful. Commercial portfolio broadened to encompass new cancer treatments & developments. Partnerships with pharma to look at new ways of delivering education.
Broaden the breadth of educational offering through academic partnerships and exploring e-technology solutions.
31.3.16 EMD
Facilitated development of 3 academic modules • Haematology with UoM • Survivorship e-learning with
Salford Uni • Experimental Cancer
Medicine with UoM Developed E-learning strategy (Technology Enhanced Learning strategy), has successfully broadcast 2 study days to national and international audience, and invested in new technology team to move e-learning forward
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4. To integrate our clinical, research and educational activities as an internationally recognised and leading comprehensive cancer centre
Annual objective Measure Timescale Director Progress
4.1 Progress plan for Proton therapy Progress milestones: - Contract signatures for equipment and build - First 12 months of forward plan implemented
31.3.16 EDoF&BD Progressing to plan
4.2 Continue to improve clinical outcomes Publication of Clinical Outcomes Unit papers 31.3.16 EDoF&BD
Complete. In the Integrated Performance & Quality report to board.
4.3 Participate in European Reference Networks for specialist surgery
Become a reference centre for Peritoneal Metastases of Colorectal origin 31.3.16 COO Business case approved for
expansion in service
Become a reference centre for lymphoedema 31.3.16 COO Business case approved for lipo-suction
4.4 Achieve reaccreditation of OECI To meet and achieve the requirements of the accreditation 31.3.16 EMD On track – date of accreditation put back
5. To provide leadership within the local network of cancer care
Annual objective Measure Timescale Director Progress
5.1 Establish a joint IOG compliant service for Gynaecology surgery
Progress the development one gynae-oncology service across both CMFT and The Christie site 31.12.15 COO IOG compliant with
exception of 2 areas
5.2 Develop chemotherapy strategy Delivery of localisation of chemotherapy in line with the strategy 31.3.16 COO Meeting in place to develop
the services at Oldham
Development of governance arrangements for delivery of trials at the outreach centres 31.3.16 COO Meeting being arranged for
trials at Christie @ Wigan
5.3 Development of Haematology (including HMDS) strategy
Develop Haematology Strategy in line with Manchester Cancer plans 31.3.16 COO
Working with Manchester Cancer to develop plans
5.4 Delivery of Radiotherapy Strategy Undertake feasibility assessment of a south sector radiotherapy centre 31.3.16 COO In progress
Work with northern trusts to explore opportunities to develop a radiotherapy alliance 31.3.16 COO In progress
5.5 Delivery of National PET Service Delivery of year 1 partnership plan with Alliance Medical 31.3.16 COO On track
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Establish Academy of Advanced Imaging through PET National Contract 31.3.16 COO Being advanced – on track
Progress work with Trust team to address phase 2 of the procurement 31.3.16 COO In work plan – on track
5.6 Develop Trusts’ strategic response to 5 Year Forward View and the Dalton Review
Development of an outline Trust Enterprise Strategy 31.3.16 EDoF&BD
Complete
6. To maintain excellent operational, quality and financial performance
Annual objective Measure Timescale Director Progress
6.1 To develop and deliver our financial strategy
Achieve a Continuity of Service Rating of 4 31.3.16 EDoF&BD On track
Agree site strategy for long term developments 31.3.16 EDoF&BD On track
Implementation of commercial partners’ strategy 31.3.16 EDoF&BD / COO
On track
6.2 Develop relationships with commissioners
Develop relationships with lead commissioners and other commissioning bodies
31.3.16 EDoF&BD
On track
6.3 To identify and deliver transformational efficiencies that demonstrate value for money and achieve our contribution to the savings target
Manage and deliver the transformational programme through the programme management office work streams. 31.3.16 COO On track
Deliver trust wide efficiency savings of 3.1% 31.3.16 COO Progress being made & issues being addressed
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6.4 Achieve and sustain upper quartile performance targets
Achieve performance targets: • Maintain governance rating of green • Achieve national and local CQUIN targets • Achieve national research performance metrics for clinical
trials • Maintain a low risk on non-compliance with the CQC
intelligence monitoring assessment • Maintain a green rating for clinical negligence claims. • Quality Impact Assessments undertaken for all efficiency
schemes signed off by Medical Director/Executive Director of Nursing and Quality
• Friends and family of patients in ambulatory care setting in place The Christie in the top decile of performance with published results
31.3.16 Executive team On track
6.5 To deliver and implement strategic plan in line with Monitor guidance
All Monitor Guidance requirements for strategic planning fulfilled
31.3.16 EDoF&BD On track
Implementation Board established to oversee strategic plan implementation
31.3.16 EDoF&BD Complete
First 12 months of milestones delivered 31.3.16 EDoF&BD On track
6.6 Provide informatics solutions to improve access to information and efficiency
Implementation of first 12 months of Informatics & PMO Strategy
31.3.16 EDoF&BD & COO
Implementation taking place – challenges being addressed
7. To be an excellent place to work and attract the best staff
Annual objective Measure Timescale Director Progress
7.1 To improve staff engagement and motivation to enhance staff and patient experience
Increased staff engagement across all professional groups 31.3.16 DoW Q2 staff F&FT advocacy scores improved
Increase engagement in education for staff throughout the Trust
31.3.16 EMD In progress
7.2 To support staff to maintain their physical and mental health and wellbeing
Develop targeted health promotion interventions for identified common causes to encourage wider wellbeing
31.3.16 DoW
Stress awareness sessions piloted. Mindfulness training underway
Reduce incidence of sickness (from 14/15 levels) 31.3.16 DoW Within target
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7.3 To support the development of a skilled, flexible workforce able to adapt to new treatments, technologies and working practices
Workforce plans to be aligned to service delivery and future developments
31.3.15 DoW Regular updates to C&WP. Q2 position on track.
Plan to deliver against specific business needs (7 day working, Proton Therapy)
31.3.16 DoW Discussions through Transformation Board
7.4 Implementation of nurse revalidation Preparation and early implementation of requirements for nursing revalidation.
31.03.16
EDoN&Q
Organisational state of readiness report submitted to Monitor. Work plan on track to ensure compliance with Nursing & Midwifery Council requirements. Internal auditors reviewing Trust against plan in Q4.
8. To play our part in the community
Annual objective Measure Timescale Director
8.1 Play our part as a corporate citizen Implement Travel Strategy in line with milestones 31.3.16 EDoF&BD On track
Proactively engage with Greater Manchester devolution agenda
31.3.16 EDoF&BD On track
Engage with Macmillan Cancer Improvement Partnership 31.3.16
EDoN&Q
Trust has 2 places on Macmillan Cancer Improvement Partnership Board and has played active part in all aspects of the programme.
Maintain opportunities for work experience, training and employment through partnerships with local schools and employment agencies
31.3.16 DoW
Progressing to plan.
Develop partnerships to allow The Christie to become involved in supporting the Public Health Agenda
31.3.16
EMD
Early detection chair in academic investment plan. National Cancer Vanguard bid contains public health.
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Agenda Item 56/15b
Meeting of the Board of Directors Friday 30th October 2015
Board Assurance Framework 2015/16
Report of Chief Executive Officer
Paper Prepared By Louise Westcott, Company Secretary
Subject/Title Board Assurance Framework 2015/16
Background Papers Corporate objectives, board assurance framework 2014/15, operational plan and revenue and capital plan 2014/15.
Purpose of Paper To note the refreshed Board Assurance Framework (BAF) 2015/16
Action/Decision Required To consider any updates to the Board Assurance Framework (BAF) 2015/16
Link to:
NHS Strategies and Policy
• NHS Cancer Reform Strategy
• NHS Financial Regime, NHS Planning Guidance, Payment by Results, Monitor annual planning review, Monitor Risk Assessment Framework
Link to:
Trust’s Strategic Direction
Corporate Objectives
• Trust’s strategic direction
• Divisional implementation plans
• 2020 vision strategy
• Key stakeholder relationships
Resource Impact
Risk Rating
You are reminded not to use acronyms or abbreviations wherever possible. However, if they appear in the attached paper, please list them in the adjacent box.
BAF Board assurance framework EDoN&Q Executive director of nursing & quality EDoF&BD Executive director of finance & business
development EMD Executive medical director COO Chief operating officer DoW Director of workforce
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Agenda Item 56/15b
Meeting of the Board of Directors Friday 30th October 2015
Board Assurance Framework 2015/16
1 Introduction
The Board of Directors reviewed the board assurance framework at its September meeting. The changes that have been made since the review are as follows;
• 2.2 – BRC status – amendment to key controls.
• 4.7 – leading comprehensive cancer centre metrics – update to key controls
• 5.1 – Devolution Manchester – amendments to gaps in control relating to board capability and identification of lead director.
• 5.2 / 6.2 – developments relating to tariff updated to reflect current position.
• 5.3 – Manchester Cancer – removal of gaps in control around capacity in executive team following medical director appointment
• 5.4 – The Christie Pathology Partnership – amendment to key controls and gaps in control to update on amendments made to operational leadership.
• New risk added – 5.6 – not delivering the operational, clinical and financial objectives of the system leader role in the ACC Vanguard.
2 Suggested updates in October
The following risks may need to be updated following board discussion in September.
• 5.1 – Devolution Manchester
• 5.2 / 6.2 – developments relating to tariff
• 5.6 – ACC Vanguard
3 Recommendation
Board are asked to note the refreshed board assurance framework (BAF) 2015/16 and to consider any updates following board discussion at the September meetings.
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Board Assurance Framework 2015/16
Num
ber
Principle Risks Exec Lead Like
lihoo
dIm
pact
Key Control established Key Gaps in Controls Cur
rent
Ris
k Sc
ore
Assurance Gap
s in
ass
uran
ce
Ope
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Pos
ition
Posi
tion
at e
nd o
f Q1
Posi
tion
at e
nd o
f Q2
Posi
tion
at e
nd o
f Q3
Posi
tion
at e
nd o
f Q4
1.1 Risk to patients and reputational risk to trust of breaching the HCAI thresholds EDoN&Q 3 4
Patients with known or suspected HCAI are isolated. Medicines management policy contains prescribing guidelines to minimise risk of predisposition to C-Diff. RCA undertaken for each known case Induction training & bespoke training if issues identified. Close working with NHS England at NIPR meetings. The Trust is working closely with NHSE re the quantum of the target
12
NHS England and NIPR meetings look at HCAI numbers. Levels reported through performance report to Management Board and Board of Directors.
12 12 12
1.2 Lack of preparedness for a CQC inspection leading to a poor performance EDoN&Q 2 3 Timetable of mock inspections arranged. Looking at Trust wide requirements e.g duty of candour /
fit & proper persons 6 Feedback from mock inspections reported to management board and board of directors 6 6 6
1.3Failure to learn from patient feedback (patient satisfaction survey / external patient surveys / complaints / PALS)
EDoN&Q 2 2Monthly patient satisfaction survey undertaken and reported through performance report. Negative comments fed back to specific area and plans developed by ward leaders to address issues. Action plans developed and monitored from national surveys. Complaints and PALs procedures in place.
4
Management Board and Board of Directors monthly Integrated performance and quality report. National survey results presented to Board of Directors. Action plans monitored through the Patient Experience Committee
4 4 4
1.4 Non achievement of the quality outcomes for the 2015-16 CQUINS indicators. EDoN&Q 3 4
Leads nominated for each CQUIN goal. CQUINs steering group (strategic and operational) are in place with strategic and operational representation agreed. New rigour introduced around submission and quality assurance of quarterly reports. Timescales established for provision of data.
12
Monitoring of performance data and contract KPIs occurs at various monthly meetings and feeds to CQUINS steering group. Commissioners confirmed achievement of Q1 outcomes
12 12 12
1.5 Not achieving projected numbers for the reduction in pressure ulcers and falls EDoN&Q 3 3
Collaborative projects in place for both pressure ulcers and falls. Changed products for anti-embollic stockings, non-invasive ventalation masks and NG tubes. All pressure ulcers and falls come through executive review process. Trailing new mattresses.
9Numbers reported through integrated performance report to Management Board and Board of Directors.
9 n/a 9
Principle Risks Exec Lead Like
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Key Control established Key Gaps in Controls Cur
rent
Ris
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Assurance Gap
s in
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Ope
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Pos
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Posi
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at e
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Posi
tion
at e
nd o
f Q2
Posi
tion
at e
nd o
f Q3
Posi
tion
at e
nd o
f Q4
2.1There is a risk to future NIHR funding if we fail to meet national patient recruitment targets and clinical research funding
EMD 3 4 Monthly review of resource with team lead. Use of overtime/ bank staff/ freelance staff; individual discussion with HR. Priority assessment for studies. Bid for CRUK grant income.
Not currently achieving the 70 day target 12 Weekly review of 70 day data, reported through
performance report to board monthly. 12 12 12
2.2 Biomedical research centre (BRC) statusfor Manchester not achieved. EMD 4 3
Setup of Christie Academic Investment Plan (AIP) group to provide key controls. Individual cases have been developed in line with AIP plan. Develop optimal bid and working with our MAHSC partners. Involvement in National Cancer Vanguard.
Insufficient capacity and capability. 12 Academic investment plan group progress against plan and MAHSC BRC group 12 12 12
Corporate objective 1 - To demonstrate excellent and equitable clinical outcomes and patient safety, patient experience and clinical effectiveness
Corporate objective 2 - To be an international leader in research and innovation which leads to direct patient benefits
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Principle Risks Exec Lead Like
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Key Control established Key Gaps in Controls Cur
rent
Ris
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Assurance Gap
s in
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Ope
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Pos
ition
Posi
tion
at e
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f Q1
Posi
tion
at e
nd o
f Q2
Posi
tion
at e
nd o
f Q3
Posi
tion
at e
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f Q4
3.1Non delivery of the School of Oncology strategy due to increased pressure within operational service delivery
EMD 2 3Development of School of Oncology strategy. Impact of key stakeholders including operational leads. Transparency of educational PA's within job descriptions. Involvement in ERG tariff development.
Gaps in infrastructure. Insufficient capacity and capability to deliver. International development strategy in development. Ambiguity for international opportunities for MAHSC global health and The Christie.
6 School of oncology board reports to Management Board.
6 6 6
Principle Risks Exec Lead Like
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Key Control established Key Gaps in Controls Cur
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Ris
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Assurance Gap
s in
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Posi
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at e
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Posi
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at e
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Posi
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at e
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Posi
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at e
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4.1Failure to meet DH/Treasury timescales of the construction of the Proton Beam Therapy (PBT) build.
EDoF&BD 3 4
Project board set up and meeting. Professional advice on capital scheme. Involvement of operational managers. Professional advisors assisting with the procurement of the Proton Therapy equipment including contract development for the equipment (and the build). Full business case approved at the Trust Board in January 2015 subject to finalisation to the development agreement. Due diligence completed by Monitor December/January. Full engagement with national steering committee. NED appointed to Programme Board
12PBT project reports to Management Board on a quarterly basis. Capital spend monitored through the finance report to Board.
12 12 12
4.2 Impact of private providers for Proton Beam therapy on our PBT service
EDoF&BD 4 2 Working with the DH. Progressing plan to see if we can bring forward the phased implementation. 8 PBT project reports to Management Board on a quarterly basis.
8 8 8
Gynaecology - Commissioning agreement for gynae-oncology surgical services to be provided across 2 sites, namely The Christie and CMFT. The Christie has put forward proposal for one service two site model. Internal project board in place.
Project board. Transfer of activity.
Urology - Project group and exec lead established. Participation in commissioner led tender process
Tender process now discontinued by commissioners. Awaiting further commissioner instructions
Robotic element of urology service excluded from tender process. Existing service provision not effected by planned reconfiguration.
4.4 Loss of trials due to no processes for accessing funding for excess treatment costs for trials
EDoF&BD 3 4 Communicating with specialist commissioners on how to access funding Informed lead clinicians to ensure no patients are enrolled on inappropriate trials.
12 Reports to research governance committee and commissioner meetings
12 12 12
4.5Lack of a solution to the patient and relative accommodation issue for the Proton Beam Therapy service
EDoF&BD 2 4 5 year strategy and estates strategy includes consideration of PBT accommodation, consideration of different options through project group. Business case will be developed.
8 PBT steering group and Strategic Plan Implementation Board
8 8 8
4.6 OECI reaccreditation not achieved EMD 2 3 Work centrally coordinated based on OECI measures. Timeframes for re accreditation identified. Funding identified. Accreditation process delayed.
Project group not yet formed 6 6 6 6
4.7Lack of metrics to evidence progress against the ambition to be leading comprehensive cancer centre
COO / EMD 2 3 Monthly integrated performance and quality report. OECI accreditation. Baseline measures identified and presented to Board of Directors time out
Don't currently show board defined metrics or benchmarking data on research, education, clinical performance and workforce to measure progress in achieving leading international cancer centre ambition
6 OECI accreditation achieved 6 6 6
Corporate objective 3 - To be an international leader in professional education for cancer care
Corporate objective 4 - To integrate our clinical, research and educational activities as an internationally recognised and leading comprehensive cancer centre
4.3Risk of comprehensive cancer status due to loss of surgery at The Christie due to uncertainty of commissioning within Greater Manchester
COO 3 4 12 12 12 12
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Principle Risks Exec Lead Like
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Posi
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Posi
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Posi
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5.1 GM devolution changes have an adverse impact on The Christie objectives
CEO 3 4
Key directors attending discussions. Input into the business case. MOU produced and shared with board between ''All local authority members of the Association of Greater Manchester Authorities (AGMA) and all Greater Manchester Clinical Commissioning Groups (CCGs) (together known as GM)' and NHS England'. Groups established & Christie staff attending. External Medical Director appointed.
Uncertainty around impact. 12
Management Board and Board of Director reports from CEO. Considered at July Board, disucssion to take place at Board time out in October (Ian Williamson attending).
12 12 12
5.2 No further growth in delivery of chemotherapy at local centres
COO / EDoF&BD
2 4Downside modelling. Involvement of key individuals in tariff discussions. Response to national tariff consultation. Options considered financially. Refreshed SACT strategy approved by Board in Q1 2015/16. Manchester Cancer to adopt Christie SACT strategy.
Impact of commissioner decision on tariff. Limited control on other trust capital approvals
8 Monitored through Strategic Plan Implementation Board that reports to Management Board
8 8 8
5.3 Limited influence within Manchester Cancer as a specialist cancer hospital CEO 2 4 Senior leadership. Attendance at The Manchester Cancer Provider Board. Christie clinicians as
pathway leads. External Medical Director appointed.8 Through membership of The Manchester Cancer
Provider Board8 8 8
5.4 The Christie Pathology Partnership objectives not achieved impacting on clinical service
COO/ EDoF&BD
3 4The Christie Pathology Partnership board established. Review of financial arrangements and turnaround plan produced. Operational leadership reviewed. Business continuity plan in place. Agreement made on part year position, payment made.
12 The Christie Pathology Partnership board meetings.
12 16 12
5.5 Incomplete pathway of care (primary care through secondary to tertiary)
EDoN&Q EMD
2 4 Patient tracking. Pathway improvement leads in place across the network. Making Safety Visible project involvement working to develop a project with Wigan on Lung patient pathway
Inability to influence across whole pathway
8
Achievement of cancer targets. Audit of patients have identified a patient cohort where a casenote review is being undertaken. Meeting between the two trusts planned for August
Don't see the data relating to the full patient pathway
8 8 8
5.6Not delivering the operational, clinical and financial objectives of the system leader role in the ACC Vanguard
EDoF&BD EMB
2 5 Part of the National Cancer Vanguard with The Royal Marsden and UCLH. Monitoring in shadow form so time for assessment of risk
Legally binding contractual arrangements need to be established. Capacity and capability of proect team
10 Regular reports to board of directors. 10 n/a 10
Principle Risks Exec Lead Like
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Posi
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Posi
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6.1 Key performance targets not achieved COO 2 4 Executive led monthly divisional performance review meetings. Integrated performance & quality report to Management Board and Board of Directors monthly 8 Continued achievement of all key performance
targets8 8 8
Exec led monthly divisional performance review meetings. Finance report to Management Board and Board of Directors monthly
Continued achievement of a Continuity of Services Rating of 4
Commissioner and Christie QIPP team established and meeting monthly. Strong relationship with commissioners enhanced by re-energising the Christie Commissioning Strategy Board (CCSB). A meeting schedule including definition of attendees is agreed with commissioners and is in place. Process in place for quick dissemination of NHS England policy.Deputy Director of Finance is a member of Specialist top Up Tariff Working Group and is a member of a working group of the Federation of Specialist Hospitals (FSH). Weekly returns submitted to Monitor tracking progress of contract negotiations. Trust has opted for ETO (enhanced tariff option) for 2015/16. QIPP schemes have been identified to enable savings to be offered to mitigate any future loss of income resulting from commissioner requests. Manage demand
No response from commissioners. Not sufficient capacity and capability. Inability to influence decisions on tariff relating to chemotherapy.
Contract signed with commissioners for 2015/16.
Programme office to continue to work across clinical and corporate divisions to identify and achieve efficiency savings. Monitor progress through Transformation Board. Schemes being developed on a transformational basis across seven identified pathways. Targets for identification and delivery of savings have been agreed at Transformation Board in February 2015
Development and delivery of the Programme Management Office (PMO) strategy. Monthly performance against recurrent CIP position through the Transformation Board via the PMO
6.3 Poor data quality EDoF&BD 3 3 Audit programme to assure performance measures, quality accounts Development and implementation of a kite mark for data quality 9 9 9 9
Corporate objective 6 - To maintain excellent operational and financial performance
6.2 Financial performance target not achieved EDoF&BD 3 4 12 15 12 12
Corporate objective 5 - To provide leadership within the local network of cancer care
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Principle Risks Exec Lead Like
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7.1 Governance failure resulting from temporary board and senior leader arrangements
CEO 1 3Recruitment complete for 2 executive (COO and EMD) and 4 non executive positions through an external recruitment partner. Process started for the appointment of the final substantive NED posts in late 2015/early 2016.
3
3 substantive NEDs appointed May 2015 (staggered start dates). Replacement COO appointed - start date 1st August. Replacement Medical Director appointed.
6 6 3
7.2 Low levels of staff engagement of non-clinical staff (bands 1-4)
DoW 3 3 Participation in national Cultural Alignment Project. One Week All Staff project. External governance review include assessment of staff engagement. OD Plan (The Christie Commitment). 9
External governance review. National staff FFT. National staff survey results. Exec safety walk rounds. Named in top 100 NHS places to work 2015.
9 9 9
7.3 Sickness targets not achieved DoW / COO 3 3 Adherence with sickness management policy monitored through performance review meetings. 9 Monthly sickness levels as reported in Integrated performance and quality report
9 9 9
7.4 Organisational development plan objectives not fit for purpose
DoW 2 3 PwC review of plan Staffing metrics not triangulated in board reports to show impact 6 All benchmarked indicators in top quartile. Track
record of achievement6 6 6
7.5 Impact of national pay awards DoW 3 3 Monitored through turnover and appraisal. Personal development discussed in appraisal. Staff engagement work as part of OD plan. Unable to influence national policy 9 Appraisal and turnover data 9 9 9
Principle Risks Exec Lead Like
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8.1
Potential disruption to clinical service as a result of the impact on retention of specialist skilled staff due to reduced car parking capacity around the hospital site.
EDoF&BD 3 3
Close working with Manchester City Council (MCC). The strategic planning framework approved and includes current and future requirements for travel to site. Temporary staff car parking available. Park & ride available from March 2015 for 120 staff. Options for non-clinical staff accommodation off site are being considered. Communication with residents through the Neighbourhood Forum and newsletters. Green travel plan and sustainability plan in place.
9Agreement by MCC of strategic development plan. 5 year Capital Plan delivery. Monitored through Management Board and Board of Directors
9 9 9
8.2 Targets set by the NHS sustainable development unit (SDU) guidance are not achieved.
EDoF&BD 3 2 Sustainable development management committee meet quarterly. National returns submitted. Quarterly reports on each requirement produced and progress monitored.
Not achieving target for energy & carbon reduction
6 Sustainable development and carbon reduction quarterly key issue reports to board of directors
6 6 6
Corporate objective 7 - To be an excellent place to work and attract the best staff
Corporate objective 8 - To play our part in the community
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Agenda item 56/15c
Meeting of the Board of Directors Friday 30th October 2015
Report of Chair
Paper Prepared By Company secretary
Subject/Title Minutes from board committees held in September 2015
Background Papers N/A
Purpose of Paper To receive minutes of board sub committee meetings held in September 2015:
1. Quality Assurance committee (escalation report and draft minutes) – 25th September 2015
Action/Decision Required To note assurance/minutes of board sub committee meetings
Link to: NHS Strategies and Policy
Link to: Trust’s Strategic Direction Corporate Objectives
Corporate Plan and Objectives
Impact on resources and risk and assurance profile You are reminded that resources are broader than finance and also include people, property and information.
None
You are reminded not to use acronyms or abbreviations wherever possible. However, if they appear in the attached paper, please list them in the adjacent box.
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Board of Directors’ Key Issues Report
Report Date: 30.10.15
Committee: Quality Assurance Committee
Date of last meeting:
25.9.15
Membership Numbers: Quorate Apologies received from Professor Jane Maher (non-executive director), Tony Blower (executive medical director), Julie Gray (lead nurse quality & standards), Debbie Rimmer (MIAA) and Matt Lomax (PwC)
1 Key risks reviewed
The Committee considered an agenda which included the following:
1. Two presentations – ‘Learning from complaints’ and ‘Review of management of pressure ulcers and patient falls’
2. Clinical audit presentation – ‘Acute kidney injury’ 3. Two MIAA reports: Bed management and discharge planning
review and Serious and moderate incidents review 4. Clinical Audit annual report 5. Patient and staff safety and experience report: April – June 2015 6. Report from risk and quality governance committee
2 Assurance level assigned
The Committee assigned the following level of assurance to the risks reviewed:
Significant assurance: • Bed management and discharge planning review • Serious and moderate incidents review • Patient and staff safety and experience quarterly report: April –
June 2015 No limited reports received
3 Action / review
The Committee has asked for the following action against the risks reviewed:
Monitoring for:
• Quality heat map – staff development reviews and training • Board assurance framework • Monitoring of pressure ulcers and patient falls
No items for escalation to the Board.
4 Report Compiled by
Committee Chair: Professor Kieran Walshe
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DRAFT Minutes of the meeting of the Quality Assurance Committee of The Christie NHS Foundation Trust held on Friday, 25th September 2015 in the
Trust Administration Meeting Room Centre
Present: Professor Kieran Walshe (KW) Chris Outram (CO) Kathryn Riddle (KR) Dr Ron Stout (RS)
Chair of the meeting & non-executive director Chair of the Trust Non-executive director Interim non-executive director
In Attendance: Jackie Bird (JB) Professor Chris Harrison (CH) Jane Sykes (JS) Eve Scott (ES) Louise Westcott (LW) Eileen Hackman (EH) Tahira Jabeen (TJ) Ali Hashmi (AH) Phil Higham (PH) Gill Goodwin (GG) Sharon Gardner (SG) Denise Saunt (DS) Linda Allen (LA) Annie Dewberry (AD) Lyn Bushell (LB) Rob Duncombe (RD)
Executive director of nursing & quality Medical Director (strategy) Deputy director of nursing & quality Head of safety and risk Company secretary (agenda items 18e/15 & 18f/15) Complaints manager (agenda item 19a/15) MIAA (agenda items 19d/15 & 19e/15) MIAA (agenda items 19d/15 & 19e/15) Clinical audit (agenda item 20a/15) Quality improvement nurse (agenda item 20d/15) Tissue Viability Nurse (agenda item 19c/15) Matron (agenda item 19c/15) Matron (agenda item 19c/15) Matron (agenda item 19c/15) Matron (agenda item 19c/15) Director of pharmacy (agenda item 19b/15)
Karen Baxter Minutes
Item Action 18/15 Standard business
a Apologies
Apologies were received from Professor Jane Maher, Tony Blower, Julie Gray, Matt Lomax (PwC) and Debbie Rimmer (MIAA).
b Minutes of previous meeting – 19th June 2015
The minutes of the meeting held on 19th June 2015 were accepted as a correct record.
c Action plan rolling programme/matters arising
All items are included on the rolling programme or are covered on the agenda.
d Declarations of interest
None.
e Board assurance framework
Louise Westcott (LW) attended to present this item. She explained that the paper describes changes to the board assurance framework (BAF) since the July Board of Directors meeting. LW drew particular attention to items that relate to risks around quality. They are:
• The risk in not achieving the projected numbers for the reduction in pressure ulcers and falls
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Item Action
• The additional assurance added around inclusion in the top 100 NHS places to work.
Members of the committee stated they are satisfied with the content of the board assurance framework and there are no amendments to be highlighted to the Board of Directors.
f Review of committee terms of reference
LW stated that the terms of reference for this committee are reviewed on an annual basis. These are in line with the terms of reference for all other board committees.
TJ asked a question about quoracy being any two members of the committee. LW stated that this was consistent with the audit committee and recommendations made following the PwC review. She clarified that membership comprised of three non-executive directors and that all other attendees were noted as in attendance at meetings.
The terms of reference for the committee were agreed.
19/15 Best outcomes
a Presentation – Learning from complaints
Eileen Hackman (EH) attended the meeting to present this item. She highlighted that The Christie had been ranked the top organisation along with two other specialist Trusts for having zero complaints referred to the NHS Parliamentary and Health Service Ombudsman (PHSO). EH stated it was important to handle complaints correctly and highlighted the role of the complaints and PALS team. There have been over 400 contacts with the PALS team to date this year which also included a large amount of positive feedback being received. EH said it was important to learn from complaints and drew particular attention to some important learning points that had been implemented over the last year. These included increased consultant presence at gynae-oncology multidisciplinary teams, a new electronic system to assist with appointment bookings and the appointment of a tissue viability nurse to assist with complex wound management.
EH highlighted that future plans for the team include redesigning the complaints/concerns section on the internet to make it easier for issues to be raised and to re-run the patient focus group to identify any additional learning from how we respond to complainants.
CO asked what criteria had been used to rank The Christie by the PHSO. EH explained that it was based on the number of complaints that had been referred to the Ombudsman during the year. The Christie had zero complaints referred this year. EH went on to state that our processes are different from most other trusts as we encourage all staff to deal with concerns when patients or their families raise them and we have empowered the divisions to investigate the issues and formulate the response to the complainant and the action plan. This process has enabled easier monitoring of complaints and action plans.
KR asked which trusts were rated numbers one and two by the Ombudsman. EH replied that they were both specialist trusts as it was Birmingham Children’s Hospital and a rheumatology trust.
CO stated she felt it was positive that the trust routinely sends complainants a questionnaire asking their views on how their complaint was handled and their opinion of the complaint response.
JS also explained that she had recently facilitated a training session attended by bands 1 – 4 which included those members of staff who would not normally attend these type
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Item Action of training sessions. This recognised that front line members of staff make a significant impact for the patient experience.
The committee noted and thanked EH for a comprehensive report.
b Clinical Audit presentation: Acute Kidney Injury (AKI)
Rob Duncombe (RD) attended to present this item in place of Dr Tamer Alsayed who was unable to attend the meeting.
RD explained that Acute Kidney Injury (AKI) is a sudden reduction in kidney function which is harmful and often preventable. It can range from minor loss of kidney function to complete kidney failure.
RD noted that a number of patients admitted to the Trusts admissions unit have AKI, detected through an abnormal blood result. RD highlighted a number of the steps staff at the Christie are taking to reduce the risk of our patients developing AKI. This includes the formation of a multi-disciplinary group to look at AKI and its management in the Trust. This group is chaired by the deputy medical director, Dr Wendy Makin, and as part of its work it reviews the Trust’s adherence to a number of national documents around AKI and its management.
RD explained that all of this has resulted in increased awareness at The Christie.
KW asked about patients with AKI and specifically what causes trigger their presentation. RD stated it is often not the AKI which will trigger an admission but another complication of the treatment which a patient is receiving, for example, neutropenic sepsis.
CO noted that there is an obvious need for collaboration with primary care and there needs to be involvement and total engagement with the patient’s GP.
RS stated that as we also now deliver chemotherapy off the main Christie site, the same standards need to apply to our peripheral sites. We need to increase awareness and build into the quality of standards here also.
CH said he would be interested to understand the data on admissions regarding patients with AKI. There is a system leadership role for the Christie which the whole pathway and system could approach.
c Review of management of pressure ulcers & patient falls
Sharon Gardner (SG) and Denise Saunt (DS) attended to present this item. They were supported by Linda Allen (LA), Lyn Bushell (LB), and Annie Dewberry (AD).
SG stated the aim of the trust was to ensure that patients are free from avoidable harm whilst in our care. She explained the trust had set a target of a 10% reduction in pressure ulcers based on the out-turn figure from 2014/15 making a target of 28 for the year and a 25% reduction in falls therefore making a target of 33 for the year.
SG explained that there was an increase in the number of pressure ulcers in May. This was found to be as a result of issues with TED stockings which were causing pressure damage. This problem had also been identified at other trusts and the trust reported the product to the MHRA. The trust has now successfully trialled and is using another brand of stockings.
SG stated that a number of actions have been introduced to reduce the number of pressure ulcers including the delivery of specific and bespoke training, introduction of pro-formas and tools through CWP and the trial of a new hybrid mattress. All pressure ulcers undergo an Executive review. She reiterated that no pressure ulcers had been found to be lapses in care.
DS then went on to talk about patient falls in the trust. She said that all falls are routinely reported and reviewed. There is also a falls specific exec review meeting held.
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Item Action She explained that there are a number of simple ideas which have been introduced and are now making a difference. She showed a ‘leaf’ symbol which is put behind beds for patients who are at risk of falling. This enables ward staff to see at a glance which patients are most at risk. She stated that the wards have recently trialled the use of small mesh baskets for bedside tables. This enables patients to keep smaller objects in and helps prevent the patient from over reaching and thus possibly falling. She also highlighted the introduction of the falls link nurse role and safety huddles on the wards, both of which have made a difference.
DS also showed a further initiative recently introduced which is a card with a ‘forget me not flower’ sign for behind the bed of dementia patients or patients who are confused.
CO stated that this was interesting work and it would be useful for the matrons to present back to this committee in six months time with an update. She said it was commendable that we are responding to data and doing something meaningful about it.
Action: This item to be an agenda item at the quality assurance committee – March 2016 meeting. KR asked a question about the mesh baskets near to the patient’s beds and where exactly these are situated. DS stated they are for small personal belongings only and are loose and do not clip on to anything but are placed on bedside lockers.
Matrons/KB
d MIAA Bed management and discharge planning review
Tahira Jabeen (TJ) presented this report which was originally a draft report to the June 2015 meeting of the quality assurance committee. The management responses have now been included. She explained that the overall objective of this review was to assess the systems and processes in place for managing safe, effective and efficient use of bed management and discharge planning. She stated that in summary discharges were found to comply with corporate processes with the trust bed statement managed through the bed management team. She said that all action plans are in progress and will be agreed and monitored with the audit committee.
KW stated that as he was new to the trust he wondered how the audit programme is agreed? TJ explained that it is risk based and there is a forward programme that was agreed at the February meeting.
The committee noted the significant assurance received in this report.
e MIAA Serious and moderate incidents review (2015/16)
Ali Hashmi (AH) attended to present this report. This review was conducted in accordance with the requirements of the 2015/16 internal audit plan. AH stated there are robust systems in place and significant assurance was obtained. Action plans have been developed where necessary. He also confirmed that there was found to be close monitoring by executive management.
Some areas for further work have been identified in relation to divisional level investigations but these do not detract from the current level of rigour and investigation.
CO stated that she was pleased with the report and that good feedback was received.
The committee noted the significant assurance received in this report.
20/15 The Christie experience
a Clinical audit annual report 2014-15
Phil Higham (PH) attended to present the clinical audit annual report 2014-15. He explained the report follows the same format as in previous years. Brief summaries of all completed audits are included together with reasons for non-completion of certain projects. He stated that the appendices form the bulk of the report.
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Item Action PH said that the number of projects registered increased again this year to 318. The number of projects with a completed report increased to 170 which is largely as a result of an executive backed drive to reduce outstanding and overdue projects.
He explained that the clinical audit department has been able to facilitate almost full completion of the core programme and an increased proportion of the non-core programme. He stated that the clinical audit team take part in the consultant revalidation process and also work closely with the clinical outcomes unit. PH explained that issues continue to be around timeliness of audits and making sure they are still current. He also commented that there has been a slight drop in the re-audit rates which remains an important measure in the effectiveness of the audit programme.
PH stated that the goals for 2015/16 are to continue liaising with key services, departments and disease groups to identify audit links in those that don’t have them and increase their ownership of individual audit programmes. There was a continued aim to work with the clinical outcomes unit to maximise the use of web-forms and electronic data for clinic audit.
CO said she was interested to know whether the work of the clinical outcomes unit had meant that the clinical audit department were able to spend more time looking at the results of data.
CH commented on the work of the clinical outcomes unit and how it differs from the work of the clinical audit department. Clinical audit is required to measure the process and delivery of care against standards (local and national benchmarks). The work of the outcomes unit will enable us to publish our outcomes data – the portal communication tool offers opportunity to do so.
KW asked about the clinical web portal and what proportion of their work is affected by this. PH stated that a large and increasing amount of their work uses the clinical web portal and the data on it, in some way.
After further discussion, the committee noted this report and commended the clinical audit department for their continued hard work.
b Patient and staff safety and experience quarterly report – April – June 2015
ES explained that the ‘staff’ element of this report has now been taken out.
She highlighted key achievements during the quarter including positive feedback received regarding departments, wards and people and the implementation of a new clinical audit software module.
ES stated that the challenges remain around identifying the most effective way of producing meaningful comparative data. She also said that much work is ongoing to address the increase in inpatient falls and pressure ulcers. This was highlighted earlier in the meeting.
ES also explained that analysis is undertaken each quarter into the category of incident with the highest incidence. The outcome of this work and learning captured is then reported. A themed review of the increase in ‘communication’ incidents has therefore been undertaken and has shown that many of the incidents in this category have been coded wrongly. She said that procedures have been reinforced to ensure that future incidents are coded appropriately.
The committee thanked ES for a very comprehensive report and noted the comments.
c Report from the risk and quality governance committee
ES presented the report from the risk and quality governance committee from June to August and highlighted the following:
Presentations had been made by the director of pharmacy regarding a themed review of controlled drug incidents over the preceding twelve months. As a result of the
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Item Action investigations improvements were identified which should mitigate risk. The committee had also received a presentation from the director of nursing and quality on the CQC mock inspection of the outpatients department.
In regard to executive reviews (from June to August 2015) the committee examined 21 incidents and all but 4 actions were completed within agreed timescales.
ES explained that with regard to internal audit recommendations it was agreed that the regular report will now be presented by exception only and will only include high risk recommendations and those audits which received limited assurance.
Regular items from the report are included in team brief to ensure wider organisational communication and learning.
KW asked about the CQC mock inspection and specifically where does the preparation for this lie? ES explained that this falls within the quality and standards team who prepare the processes. She stated that the outcome of the inspection is monitored through performance review and the risk and quality governance committee.
The report was noted.
d Quality heat map
Gill Goodwin (GG) attended to present the quality heat map and reminded the committee that this report was a recommendation of the independent review of leadership and governance undertaken by PwC. GG explained that the heat map provides a visual representation of the quality performance of in-patient areas for Q1 and enables the committee to easily identify positive and negatives areas of performance. The areas colour coded ‘green’ represent high levels of performance. GG also explained that arrows had now been added to the report to show direction of trend.
GG stated that the report highlighted that development reviews and training remain the weakest area of performance at the end of June 2015 but have since improved. She said this will be reflected in the next report.
She explained that the overall trend from the previous quarter is one of improvement.
KW asked what other committees receive this report. GG explained that it is only presented to this committee in this particular format although it is circulated to wards and departments for information. However, GG noted that the information contained is included in various other reports.
CO stated that the issue regarding staff development reviews and training may need to be scrutinised further following the November meeting.
Discussion took place regarding whether the quality heat map is useful to see at this committee meeting. It was agreed that the report will be presented to the November meeting when a final decision will be made.
Action: GG to prepare a Quality Heat Map paper for the November meeting.
GG
21/15 Escalations to the Board of Directors
• None
22/15 Any other business
No items were raised.
Date and time of next meeting:
Friday 27th November 2015 at 10 a.m. in trust administration, meeting room 6
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Chairman: Christine Outram Chief Executive: Roger Spencer
The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX Tel: 0161 446 3000 Fax: 0161 446 3977 www.christie.nhs.uk
