This page has been left blank - kch.nhs.uk - 503.1 - cog... · 14 Enc_4-2_Q4_Monitor_Submission 123 ... Wednesday, 05 October 2016 from 14:30-15:30 at Bromley Central Library. Sue

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1 Enc_0_CoG_Agenda_Public_04052016_rev 32 Enc_1-4_Pub_CoG_MM_17032016_Confirmed 53 Enc_1-5_PCoG_Actions_Tracker_04052016 154 Enc_3-1-1a_Draft_Quality_Report 175 Enc_3-1-1b_Draft_3_QA_Working_Doc 196 Enc_3-2-1a_National_Staff_Survey_April_2016_V2 897 Enc_3-2-1b_Appendix 958 Enc_3-3-1_Governor_Elections_2016 979 Enc_3-3-2_Governor_Engagement_and_Involvement 10710 Enc_3-3-3-1_MEC_Key_Discussions_04052016 11311 Enc_3-3-3-2_GSC_Key_Discussions_04052016 11512 Enc_3-3-3-3_PESC_Key_Discussions_19042016_VS 11713 Enc_4-1_CoG_Attendance_Register_04052016 12114 Enc_4-2_Q4_Monitor_Submission 12315 Enc_4-3-1_Confirmed_MCE_Minutes_18022016 12716 Enc_4-3-2_Confirmed_MM_GSC_15022016 13317 Enc_4-3-3_Confirmed_MM_PESC_18022016 139

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Key: FE: For Endorsement; FA: For Approval; FR: For Report; FI: For Information

AGENDA

Meeting Public Council Of Governors

Time of meeting 14:30-15:30

Date of meeting Wednesday, 04 May 2016

Meeting Room Large Hall, 4th Floor, Bromley Central Library

Site High Street, Bromley, BR1 1EX

Encl. Lead Time

1. STANDING ITEMS Chair 14:30 1.1. Apologies

1.2. Declarations of Interest

1.3. Chair’s Action

1.4. Minutes of Previous Meeting – 17/03/2016 FA Enc. 1.4

1.5. Matters Arising FE Enc. 1.5

2. Reflection Session on Board of Directors Meeting Verbal 14:35 3. FOR REPORT

3.1. Best Quality of Care

3.1.1. Draft Quality Report 15/16 FE Enc. 3.1.1 G Walters

14:45

3.2. Skilled ‘Can Do’ Teams

3.2.1. National Staff Survey FR Enc. 3.2.1 D Brodwick 14:55

3.3. Governor Involvement & Engagement

3.3.1. Governor Elections FI Enc. 3.3.1 J Seddon 15:05

3.3.2. Governor Engagement & Involvement Activities

FI Enc. 3.3.2 C North 15:10

3.3.3. Sub-Committees Summaries/Actions

3.3.3.1. Membership & Community Engagement FR Enc. 3.3.3.1 F Clark

3.3.3.2. Strategy FR Enc. 3.3.3.2 A McCall

3.3.3.3. Patient Experience & Safety FR Enc. 3.3.3.3 T Duffy

4. FOR INFORMATION 15:25

4.1. Register of Governors Attendance FI Enc. 4.1

4.2. Monitor Quarterly Submission – Quarter 4 FI Enc. 4.2

4.3. Sub-Committee – Confirmed Minutes 4.3.1. Membership & Community Engagement 4.3.2. Strategy 4.3.3. Patient Experience & Safety

FI Enc. 4.3.1 Enc. 4.3.2 Enc. 4.3.3

5. ANY OTHER BUSINESS Chair 15:30

6. DATE OF NEXT MEETING Wednesday, 05 October 2016 from 14:30-15:30 at Bromley Central Library

Sue Slipman Vice Chair Elected: Anoushka de Almeida-Carragher Bromley Eniko Benfield Bromley Fiona Clark Lambeth Paul Corben Bromley Penny Dale Bromley Chris North Lambeth Nanda Ratnavel Lambeth Grace Okoli Lambeth Tim Bradley Lewisham Derek St Clair Cattrall Patient Pida Ripley Patient Helen Ahmet Patient Jan Thomas Patient Craig Jacobs Patient Barbara Pattinson Southwark Andrew McCall Southwark Victoria Silvester Southwark Jo Millet Staff – Nurses and Midwives Nicky Hayes Staff – Nurses and Midwives Daniel Beasley Staff - Allied Health Professionals, Scientific & Technical Roger Engwell Staff – Administration, Clerical & Management Nominated/Partnership Organisations: Cllr Robert Evans Bromley Council Phidelma Lisowska Joint Staff Committee Chris Mottershead King’s College London Cllr. Jim Dickson Lambeth Council Dr Sadru Kheraj Lambeth Clinical Commissioning Group Kieron Williams Southwark Council Dr Noel Baxter Southwark Clinical Commissioning Group Diane Summers Guy’s & St. Thomas’ NHS Foundation Trust In attendance: All Executive Directors All Executive Directors All Non-Executive Directors All Non-Executive Directors Tamara Cowan (TC) Board Secretary Silviyana Yankova (SY) Corporate Governance Assistant (Minutes) Apologies: Lord Kerslake Trust Chair Trudi Kemp Director of Strategic Development Pam Cohen Southwark Roger Paffard South London & Maudsley NHS FoundationTtrust Anand Arya Staff – Medical & Dental Tom Duffy Patient Vacancies Vacant Bromley Clinical Commissioning Group Circulation to: Council of Governors and Board of Directors

Enc. 1.4 Subject to Chair’s Approval

1

Council of Governors – Public Session Minutes of the meeting held on Thursday, 17 March 2016, Bill Whimster Suite, Weston Education Centre, King’s College London, Denmark Hill, London, SE5 9RS Lord Kerslake Trust Chair Elected: Anoushka de Almeida-Carragher Bromley (part) Penny Dale Bromley Fiona Clark Lambeth Chris North Lambeth Grace Okoli Lambeth (part) Nanda Ratnavel Lambeth Tim Bradley Lewisham Helen Ahmet Patient Tom Duffy Patient (part) Pida Ripley Patient Craig Jacobs Patient Jan Thomas Patient Andrew McCall Southwark Victoria Silvester Southwark Pam Cohen Southwark Barbara Pattinson Southwark Roger Engwell Staff – Administration and Clerical Jo Millett Staff – Nurses and Midwives Nicky Hayes Staff – Nurses and Midwives Cornelius Lewis Staff – Allied Health Professionals, Scientific and Technical Anand Arya Staff – Medical and Dental Nominated/Partnership Organisations: Diane Summers Guy’s & St Thomas’ NHS Foundation Trust Chris Mothershead King’s College London Phidelma Lisowka Joint Staff Committee Cllr Jim Dickson Lambeth Council Cllr. Kieron Williams Southwark Council Sadru Kheraj Lambeth CCG In attendance: Judith Seddon Acting Director of Corporate Affairs Tamara Cowan Board Secretary (Minutes) Nick Moberly Chief Executive Officer Colin Gentile Chief Financial Officer (part) Jane Badejoko Corporate Governance Officer Silviyana Yankova Corporate Governance Assistant Apologies: Eniko Benfield Bromley Paul Corben Bromley Derek St Clair Cattrall Patient CV Praveen Staff – Medical and Dentistry Roger Paffard South London & Maudsley NHS Foundation Trust Cllr. Robert Evans Bromley Council Dr Noel Baxter Southwark CCG In attendance: Judith Seddon Acting Director of Corporate Affairs Tamara Cowan Board Secretary


2

Nick Moberly Chief Executive Officer Colin Gentile Chief Financial Officer Jane Badejoko Corporate Governance Officer (Minutes) Silviyana Yankova Corporate Governance Assistant Geraldine Walters Director of Nursing & Midwifery Alan Goldsman Acting Director of Strategic Development

David Dawson Deputy Director of Strategy Jez Tozer Interim Chief Operating Officer Paul Donohoe Deputy Medical Director Item Subject Action

016/01 Welcome & Apologies The apologies for absence were noted. The Council welcomed Dr Sandru Kheraj nominated governor representative for Lambeth Clinical Commissioning Group, Dr Anand Arya, Medical and Dental staff representative and Daniel Beazley, Allied Health Professionals Scientific and Technical staff representative shadowing Governor Cornelius Lewis, to their first Council of Governors meeting.

016/02 Declarations of Interest There were no declarations of interest.

016/03 Chair’s Action There were no Chair’s action to report.

016/04 Minutes of Previous Meeting The minutes of the meeting held on 10 December 2015, were approved as a correct record. Subject to verification of the reasoning for the insertion of the word ‘and’ at the end of page 7.

016/05 Matters Arising/Action Tracking There were no matters arising from the last meeting.

FOR REPORT

Best Quality of Care

016/06 Patient Experience Report The Council received and noted the Patient Experience Report presented by Jessica Bush. The following key points were reported:


3

Item Subject Action

The Trust is always striving to improve patient experience across all its sites. Patient experience is measured against CQC fundamental performance standards and Friends and Family Test(FFT). Each year the results are reviewed and an action plan to address low performing areas is completed;

Results from last year indicated that the inpatients services had low scores.

The Trust implemented improvement measures which have produced positive outcomes reflected in the current results. Patient satisfaction on both sites is exceeding the overall ‘How are we doing’ score and FFT targets for the year;

The Trust’s outpatient services results are less positive with both sites

performing below target for overall ‘How are we doing’ scores and FFT. The Trust’s FFT scores are also 5% below the national average;

Outpatient services areas will be subject to a targeted improvement campaign focussing on patient appointments, waiting times in clinic and not providing patients with information or reasons for the length of their wait.

The Trust’s complaints performance improved in quarter 3 (Q3), 46% of all

complaints were responded to within 25 working days of their receipt. Current to date performance indicates that the Trust is operating at 42%;

NHS choices website rated the Trust’s Denmark Hill(DH) site, 4.5 stars out of 5 which was the same as last year. The Princess Royal University Hospital (PRUH) was rated 4.5 stars which is an improvement on last year’s rating of 3.5 stars;

The Trust is currently performing in the top quartile for teaching hospitals

despite the unfavourable outpatients scores; The Council raised the following points in discussions: The overall number of complaints for Q3 have reduced compared to the

increased activity and the number of patients treated by the Trust. This is a positive point; The biggest issue with complaints for the Trust is response time. The Trust is attempting to improve this by having clinical and divisional contribution into complaints to better assess and respond to all issues at the appropriate level.

The outpatient services results are not ideal and there is much work to be

done to improve these but the Trust will be focusing on these areas with a number of initiatives which will also form part of the wider transformation programme;

It was noted that complaints are processed differently from those complaints

that involve duty of candour. Duty of candour cases are put through the rigorous serious complaints procedures;


4

Item Subject Action

There were high levels of complains in July to August 2014 at the PRUH. This was due to the post-merger organisational redevelopment. The Trust was implementing a number of new patient pathways to improve services. In was also noted that in the last 3 months the PRUH has had restricted access to visitors due to a Norovirus contamination, there may be some complaints associated with the restricted conditions;

The Trust target of 60% response time to complaints is not the final objective the Trust will be satisfied with, it is milestone and a realistic target given the current resources and organisational pressures. The Trust plans to keep increasing this target until it reached 80%;

It was noted that 25% of all Trust complaints relate to the emergency department. Analysis have indicated that there is a direct correlation between numbers of complaints and breaches of the 4 hours emergency department (ED) performance target; and

The Trust plans a number of improvements intermediate schemes aimed at short term relief solutions to the ED problems. But there are wider plans for major changes in services delivery which will be covered under the transformation agenda and should provide a permanent solution to ED issues.

016/07 Quality Priorities & Indicators The Council received the Trust’s proposed quality priority indications for 2016/17. The following key points were reported: The Trust has begun work on proposals for the 2016/17 quality priorities.

They will form the key areas of focus for the Trust in relation to quality of patient care. The Trust will draft these followed by a wider stakeholder consultation programme;

The Trust plans to concentrate on three domains for the year, patient:

safety, outcomes and experience;

Last year the Trust focused on reducing smoking, increased alcohol awareness and exercise promoting to tackle obesity. The results were good with notable success in the increased referrals to stop smoking clinics and alcohol awareness but exercise promotion did not perform as well;

In the patient outcomes domain the Trust achieved success in the improved outcome for patients with hip fractures. In the patient safety domain the Trust concentrated on: surgical safety culture around never events in surgery and medication administration safety;

Performance on most indicators has been successful with some performing

better than others and valuables lessons have been learned by the Trust;


5

Item Subject Action

For next year the Trust plans to continue with the medication safety theme by focusing on patient use of antibiotics and medication omissions;

The Trust will also be complying with Monitor guidance in the following areas: Referral to treatment within 18 weeks for patients on incomplete pathway:

o A&E four hour wait; o 62 day cancer treatment wait; and o 28 day readmissions.

The list is in order of Monitor’s preference, accordingly the Trust is required

to conduct data testing on the following: o A&E four hour wait; and o Referral to treatment within 18 weeks for patients on incomplete

pathway. The Trust requests that the Council of Governors chose one local indicator

from the following options: • Medication Safety Errors • Venous Thromboembolism (VTE) • 62 day cancer waits; and • 28-day readmission.

The following key points were raised and discussed: The surgical safety priority facilitates the used of surgical safety checklist to

ensure everyone present will contribute to the patient care and all instruments are accounted for at the start and end of every procedure;

The Council was informed that the medical safety priority is recommended for further work in the current year not because it was unsuccessful last year, but because more could be gained by expanding the initiative.

The Council decide by a show of hands that they select the Medication Safety Errors as one of the local indicator for 2016/17. The Council decided that the final quality priority indicators will be presented to the Patient Experience and Safety Governor sub-committee.

PESC

016/08 Report from the Board The Council received the Chief Executive’s Board Report. The following key points were reported: With the end of the financial year fast approaching the Trust will be focusing

on three key objectives: o Maintaining financial and operational grip; o Achieve the targets for the year and setting up the start of the new

2016/17 year; and o Pushing ahead with strategic initiatives.


6

Item Subject Action

The Trust must continue to maintain a firm grip on its spending and financial controls. There is also important work underway to formulate the longer term future objectives. There are work streams relating to major services reconfiguration, improved infrastructures and capital developments;

The Trust is working closely with the health and social care partners in both Lambeth and Southwark, and Bromley, on how they can work together more effectively to deliver joined up care for local people with sustainable options;

Through OHSEL work the Trust will de undertaking to develop joint sustainability and transformation plans which will drive equality, efficacy and productivity with such things in the agenda as an Orthopaedics sector centre at Orpington;

The Trust will also be looking to move forward on the King’s Health Partners

(KHP) portfolio of services. Work is focused on developing plans to build a Haematology Institute on the DH site and Cardiovascular Services at Guy’s and St Thomas’ NHS Trust(GSTT) site. The partnership is also looking at opportunities for collaboration in Child Health and Neuroscience;

The Trust is looking to drive efficiencies and savings by working on clinical

support services via such forums as Viapath, a pathology service which it jointly owns with GSTT and Serco, which as one of the largest pathology providers nationally is driving sector changes and influencing provision of services;

Teaching and research are key initiatives that will help the Trust become a

word class institution and will also improve the care it provides by being a pioneer in medical innovation;

The Trust is also looking at its internal structures and carrying out reviews

and audits of various services to ensure all are fit for purpose and also to ascertain if some areas are lacking in resource and require support;

The following key points were raised and discussed: The Trust’s largest resource is its staff, the last staff survey results indicated

that there is low staff morale. The Trust has noted the results. A business case has been submitted to Monitor for funding of the transformation programme which will offer staff learning support;

The Trust is planning to complete majority of the CQC ‘must do’ items in 2016 with the exception of those relating to the distance between critical care beds. This item will be completed once the Trust opens its new 60 bed critical care unit; and

A new patient electronic system has been rolled out across the Trust as part

of the transformation plans and joined up working. The new system will permit clinicians access to patient records instantly across all sites. It is expected that there will be learning period for staff.

The Trust will present its capital development vision for the Trust at the Governor workshop in November.

NM/AT


7

Item Subject Action

016/09 Trust Performance Report The Council received and discussed the month 10 performance report. The following key points were reported and noted: The Trust is showing strong performance in cancer targets for a quarter 3

(Q3), non-validated figures indicate that the Trust is on trend to also achieve cancer target in quarter 4 (Q4) ahead of all other south east London providers;

However, the Trust is an outlier for patients transferred within 100 days from start of their treatment, these are patients who are transferred during their treatment to other providers;

The Trust has not been reporting on the backlog of its referral to treatment

patients. A full scale validation programme has been in effect over the past 12 months to ensure the Trust data is accurate and complete;

The Trust target on return to reporting is 92%, but it will likely average around

85%. The Trust plans to resume reporting of its March 2016 figures;

On its return to reporting the Trust will be publishing large numbers of patients waiting over 18 weeks. The Trust is working closely with its commissioning partner to ensure it can safely clear its back of patients;

The PRUH was behind on its emergency department (ED) trajectory,

performance declined from 89.9% in November to 86.1% in December against target of 95%. However, this is still a 10% improvement on the same period last year;

The introduction of the Transfer of Care Bureau (TCB) at the PRUH has not produced the increase in discharges and bed capacity anticipated. Bromley CCG have set aside a budget to review the performance of the TCB;

The ED at DH and the PRUH have different calibre of patients and local

community pressures;

The DH site ED performance is affected by capacity issues and trauma surgery patient. There has also been sudden increase in the number of patients seeking treatment with 485 patients attending the accident and emergency department in a single week. The growth factor for past year has been over 3.5% and rising.

The following key points were noted in discussions: The specialities with the largest number of backlog patients are

Orthopaedics, Ophthalmology and Neurosurgery. While the Trust is preparing plans that will clear the backlog which is subject to commissioner funding for Orthopaedics and Ophthalmology;


8

Item Subject Action

Neurosurgery services have a larger national system wide problem, which cannot be solved by the Trust working alone; and

One of the many factors identified that leads to an increase in the number of

patient attendance to ED is no access to General Practitioner (GP). Other factors include an elderly local population with complex medical conditions. There is need for further analysis to better understand the reason for the increase in patient numbers to ED.

016/10 Trust Finance Report The Council received and discussed the month 10 finance report. The following key points were reported and noted: At the end of month 10 the Trust is £73.75m overspend against a target

year-end deficit of £65m. This is after the application of £6.9m of new mitigation measures which are non-recurrent;

The Trust has also received one off support from its Clinical Commissioning Group(CCG) partners;

The Trust debt levels are being managed but they are worse off. NHS England (NHSE) remains the Trust’s largest debtor, negotiations for outstanding payments have been at deadlock and the Trust will going into arbitration;

Cashflow remains stable but very tight;

Initial non-validated figures for month 11 indicate that the Trust may end the

month with a £3m non recurrent surplus; The following key points were noted in discussions: The Trust is not delivering on it’s CIP programme as anticipated. To

minimise slippage in months 11 and 12 the Trust has carried out granular reviews of all CIPs scheme;

The Trust must improve its collection process relating to oversees private patients to whom it provides care. This is a income stream with great potential for success; and

The Trust has been give verbal confirmation that it will receive working

capital facility for next year.

The Council will receive an update on private patient’s income at the October meeting.

CG


9

Item Subject Action

Governor Involvement & Engagement

016/11 Governor Elections The Trust will be holding Governor election for eight positions in September 2016 A full report will be presented to the Council on 4 May.

016/12 Governor Engagement & Involvement Chris North (CN) updated the Council on the following: Governors started attending Board of Director’s Sub-Committee meetings

form January 2016. This is a positive step which will provide greater interaction between Governor and the Board;

A number of Governors attended the Joint KHP Governor event on 15 January hosted by GSTT. The event was well attended, but feedback from all Governors was that they would prefer a more interactive session for future meetings;

The Governor workshop on 31 January focused on discharge procedures in

the Trust, the presentations were well received; The Trust will be holding a formal review session of the Trust’s

Non-Executive Directors on 9 March all Governors are invited to attend this session; and

Governors are urged to get more involved in the Council of Governor’s

Sub-Committees and workshops. These are an excellent platform to gain further understanding into the Trust and a forum to drill down on specific issues.

016/13 Sub-Committees Summaries/Actions Membership & Community Engagement The Committee received a presentation from Nicola Kingston and Valerie

Dinsmore from Southwark and Lambeth Integrated Care (SLIC). The organisation is an open forum for discussion on all things integrated care; and

The Committee were also informed that SLIC as function will be transforming into a different organisation in April 2016.

Strategy Committee The Committee received and discussed the emerging Trust strategy which

lists the strategic objectives that the Trust will adhere to. These objective will form a key part of the Trust’s transform into a financially sustainable and operationally efficient health provider; and


10

Item Subject Action

The Committee also received presentations Cllr Jim Dixon and Aland

Goldsman Interim Director of Strategy. Patient Experience & Safety Committee The Committee received a video patient story from Maxine Spencer, Director

of Midwifery. The Committee had trouble hearing the video and understanding the content. It was noted that there was need for further editorial of the video before it was presented as any educational value was lost due to the poor quality.

FOR INFORMATION

016/14 Register of Governors Attendance The Council noted the register of Governors attendance.

016/15 Monitor Quarterly Submission – Quarter 3 The Council noted the Trust’s quarter 3 Monitor submission.

016/16 Sub-Committee – Confirmed Minutes The Council noted the following sub-committee minutes: Membership & Community Engagement Committee –09/07/2015 Strategy Committee – 09/07/2015 Patient Experience and Safety Committee – 09/07/2015

016/17 ANY OTHER BUSINESS

It was noted that Tooba Ahmadi will be leaving the Trust in April, the Council thanked Tooba for all her hard work; and

The Council was informed that Trust will not be moving the Chartwell Inpatient Unit as published in the News Shopper local newspaper, pending the results of a formal consultation.

DATE OF NEXT MEETING Joint Board of Directors and Council of Governors Meeting on Wednesday, 4 May 2016 from 14:30-15:30 at Bromley Library

Enc. 1.5

Action Status as at: 27 April 2016 1

COUNCIL OF GOVERNORS (PUBLIC MEETING) ACTION TRACKER

Date Item Action Who Due Update COMPLETED

17/03/2016 16/07 Quality Priorities & Indicators - The Council decided that the final quality priority indicators will be presented to the Patient Experience and Safety Governor sub-committee.

The action item has been transferred to Patient Experience & Safety Committee. The Committee Chair will feedback to the Council of Governors in due course.

NOT DUE

17/03/2016 16/08 Report from the Board- The Trust will present its capital development vision for the Trust at the Governor workshop in November.

NM/AT 03/11/2016


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King’s College Hospital NHS Foundation Trust Quality Report & Accounts 2015/16

Presented to Parliament pursuant to Schedule 7, paragraph 25(4) (a) of the National Health service Act 2006

Enc.3.1.1

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Enc.3.1.1

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CONTENTS

PART 1: CHIEF EXECUTIVE’S STATEMENT OF QUALITY 5

PART 2: PRIORITIES FOR IMPROVEMENT AND ASSURANCE STATEMENTS 17

SELECTING OUR IMPROVEMENT PRIORITIES 19

PERFORMANCE AGAINST 2015/16 QUALITY PRIORITIES 21

2016/17 IMPROVEMENT QUALITY PRIORITIES 28

STATEMENTS OF ASSURANCE FROM THE BOARD 32

STATEMENT OF ASSURANCE EVIDENCE 37

TRUST PARTICIPATION IN NCEPOD STUDIES 41

CLINICAL AUDIT PROJECTS REVIEWED BY THE TRUST 41

LOCAL AUDITS – CP TO PROVIDE 49

REPORTING AGAINST CORE INDICATORS 50

PERFORMANCE MEASURES 50

RESPONSIVENESS TO PATIENTS PERSONAL NEEDS 53

FRIENDS & FAMILY TESTS 55

PART 3: OTHER INFORMATION 60

OTHER UNDERLYING QUALITY OF CARE INDICATORS 60

OTHER UNDERLYING QUALITY OF CARE INDICATORS 62

TRUST ACTIONS ON DUTY OF CANDOUR (INCIDENTS/ACTIONS) 65

ANNEX 1: STATEMENTS FROM COMMISSIONERS, LOCAL HEALTHWATCH ORGANISATIONS AND

OVERVIEW AND SCRUTINY COMMITTEES 67

ANNEX 2: STATEMENT OF DIRECTORS’ RESPONSIBILITES FOR THE QUALITY REPORT 68

Enc.3.1.1

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Enc.3.1.1

9

GLOSSARY ACRONYM/WORD MEANING – To be updated

A&E Accident & Emergency

ACC Accredited Clinical Coder

AHP Allied Health Professionals i.e. Physiotherapists, Occupational Therapists, Speech & Language Therapists etc.

AHSC Academic Health Science Centre

ANS Association of Neurophysiological Scientists Standards

BCIS Bone Cement Implantation Syndrome

BHRS British Heart Rhythm Society

BME Black and Minority Ethnic

BREEAM Building Research Establishment Environmental Assessment Method

BSCN British Society for Clinical Neurophysiology

BSI The British Standards Institution

BSS Breathlessness Support Service

CCG Clinical Commissioning Groups (previously Primary Care Trusts)

CCS Crown Commercial Service

CCTD Critical Care and Trauma Department

CCUTB Critical Care Unit over Theatre Block

C-difficile Clostridium Difficile

CDU Clinical Decisions Unit

CEM Royal College of Emergency Medicine

CHD Congenital Heart Disease

CHR – UK Child Health Clinical Outcome Review Programme (UK)

CLAHRC Collaboration for Leadership in Applied Research and Care

CLINIWEB The Trust's internal web-based information resource for sharing clinical guidelines and statements.

CLL Chronic Lymphocytic Leukaemia

CLRN Comprehensive Local Research Network

CNS Clinical Nurse Specialist

COPD Chronic Obstructive Pulmonary Disease

COPD Chronic Obstructive Pulmonary Disease

COSD Cancer Outcomes and Services Dataset

COSHH Control of Substances Hazardous to Health

CPPD Continuing Professional and Personal Development

CQC Care Quality Commission

CQRG Clinical Quality Review Group (organised by local commissioners)

CQUIN Commissioning for Quality and Innovation

CRF Clinical Research Facility

CRISP Community for Research Involvement and Support for People with Parkinson’s

CT Computerised Tomography

Enc.3.1.1

10

DAHNO National Head & Neck Cancer Audit

DH/KCH DH Denmark Hill. The Trust acute hospital based at Denmark Hill

DNAR Do Not Attempt Cardiopulmonary Resuscitation

DoH Department of Health

DTOC Delayed Transfer of Care

ED Emergency Department

EDS Equality Delivery System

EMS Environmental Management System

EPC Energy Performance Contract

EPMA Electron Probe Micro-Analysis

EPR Electronic Patient Record

ERR Enhanced Rapid Response

ESCO Energy Service Company

EUROPAR European Network for Parkinson’s Disease Research Organization

EWS Early Warning Score

FFT Staff Friends & Family Test

FY Financial Year

GCS Glasgow Coma Scale

GP General Practitioner

GSTS Pathology Venture between King’s, Guy’s and St Thomas’ and Serco plc

GSTT Guy's St Thomas' NHS Foundation Trust

H&S Health & Safety

HASU Hyper Acute Stroke Unit

HAT Hospital Acquired Thrombosis

HAU Health and Aging Units

HCAI Healthcare Acquired Infections

HCAs Health Care Assistants

HESL Health Education South London

HF Heart Failure

HIV Human Immunodeficiency Virus

HNA Holistic Needs Assessment

HQIP Healthcare Quality Improvement Partnership

HRWD ‘How are we doing?’ King’s Patient/User Survey

HSCIC Health and Social Care Information Centre

HSE Health and Safety Executive

HTA Human Tissue Authority

IAPT Improving Access to Psychological Therapies

IBD Inflammatory Bowel Disease

ICAEW Institute of Chartered Accountants in England and Wales Code of Ethics

ICNARC Intensive Care National Audit & Research Centre

ICO Information Commissioner’s Office

ICT Information and Communications Technology

ICU Intensive Care Unit

IG Toolkit Information Governance Toolkit

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11

IGSG Information Governance Steering Group

IGT Information Governance Toolkit

IHDT Integrated Hospital Discharge Team

iMOBILE Specialist critical care outreach team

IPC Integrated Personal Commissioning

ISO International Organization for Standardization

ISS Injury Severity Score

JCC Joint Consultation Committee

KAD King’s Appraisal & Development System

KCH, KING's, TRUST King's College Hospital NHS Foundation Trust

KCL King’s College London – King’s University Partner

KHP King's Health Partners

KHP Online King’s Health Partners Online

KPIs Key Performance Indicators

KPMG LLP King’s Internal Auditor

KPP King’s Performance and Potential

KWIKI The Trust's internal web-based information resource. Used for sharing trust-wide polices, guidance and information. Accessible by all staff and authorised users.

LCA London Cancer Alliance

LCN Local Care Networks

LIPs Local Incentive Premiums

LITU Liver Intensive Therapy Unit

LUCR Local Unified Care Record

MACCE Major Adverse Cardiac and Cerebrovascular Event

MBRRACE-UK Maternal, Newborn and Infant Clinical Outcome Review Programme

MDMs Multidisciplinary Meeting

MDS Myelodysplastic Syndromes

MDTs Multidisciplinary Team

MEOWS Modified Early Obstetric Warning Score

MHRA Medicine Health Regulatory Authority

MINAP The Myocardial Ischaemia National Audit Project

MRI Magnetic Resonance Imaging

MRSA Methicillin-resistant staphylococcus aureus

MTC Major Trauma Services

NAC N-acetylcysteine

NADIA National Diabetes Inpatient Audit

NAOGC National Audit of Oesophageal & Gastric Cancers

NASH National Audit of Seizure Management

NBOCAP National Bowel Cancer Audit Programme

NCEPOD National Confidential Enquiry into Patient Outcome & Death Studies

NCISH National Confidential Inquiry into Suicide & Homicide for People with Mental Illness

NCPES National Cancer Patient Experience Survey

NDA National Diabetes Audit

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12

NEDs Non-Executive Directors

NEST National Employment Savings Trust

NEWS National Early Warning System

NHFD National Hip Fracture Database

NHS National Health Service

NHS Safety Thermometer

A NHS local system for measuring, monitoring, & analysing patient harms and ‘harm-free’ care

NHSBT NHS Blood and Transplant

NICE National Institute for Health & Excellence

NICU Neonatal Intensive Care Unit

NIHR National Institute for Health Research

NJR National Joint Registry

NNAP National Neonatal Audit Programme

NPDA National Paediatric Diabetes Audit

NPID Pregnancy Care in Women with Diabetes

NPSA National Patient Safety Agency

NRAD National Review of Asthma Deaths

NRLS National Reporting and Learning Service

NSCLC Non-Small Lung Cancer

OH/ORPINGTON HOSPITAL

The Trust acquired services at this hospital site on 01 October 2013

OSC King’s Organizational Safety Committee

PALS Patient Advocacy & Liaison Service

PbR Payment by Results

PICANet Paediatric Intensive Care Audit Network

PiMS Patient Administration System

PLACE Patient Led Assessments of the Care Environment

POMH Prescribing Observatory for Mental Health

POTTS Physiological Observation Track & Trigger System

PROMS Patient Reported Outcome Measures

PRUH/KCH PRUH Princess Royal University Hospital. The Trust acquired this acute hospital site on 01 October 2013

PUCAI Paediatric Ulcerative Colitis Activity Index

PwC PricewaterhouseCoopers

QMH Queen Mary’s Hospital

RCPCH Royal College of Paediatric and Child Health

RIDDOR Reporting of Injuries, Dangerous Diseases and Dangerous Occurrences Regulations

ROP Retinopathy of Prematurity

RRT Renal Replacement Therapy

RTT Referral to Treatment

SBAR Situation, Background, Assessment & Recognition factors for prompt & effective communication amongst staff

SCG Specialist Commissioning Group (NHS England)

SEL South East London

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13

SEQOHS Safe Effective Quality Occupational Health Service

SHMI Standardised Hospital Mortality Index. This measure all deaths of patients admitted to hospital and those that occur up to 30 days after discharge from hospital.

SIRO Senior Information Risk Owner

SLAM South London & Maudsley NHS Foundation Trust

SLHT South London Health Care Trust. SLHT dissolved on 01 October 2013 having being entered into the administration process in July 2012.

SLIC Southwark & Lambeth Integrated Care Programme

SSC Surgical Safety Checklist

SSIG Surgical safety Improvement Group

SSNAP Sentinel Stroke National Audit Programme

SUS Secondary Uses Service

SW Social Worker

TARN Trauma Audit & Research Network

TTAs Tablets to take away

TUPE Transfer of Undertakings (Protection of Employment) Regulations

UAE United Arab Emirates

UNE Ulnar Neuropathy at Elbow

VTE Venous-Thromboembolism

WHO World Health Organisation

WTE Whole Time Equivalent

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14

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has been made in the outcomes for patients following hip fracture and interventions to reduce preventable ill health. Good progress has also been made in some areas to improve the experience of cancer patients but we recognised more needs to be done and will form part of our transformation programme. Unfortunately, we did not make the level of progress wanted to improve the safer surgery culture and in particular reduce the number of never events to zero. This initiative will be carried forward for another year. Our 2016/17 quality improvement priorities include: 1. Enhanced recovery after surgery

(ERAS).

2. Improved outcomes after emergency abdominal surgery.

3. Improve implementation of sepsis bundles for patients with positive blood cultures and diagnosis of sepsis.

4. Improve the quality of the surgical safety.

5. Improve access to information for patients, service users, carers and parents, where those needs relate to a disability, impairment or sensory loss.

6. Improving outpatient experience.

Data Quality There are a number of inherent limitations in the preparation of Quality Accounts which may affect the reliability or accuracy of the data reported. These include: Data is derived from a large number of

different systems and processes. Only some of these are subject to external assurance, or included in internal audits programme of work each year.

Data is collected by a large number of

teams across the trust alongside their main responsibilities, which may lead to differences in how policies are applied or interpreted. In many cases, data reported reflects clinical judgement about individual cases, where another clinician might have reasonably have classified a case differently.

National data definitions do not

necessarily cover all circumstances, and local interpretations may differ.

Data collection practices and data

definitions are evolving, which may lead to differences over time, both within and between years. The volume of data means that, where changes are made, it is usually not practical to reanalyse historic data.

During the period, we took a reporting holiday for referral to treatment (RTT) data with the endorsement of Monitor and commissioners. During the reporting holiday, we have worked hard on the robustness of our data to ensure we have best information and can treat our patients effectively. We return to reporting in March 2016 with renewed confidence in our systems and accuracy of our RTT data. The Trust and its Board have sought to take all reasonable steps and exercise appropriate due diligence to ensure the accuracy of the data reported, but recognises that it is nonetheless subject to the inherent limitations noted above. Having had due regard for the contents of this statement to the best of my knowledge, the information contained in the following Quality Account is accurate.

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17

Signature

Nick Moberly, Chief Executive Officer

Date

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Part 2: Priorities for improvement and assurance statements

Selecting our improvement priorities This quality report provides a summary of our performance against our chosen quality improvement priorities for 2015/16 and outline what we aim to achieve in 2016/17. In choosing the quality improvement priorities, we consult with local commissioners, healthwatch, staff, governors, senior executives and the Board of Directors. We are committed to driving our patient focus strategy which informs our decision making processes. Embedded in the fabric of the Trust’s culture is the ethos of providing of the best quality of care to patients always. We are a busy acute hospital and as such are always making improvements to our services and practices. In addition to our regular programme of improvement works, we chose six priorities within the patient outcomes, patient experience and patient safety domains to give additional focus each year. Periodically we may decide give more focus to some improvement priorities hence they span more than one year. The table overleaf details our past and present priorities.

In accordance with the NHS Quality Accounts Amendment Regulations 2013 and the guidelines set out by Monitor and the Department of health, we have included the following in this report: standardised statements of

assurances from the Board and the required evidence;

performance against key quality indicators;

other information including data key

performance indicators and quality information;

statements from commissioners local

healthwatch organisations and overview and scrutiny committees; and

published statement of the directors’

responsibilities for the quality report.

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20

Past and Present – Our Quality Improvement Priorities

2012/2013 2013/2014 2014/2015 2015/2016 2016/2017

Pat

ien

t O

utc

om

es

Improve

responsivenes to inpatients personal

needs

Dementia

Reducing mortality

associated with alcohol and

smoking

Maximising King’s contribution towards

preventing disease e.g. smoking and alcohol

Improve surgery outcomes – enhanced recovery after surgery

(ERAS)

Chronic obstructive pulmonary

disease

Improve outcomes of patients with hip

fracture

Improve care of patients with hip fracture

Improve emergency abdominal surgery

outcomes

Pat

ien

t E

xper

ien

ce

Improve end of life care

Improve

outpatient experience

Improve experience of

cancer patients

Improve experience of cancer patients

Improve outpatient experience

Improve diabetes

care

Improve patient experience of

discharge

Improve experience of discharge for

patients

Improve experience and co-ordination of

discharge

Improve access to information for patients, service users, carers and

patients

Pat

ien

t S

afet

y

Improve identification and escalation of acutely ill patients

Management of acutely unwell

patient Reduction in falls Medication safety

Improve implementation of sepsis bundles

Minimise harm acquired in the

hospital

Surgical Safety

Checklist

Surgical safety

Safer surgery

Improve quality of the surgical safety checks

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Performance against 2015/16 Quality Priorities

PRIORITY 1. Working to reduce preventable ill health

We said we would: Develop our acute sites as ‘health

promoting hospitals’, continuing the culture change started in 2014/15 to make health promotion mainstream.

Increase the number of staff trained to

support patients in reducing smoking and harmful alcohol use.

Increase provision of advice and brief

interventions relating to smoking and harmful alcohol use.

Increase referrals into smoking

cessation and alcohol services. Work with the providers of hospital

food, both on the wards and in our cafes, to promote and deliver healthier food.

Review ways in which we can increase

promotion of exercise to improve health.

Continue work to implement NICE

public health guidance. We were successful in: Rolling out screening programmes for

alcohol and smoking in 31 wards across both acute sites.

Providing brief intervention to all patients that smoke, and those who scored higher than three on the Fast Alcohol Screening Test (FAST) audit tool for alcohol.

Making both acute sites smoke free

and offering patients nicotine replacement therapy whilst in the hospitals.

Launching Carbon Monoxide

monitoring on two wards.

Increasing the numbers of referrals for smoking.

Reviewed the food provided and launched initiatives for promoting healthier eating for patients and staff.

We are also working: Completing training for staff, including

clinical and nurse leads, so they can support and provide screening and brief intervention for alcohol and smoking.

With the Department of Health’s

Prevention, Obesity and Diabetes team take forward obesity screening and related health promotion.

Expanding the screening programme

into paediatric asthma clinics and maternity services.

Developing plans for advice around physical activity for patients and staff.

Developing more initiatives around

balanced diet and healthier food choices.

INSERT IMAGE/QUOTE

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PRIORITY 2. Improving outcomes following hip fracture

We said we would: Increase the proportion of patients

getting the surgery they need to repair their hips in less than 36 hours.

Ensure that all patients receive the physiotherapy they need.

Ensure effective shared care between orthopaedics and geriatrics.

Increase the proportion of patients who have a geriatric assessment within 72 hours.

Ensure all patients are tested for delirium before and after surgery.

Ensure all patients have a falls assessment and a bone health review.

Increase the proportion of our patients who have an admission anaesthetic review prior to surgery, to ensure that our patients are in the best health for surgery.

Focus on the care pathway for hip fracture patients on both of our acute hospital sites of, Denmark Hill and the PRUH.

We were successful in: Achieving all these criteria for all our

patients above the national target level since August 2015 (see Figures 1 and 2). When we began this work three years ago, we met the criteria for all patients in just 4% of cases on our Denmark Hill site. We now meet all the criteria for 70% of patients, exceeding the national target of 60%, and meaning that King’s is now one of the best performing Trusts in the country.

Reducing the length of stay for our hip fracture patients cared for in our new hip fracture care areas – by an average of 10 days at Denmark Hill and 9 days at the PRUH.

2: Achievement of all best practice criteria (Denmark Hill)

3: Achievement of all best practice criteria (PRUH)

We are also working: Developing an early mobilisation

protocol for patients.

Development of post-operative care protocol, across both of our sites, and embed this in our Electronic Patient Record system.

Continuing to ensure effective support for these vulnerable patients from our care-of-the-elderly teams.

To streamline our discharge processes and ensure patient and family involvement.

To ensure that our new care pathways are embedded and continue to work well to improve patient care on both of our main acute sites.

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PRIORITY 3. Improving experience and coordination of discharge

We said we would: Southwark and Lambeth Integrated

Care (SLIC): Achieve integrated working in the hospital environment building better communications between all parties (internal & external) to facilitate safer patient discharge.

SLIC: Increase and embed Care Home interface meetings - group including hospital and care home managers to enable effective admission and discharge communications.

Continue to increase usage and profile of Homeless team.

Increased usage of the @Home service across all specialties.

Improve timeliness and quality of information around medications for patients and carers.

Ensure all inpatient wards have

individual actions plans to improve discharge, share good practice and innovative ideas.

Ensure all patients who have received care from a therapist has a detailed discharge summary sent to their GPs.

Increase the number of discharges before 11:00 at PRUH.

Ensure a robust referral system to

external agencies such as, Bromley Health and Medihome.

Implement criteria led discharge

throughout medicine and surgery at PRUH.

Commit to Care ward accreditation system discharge indicators to be green across the organisation.

Embed telephone follow-up calls to as routine in all appropriate in patient wards areas (50% in first 6 months up to 85% by year end).

We were successful in: With SLIC, implementing a successful

pilot of an integrated approach to discharge on Donne ward which is now informing how we develop our teams going forward. Time taken for ward based assessments reduced from 22 days to 6 days during the pilot period.

With SLIC, developing and rolling out a Transfer of Care Bundle setting out best practice steps for discharge from hospital to Care Homes. Readmission rates from Care Homes reduced from 22% to 6% during the test period.

Getting @Home established as the

first choice provider for acute out of hospital care for our local Lambeth and Southwark discharges.

Developing our KHP Homeless Team,

linking directly with the new SLaM service to join up support and planning for patients with mental and physical health needs.

Establishing a Transfer of Care

Bureau in autumn 2015 to support discharges and associated communication across the PRUH site.

Finalising a SOP for board rounds at the PRUH with clear roles and responsibilities for discharging patients before lunch.

Introducing registered nurses to the discharge lounge of the PRUH to facilitate patients moving from ward areas.

Introducing use of electronic integrated assessment form now on EMIS system which is used by Bromley GP and community providers.

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Rolling out electronic notifications of assessment and discharge now.

Commencing criteria led discharge on

surgical wards at weekends at the PRUH site.

Adopting C2C ward accreditation system for discharge indicators to reflect the changes above.

We are also working: Developing our Integrated Care and

Partnership structure as SLIC comes to an end (March 2016) ensuring effective ongoing links with community, social care and voluntary sector providers.

Developing a more integrated approach to hospital discharge, responding to both local CCG and NHS England CQUINs.

Completing baseline ward audits

which use the safer care bundle to assess ward discharge processes.

Identifying an exemplar ward to and

then developing appropriate actions plans.

INSERT IMAGE/QUOTE

PRIORITY 4. Improving the experience of cancer patients

We said we would: Ensure that all the core MDT members

(doctors and CNSs) are trained in national advanced communication skills training.

Ensure that all patients are seen by the CNS/support worker at diagnosis.

Increase the number of holistic needs assessments undertaken within 31 days of diagnosis and within 6 weeks of completion of treatment.

Ensure all patients receive a FU call from the CNS teams within 48 hours of diagnosis, and within 24 hours of discharge from hospital following treatment.

Ensure that the CNS teams review inpatients at least once during their in-patient stay in order to provide further information and support.

Ensure patients and GPs are provided with an end of treatment summary or care plan.

Establish health and well-being events for patients (for example HOPE courses).

Undertake specialist training for nurses and HCAs on the in-patient wards.

Work with Macmillan to develop the band 4 support worker role in each MDT – an innovative role aimed at helping patients to navigate through their pathways and to provide ‘one to one support’.

Introduce designated nurse led pre-assessment clinics for patients commencing chemotherapy treatment.

Continue with the rolling annual internal peer review of each MDT – holding teams to account for progress

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25

being made against their patient experience action plans.

Develop a designated cancer

information hub in the PRUH Chartwell unit and work with Macmillan to ensure that information pods are available in key areas throughout the PRUH.

Establish a Trust cancer patient experience steering group.

Develop KPIs for the CNS teams, which aid to hold the teams to account for quality improvements.

We were successful in: Securing funding to run four advanced

communication courses for 40 MDT members.

Getting 88% of patients seen by the CNS at diagnosis. The LCA data showed that the Trust was ranked 7th for compliance out of 157 trusts.

Offering patients a HNA at diagnosis in all services and approximately 20% receive one at completion of treatment and this is on an upward trajectory.

Getting more clinical specialties to provide end-of-treatment summaries. This is on an upward trend.

Having a higher presence of CNS’s visiting the wards providing some teaching.

Holding Health and Well Being (HWB) sessions. Two breast specific sessions took place in 2015 with approximately 30 patients in attendance. One generic HWB session focusing on mainly colorectal, haematology and hepatobiliary was also held with 14 patient’s attending.

Inviting all patients to a nurse led pre-

assessment clinic prior to commencing chemotherapy.

Rolling programme of peer review continues for all Cancer MDT’s with

patient experience being the core element for discussion

3 information stands have been funded for the PRUH by Macmillan.

We are also working on: KPI’s for the CNS’s have been written

and will be implemented by April 2016.

Plans to hold six HWB events in 2016 (2 breast and 4 generic).

Continuing to engage patients’ help to design services to meet their needs.

4: Macmillan Information Pods

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PRIORITY 5. Medication Safety We said we would: Reduce incidents involving

administration of drugs to patients with known allergies.

Increase in the percentage of nursing staff passing the drug calculation competency assessment at 100%.

Reduce the number of medication

errors involving the wrong patient. Reduce incidents involving 10-fold

errors. We were successful in: Achieving a modest reduction in the

number of incidents involving administration drugs to patient with known allergies reported. This moved from 59 in 2014/15 to 48 (as at February 2016) in 2015/16. The majority of clinical areas are recording 0-1 per month – these are very low compared to the total number of medications administered and further benchmarking is required to assess the scale of this as an issue.

Increasing the percentage of nursing staff passing the drug calculation competency to 52% (excluding new starters). This is a good result given it was a new initiative starting from a baseline of zero in 2015 (calculation based on existing workforce).

Reducing the total number of medication errors to 65 in 2015/16 (79 in 2014/15). The small reduction is very positive but has now plateaued at 7-8 per month.

In year, quarter on quarter there has

been a reduction in 10-fold errors data (10 in Q1; 7 in Q2; 9 in Q3; and 4 in the first 2 months of Q4). Because the data for 2014/15 was incomplete, it is not possible to carry out a year on year analysis but it is encouraging to note the reduction in each quarter.

We are also working on: Developing dose verification chart in

paediatrics to further reduce incidence of tenfold errors.

Amending Denmark Hill discharge letters to include allergy status as part of new EPR upgrade – this will improve the communication of allergy statuses between secondary and primary care.

Rolling out patient wristband printers for Minors and Urgent Care Centre in the Emergency Department to help reduce medication errors from patient misidentification.

An emerging theme from medication incidents in the last year is the number of delayed or omitted medications. Work has been targeted to reduce the number of medicines omitted, including specific training sessions for PDNs and focus groups to identify the underlying reasons for omissions.

INSERT IMAGE/QUOTE

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PRIORITY 6. Safer Surgery We said we would: Develop and implement a strategy to

ensure the surgical safety checklist (SSC) is integrated into the working practices of all theatre and/or interventional teams. Improvement was to be assessed against the following objectives: Zero Surgical Never Events.

100% compliance with completion of safer surgical checklist.

>75% compliance with quality of checks performed.

20% improvement in Surgical Safety Culture rating.

We were successful in: Improving the quality of the surgical

safety checks that are performed from 41% in 2014/15 to 61% in 2015/16 (as measured by the annual observational audit). As one of the Trust’s Sign-Up to Safety priorities the Trust has committed to improving the quality of checks by 10% year-on-year

In 2015/16, there was 97% compliance with completion of the checklist (in only 1 endoscopy list at PRUH was there no evidence it was completed).

In 2015/16, 8 surgical Never Events have been reported (as at 14/3/16) which is the same number as were reported in 2014-15. A number of the actions being taken to drive out Never Events are listed below

We are also working on: Revising doctor’s induction and e-

learning to reference surgical safety.

Making routine checklist completion data (broken down by speciality, theatre and surgeon) available on a regular basis to enable remedial

action (such as simulation training) to be focussed on high risk areas.

An externally facilitated training session, run annually on the combined surgical safety consultant development morning. Providing in-house simulation training to areas where particular concerns have been raised through audit or incident data.

Adding ‘Team Brief’ and ‘Debrief’ as a specific time slot on the Trust’s electronic theatre system (Galaxy) to ensure that time is available to perform team briefings and debriefings before and after each theatre list & that performance can be monitored.

Developing local surgical safety interventional procedure standards (LOCSSIPs) in accordance with recently published national standards for all specialties that undertake invasive procedures. Specialties will be asked to present these at the Surgical Safety Improvement Group by September 2016. Higher risk specialties (based on Never Event occurrence) will be prioritised.

A review of junior doctor competency sign-off to ensure that adequate training and support is available to junior staff undertaking invasive procedures using seldinger technique

Continued rollout of the seldinger invasive device insertion sticker and process (2 person contemporaneous check) across all areas (including non-ICU areas) where seldinger technique used

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2016/17 Improvement Quality Priorities 2016/17 IMPROVEMENT PRIORITY 1. Enhanced recovery after surgery (ERAS) Aim is to improve outcomes following surgery by ensuring that all interventions clinically proven to have a positive impact are provided, and working well, in our hospitals. We will: Take actions to ensure that all the

relevant steps in the pathways are undertaken on all the Trust’s sites.

Review the pre-assessment, admission and discharge information provided to patients.

Initially work to build and develop from

areas already undertaking ERAS (colorectal, orthopaedic, cardiac and hepatobiliary).

Measures of success: Reduced length of stay.

No increase in emergency

readmission rate.

Increased day-of-surgery admission. 2016/17 IMPROVEMENT PRIORITY 2. Emergency abdominal surgery Aim is to improve outcomes following emergency abdominal surgery by ensuring a well-coordinated, standardised care pathway is in place at Denmark Hill and PRUH. We will: Improve data entry to the National

Emergency Laparotomy (abdominal surgery) Audit project and take local action to improve against the key audit criteria.

Develop internal outcomes monitoring management including sepsis management and decrease AKI progression.

Co-ordinate care of emergency surgery pathways and patient management.

iMobile review of post operative emergency laparotomy and or admission to critical care.

Measures of success: Improvement against key National

Emergency Laparotomy Audit (NELA) criteria, including: o Consultant surgeon review within

12 hours of admission.

o CT scan reported before surgery by a Consultant Radiologist or post FRCR SpR.

o Documentation of risk

preoperatively.

o Preoperative review by consultant surgeon and consultant anaesthetists.

o Consultant surgeon and

consultant anaesthetist present in theatre.

o Postoperative assessment by

care of the elderly specialist in patients aged over 70.

o Daily consultant review and clear

management pathway

o Reduced length of stay.

o Reduced mortality.

2016/17 IMPROVEMENT PRIORITY 3. Sepsis Aim is to improve implementation of sepsis bundles for patients with positive blood cultures and diagnosis of sepsis as defined by EPR order set. We will: Undertake an audit of all positive blood

cultures in early 2016/17 and review

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adherence to sepsis bundles in order to achieve baseline data.

Patients with positive blood cultures to be reviewed at least once per day (7 days per week) by a consultant with a clear management plan and microbiology input into drug Rx and duration.

Develop an EPR order set for sepsis

(culture set) this will then allow assessment of this identified cohort against sepsis bundles , consultant and microbiology review

Measures of success: 50% improvement in sepsis bundle

implementation will be expected at the end of 2018-19.

Aim to decrease length of stay for patients with a diagnosis of sepsis.

2016/17 IMPROVEMENT PRIORITY 4. Surgical Safety Aim is to improve the quality of the surgical safety checks by 10% year-on-year, as measured by the annual surgical safety checklist observational audit and quality assessment. Specific focus on sign out. We will:

Training: Provide Annual simulation training on

one of the combined audit mornings.

Deliver in-house scenario training in hotspot areas.

Specific slot on new doctor’s induction

and e-learning.

Procedure and policy: Add ‘Team Brief’ and ‘Debrief’ as a

specific time slot on Galaxy to ensure that time is available to perform it and performance can be tracked.

Implementation of Local surgical safety invasive procedure standards (LocSSIPs) in all interventional areas by September 2016, focussing on

high risk areas first (as identified by previous Never Event and audit data).

Audit compliance of all areas as per Safer Surgery Improvement Group (SSIG) and ensure feedback to SSIG committee.

Feedback and audit

Twice-yearly observational audits in hotspot areas.

Continuation of annual observational audit of invasive procedures across all areas and sites.

Audit specific areas e.g. handover of

plan and procedures to Recovery, ward and CC areas. Define baseline mid-2016.

Measures of success: Audit of overall quality checks needs

to be increased to 92% form 62% by March 2019. Several associated performance indicators will also be measured: o Improvement in the

documentation of surgical handover to recovery and the ward. 50% improvement against baseline expected by March 2019.

o Audit of seldinger technique device insertion checklists. A baseline audit will be undertaken in early 2016/17 and a 50% improvement against baseline expected by March 2019.

o Audit of junior doctor competency

documents (to include competency in central line insertion, chest drain insertion, NGT placement confirmation through aspirate and x-ray interpretation).

o Improvement in the overall % of

procedures that have sign-in, time-out and sign-out recorded on Galaxy (to at least 95% by March 2019).

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2016/17 IMPROVEMENT PRIORITY 5. Accessible information Aim is to improve access to information for patients, service users, carers and parents, where those needs relate to a disability, impairment or sensory loss. We will: Put systems in place to ensure that

invite letters for appointments and admission provide opportunity for patients and carers to highlight any adjustments that need to be made for their visits.

Put systems in place to ensure that inpatients assessment includes identification of any impairment or sensory loss and subsequent actions and adjustments.

Develop, pilot and implement

feedback tools for patients with communication difficulties / learning disability.

Training and support King's

Foundation Trust Members / Volunteers to support gathering of feedback in targeted areas of need

Ensure admission, pre assessment

and discharge information is appropriate.

Measures of success: Associated audits demonstrate good

rates of responsiveness, action and patient feedback.

2016/17 IMPROVEMENT PRIORITY 6. Improving outpatient experience Aim improve one key metric where our performance is particularly disappointing – communication in clinic about delays We will Identify specific divisions and

specialties where the most improvement is required for the question “If you had to wait for your appointment, were you told how long you would have to wait?”

Roll-out the Trust’s ‘Experience’

patient feedback reporting system within target areas to provide staff with timely and accessible patient feedback.

Increase survey response rates in our

focus areas to ensure that improvement plans are based on robust data.

Improve information and

communication about waiting. Measures of success Based on the ‘how are we doing?’

survey and Friends and Family Test data, identify clinics in two of our clinical divisions at both the PRUH and Denmark Hill which are most in need of improvement.

Identify areas where performance is good as a means to share good practice and learning.

Gather a better understanding of what

makes for poor experience and, importantly, how patients think we can improve by conducting interviews with patients and relatives.

Establish baseline data and agree

improvement targets. Key staff will have access to and

training on ‘Experience’ system Regular discussion of patient

feedback at clinical and operational team meetings.

‘You Said We Did’ posters to be

displayed in clinic areas. Develop plan to increase survey

responses.

Implement a range of accessible options for patients to provide feedback about their experience, e.g. the use of electronic surveys and

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SMS and supported completion with the help of King’s volunteers.

Develop action plan for improvement.

Implement agreed improvement

interventions. Increase scores for “If you had to wait

for your appointment, were you told how long you would have to wait?”

Decrease in the number of negative

comments relating to information on waiting.

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Statements of assurance from the board Relevant health services During 2015/16 the Trust provided and/or sub-contracted [9] relevant health services The Trust has reviewed all data avalaible to them on the quality of care in [all] these relevant health services. The income generated by the relevant health servives reviewed 2015/16 represents [100]% of the total income generated fromt heprovision of relevant health services by the Trust for 2015/16.

Clinical Audits and National Confidential Enquiries During the 2015/16, [50] national clinical audits and [2] national confidential enquires covered relevant health services that the Trust provides. During that period the Trust participated in [100]% national clinical audits and [100]% national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in. The national clinical audits and national confidential enquiries that the Trust was eligible to participate in during 2015/16 are listed on pages 142-146. The national clinical audits and national confidential enquires that the Trust participated (with data collection completed) during 2015/16 can be found on pages 142-146. The national clinical audits and national confidential enquires that the Trust participated in and for which data collection was completed during 2015/16 are listed on pages 142-146 alongside the

number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry. The NCEPOD studies the Trust participated in are detailed on page 146. The reports of [50] national clinical audit were reviewed by the provider in 2015/16 and the Trust intends to take the actions detailed on pages [147-165] to improve the quality of healthcare provided. The reports of [??] local clinical audits were reviewed by the provider in 2015/16 and The Trust intends to take the actions described on pages [166-168]. Information on participation in clinical research The number of patients receiving relevant health services provided or sub-contracted by the Trust in 2015/16 that were recruited during that period to participate in research approved by a research ethics committee was [13,384 – current figure needs to be updated with end-March data]. Clinical coding error rate Payment by Results (PbR)

King’s was not identified as necessary for a Payment by Results (PbR) clinical coding audit in 2015/16, however for Trusts that were subjected to PbR audit in 2014/15, the national average coding error rate identified in the Data Assurance Framework was 8.0% for inpatients.

From the above statements, assurance can be offered to the public that the Trust has in 2015/16:

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Performed to essential standards (e.g. meeting CQC registration), as well as excelling beyond these to provide high quality care;

Measured clinical processes and performance to inform and monitor continuous quality improvement;

Participated in national cross-cutting project and initiatives for quality improvement e.g. strong and growing recruitment to clinical trials.

Payment by Results (PbR) The Trust was not identified as necessary for a Payment by Results (PbR) clinical coding audit in 2015/16, however for Trusts that were subjected to PbR audit in 2015/16, the national average coding error rate identified in the Data Assurance Framework was [8]% for inpatients. The percentage of records in the published data:

Patient’s valid NHS Number:

98% for admitted patient care; 99% for outpatient (non-admitted)

patient care; and 92.5% for accident and emergency

care.

Patient’s valid General Medical Practice code: 100% for admitted patient care; 99.8% for outpatient (non-

admitted) patient care; and 99.8% for accident and emergency

care. Information Governance Assessment The Trust’s Information Governance Assessment Report overall score 2015/16 was [74]% and was graded green (satisfactory)

Commissioning for Quality and Innovation (CQUIN) framework

The Trust income in 2015/16 was not conditional on achieving quality improvement and innovation goals through the Commissioning for Quality and Innovation payment framework because the Trust was operating on the default rollover tariff (DTR) and was therefore not entitled to access CQUIN funding. Therefore, King’s has agreed with its Commissioners the implementation of four Local Incentive Premium initiatives for the 2015/16 (£6.4m) in place of local CQUIN schemes and are listed below:

Local Incentive Premium Scheme 1 - Medicines Optimisation (DH)

Local Incentive Premium Scheme 2 - Care Planning (DH)

Local Incentive Premium Scheme 3 –

Prevention - Every Contact Counts (DH and PRUH)

Local Incentive Premium Scheme 4 –

Emergency Care (PRUH).

The value of the CQUIN for 14/15 was £17.5m.

Care Quality Commission+ The Trust is required to register with the Care Quality Commission (CQC) and its current registration status is requires improvement with no conditions. The Trust has not participated in any special reviews or investigations by the CQC during the reporting period. The CQC inspected all three hospital sites in April 2015. The Trust received a rating of requires improvement for the Denmark Hill and PRUH sites. Orrington Hospital received an overall rating of good. The trust continues to work on delivering actions against each of the ‘must do’ and ‘should do’ actions. These actions are

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being reviewed through the CQC Steering Group and at executive meetings, with up-dates to the Board of Directors. Inadequate ratings at core services level at the PRUH related to below. Patient flow in PRUH urgent and emergency services The Trust commissioned and delivered an Emergency Pathway Whole System review. We engaged with over 100 stakeholders to understand the root causes of poor performance in Emergency Care across the entire South East health care economy and what needs to be put in place for the end to end emergency care pathway to achieve the desired quality, safety and patient experience. The resulting PRUH Emergency Care Recovery Plan has been put in place comprising: Improvement to patient flow for

supported and simple discharge through creation of a supported Transfer of Care Bureau with the mandate and authority to manage the interface between in-hospital and out-of-hospital services.

Improvement to the management of patient flow through the Emergency Department and enhancement of Emergency Department’s controllable processes.

Improvement of time from referral to

be seen by specialists through agreement of new Standard Operating Procedures for timely patient handover and its implementation between Emergency Department and specialty teams.

Creation and implementation of a

sustainable performance management

system (in-hospital and between PRUH and out of hospital services)

Creation of a separate emergency pathway for frail elderly patients and provision of alternative treatment options beyond inpatient care.

All key milestones on the Emergency Department Recovery Plan have been met, but the Trust still continues to face challenges related to activity levels. Waiting times and patient flow in PRUH outpatient department are being addressed through: A review of booking and scheduling of

existing capacity to support demand and capacity analysis of key specialties, which was completed.

Ongoing review of utilisation of Outpatient Department capacity across the Trust by Outpatient Steering Group and review of how QUIPP Programme can be utilised to reduce new and follow-up attendances. This will feed into the scoping of the outpatient transformation programme (see below).

Scoping of outpatient transformation work stream currently undertaken to achieve step change in outpatient patient flow. Work to cover all areas from booking to in-clinic processes.

Actions to address key issues underlying the rating of requires improvement

Referral to treatment times at Denmark Hill and PRUH: To enable the Trust to improve its performance against the national referral to treatment targets a programme of work

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was completed. This Referral to Treatment Recovery Plan included development and implementation of policies, procedures, training and education, standard operating procedures, action cards, standardisation of documentation, launch of RTT systems and reporting, including trust-wide Patient Tracker List, nationally compliant reporting rules and validation timelines. This has provided a clear understanding of the number of patients waiting. Patients are now prioritised and seen as appropriate to reduce the backlog. Documentation of care, including incomplete records, DNACPR documentation and safer surgery checklist These actions all include improvement of process, staff skills and knowledge as well as improvement in monitoring and ensuring that processes are being followed. This work is still ongoing and we expect to achieve significant milestones in Quarter 4 2015/16 and in autumn 2016. We are also introducing e-DNACPR forms by the end of 2016 at DH and in December 2017 at the PRUH. CQC also commented on availability of paper records at the PRUH. Availability of paper notes in clinic at PRUH improved to 94% in November 2015. Work is ongoing with next milestones to be achieved in March 2016 and introduction of EPR at the PRUH towards beginning of 2017. Environment and Capacity Denmark Hill’s environments for Liver and Renal outpatients, Maternity and Critical Care wards and PRUH’s Surgical Admission Lounge were found to require improvement. Where possible, changes to the environment have been, or are currently being made. Alternatively services have been moved to locations that better meet patients’ needs.

Regular reviews of capacity are in place for areas with capacity constraints ensuring that patient safety is maintained. Where required practice has been reviewed and changes communicated to staff to ensure that capacity is managed as efficiently as possible. All capacity issues have been resolved within the limitations of the existing estate of DH. We are in the process of building a new Critical Care Unit with a planned completion date of early 2018. A consultation for the move of the surgical admission lounge at the PRUH is currently being undertaken and the move will take place as soon as issues have been resolved. Improving skills, knowledge and processes to improve patient safety The trust is improving the up-take of training on Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards for staff working in the Emergency Department, Medical Care, Surgery and Children’s. We also appointed MCA leads for both sites and are reviewing all policies and guidance to support staff in meeting their responsibilities. This work is progressing at pace and completion is planned for December 2016. At the DH site a clear pathway for the admission and discharge of end of life care patients with T34 pumps in situ has been developed, published and communicated to relevant staff. Relevant staff have been trained to switch pumps on admission. 24/7 access to trained staff is available to ensure patients receive appropriate care at the right time. Assurances have been received that risks are managed appropriately. An internal audit report on the effectiveness of the CQC action plan is currently awaited and will inform any

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further actions that need to be taken to ensure robustness of our actions on our journey to an outstanding CQC rating. The Trust will be taking the following actions to improve data quality: Training programmes have been

established in 2015/16 to deliver education on waiting list and RTT and the impact of poor data quality on these items.

Uncashed appointments have been highlighted trust-wide as an area of focus. These have a significant financial impact along with impact on waiting lists, operational planning and finances.

In conjunction with the RTT training a review was undertaken of outpatient procedures undertaken at Denmark Hill and recording commenced in September 2015.

GP practice closures have now had a systematic approach applied to them and all patients at these practices are traced to minimise clinical risk.

A significant amount of work has been invested across BIU to improve the data quality of our SUS and contract monitoring data which has suffered significantly since the acquisition of SLHT services. The work has also uncovered many data quality issues relating to commissioning data – this work has informed the 2016/17 planning round and has enabled a more robust understanding of our data both internally and externally.

Work has been continuing on aligning

all centrally reported data which has allowed many operational reports to be rolled out across all sites, allowing greater transparency across the trust.

Actions planned for 2016/17:

Continuing the existing trust-wide training programme for all outpatient staff to ensure all outcome fields and referral information is complete to assist with waiting list monitoring, therefore improving quality of care and also to ensure all appointments are charged for.

The recording of outpatient procedures at Denmark Hill will continue to be monitored and will become a key income stream for 2017/18 – this has historically been an area of very poor data quality for the trust and some services running at a loss due to under-recovery of income.

Continue progress on aligning all data

systems trust-wide to allow for easier operational reporting and minimising duplication of work.

These statements are included in accordance with both Monitor’s NHS Foundation Trust Annual Reporting Manual (December 2013) for the quality report, as well as the Department of Health’s Quality Accounts Regulations (2013, 2012, 2011, 2010).

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Statement of assurance evidence

The following list is based on that produced by the Department of Health and Healthcare Quality Improvement Partnership (HQIP). Audit Title Reporting period Participation Number (%) of cases submitt

National Diabetes Adult 01/01/13 - 31/03/15 Yes 5323 cases (100%).

National Diabetes Footcare Audit

14/07/15 - 31/03/16 Yes Data collection in progress until Jul-16.

National Inpatient Audit 21/09/15 - 25/09/15 Yes Due to be published Jul-16.

Pregnancy Care in Women with Diabetes

01/01/15 - 31/12/15 Yes Due to be published in 2016.

Adult Cataract Surgery 21/09/15 - 25/09/15 Yes Due to be published Dec-16.

Rheumatoid and Early Inflammatory Arthritis

Organisational audit: 01/07/15 - 31/07/15

Clinical Audit:

01/07/15 - 30/09/15

Yes Due to be published Jan-17.

Intensive Care National Audit and Research Centre (ICNARC) Case Mix Programme

- General Intensive Care Unit

01/04/15 – 30/06/15 Yes 100%.

National Emergency Laparotomy Audit

01/12/14 - 30/11/15 Yes Due to be published Jun-16.

NHS Blood and Transplant – Audit of Patient Blood Management in Scheduled Surgery

01/02/15 – 30/04/15 Yes 55 cases (100%).

NHS Blood and Transplant – Audit of the Use of Blood in Haematology

01/01/16- 26/02/16 Yes Due to be published Jul-16.

NHS Blood and Transplant – Audit of the Use of Blood in Lower Gastrointestinal Bleeding

01/09/15 – 31/10/15 Yes Due to be published Mar-16.

Inflammatory Bowel Disease – Biologics Audit

11/09/11 – 29/02/16 Yes Data collection in progress until Mar-16.

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Audit Title Reporting period Participation Number (%) of cases submitt

Oesophago-gastric Cancer 01/04/14 – 31/03/15 Yes Data collection in progress until Mar-16.

ICNARC Case Mix Programme

- Liver Intensive Therapy Unit (LITU)

01/07/15 – 30/09/15 Yes 100%

Liver Transplant 01/04/06 – 31/03/16 Yes Due to be published Sep-16.

Renal Registry 01/01/15 – 31/12/15 Yes Due to be published Dec-16.

Bowel Cancer 01/04/14 – 31/03/15 Yes Due to be published Dec-16.

Falls and Fragility Fractures Programme - National Hip Fracture Database

01/01/15 – 31/12/15 Yes Due to be published Sep-16.

Falls and Fragility Fractures Programme - Fracture Liaison Service Database

01/01/16 – (end date TBC)

Yes Data submission cut-off date and publication date not yet confirmed by audit supplier.

Falls and Fragility Fractures Programme - National Audit of Inpatient Falls

12/05/15 – 13/05/15 Yes 60 cases (100%)

National Complicated Acute Diverticulitis

01/07/15 – 30/09/15 Yes Due to be published Feb-16.

National Joint Registry 01/01/15 – 31/12/15

Yes Due to be published Sep-16.

Prostate Cancer 01/08/14 – (end date TBC)

Yes Data submission cut-off date and publication date not yet confirmed by audit supplier.

National Patient Reported Outcome Measures (PROMs) Programme

01/04/14 – 31/03/15 Yes Groin hernia surgery: 16%

Varicose vein surgery: 69%

Hip replacement surgery: 88%

Knee replacement surgery: 98%

National Adult Cardiac Surgery Audit

01/04/14 – 31/03/15 Yes Due to be published Sep-16.

Acute Coronary Syndrome or Acute Myocardial Infarction

01/04/14 – 31/03/15 Yes Due to be published Apr-16.

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Audit Title Reporting period Participation Number (%) of cases submitt(MINAP)

Cardiac Rhythm Management 01/04/14 – 31/03/15 Yes Due to be published Apr-16.

Congenital Heart Disease - Adults

01/04/14 – 31/03/15 Yes Due to be published Apr-16.

National Audit of Percutaneous Coronary Interventional Procedures

01/01/2015 -31/12/2015

Yes Publication date not yet confirmed by audit supplier.

National Heart Failure Audit 01/04/14 – 31/03/15 Yes Due to be published Apr-16.

Sentinel Stroke National Audit Programme (SSNAP) - Clinical Audit

01/04/14 – 31/03/15 Yes DH HASU = 80-89%; PRUH HASU = 90%; DH and

PRUH stroke units = 90%+

National Vascular Registry – Abdominal Aortic Aneurysm Repairs

01/10/14 – 31/09/15 Yes Publication date not yet confirmed by audit supplier.

National Vascular Registry – Carotid Endarterectomy

01/10/14 – 31/09/15 Yes Publication date not yet confirmed by audit supplier.

UK Parkinson’s Audit: Occupational Therapy Speech and Language

Therapy Physiotherapy Patient Management

Elderly Care and Neurology

30/04/15 - 30/09/15 Yes Due to be published Mar-16.

College of Emergency Medicine - Procedural Sedation in Adults

01/08/15 – 31/01/16 Yes Due to be published May-16.

College of Emergency Medicine - VTE Risk in Lower Limb Immobilisation


Emergency Oxygen 15/08/15 – 01/11/15 Yes 186 cases

Lung Cancer 01/01/15 – 31/12/15 Yes Due to be published Dec-16.

National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme – Pulmonary Rehabilitation Service Clinical Audit

12/01/15 – 10/04/15 Yes Due to be published Feb-16.

National COPD Audit Programme – Pulmonary

12/01/15 – 24/04/15 Yes 100%

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Audit Title Reporting period Participation Number (%) of cases submittRehabilitation Service Organisational Audit

Trauma Audit and Research Network (TARN)

01/01/15 – 31/12/15 Yes 715 cases

UK Cystic Fibrosis 01/01/15 – 31/12/15 Yes Due to be published Aug-16.

ICNARC National Cardiac Arrest Audit

01/04/15 – 31/03/16 Yes Due to be published Jun-16.

Maternal, Newborn and Infant Clinical Outcome Review Programme

01/04/13 – 31/12/15 Yes 100%.

Medical and Surgical Clinical Outcome Review Programme

See information below on NCEPOD

participation

Yes See information below on NCEPOD participation.

National Neonatal Audit Programme

01/01/15 – 31/12/15 Yes Due to be published Nov-16.

National Paediatric Diabetes Audit

01/04/15– 31/03/16 Yes Due to be published Nov-16.

Paediatric Asthma 01/11/15 - 30/11/15 Yes Data collection in progress.

Paediatric Intensive Care Audit Network

01/01/12 – 31/12/14 Yes Data collection in progress.

College of Emergency Medicine - Vital Signs in Children


Adult Asthma N/A N/A Did not collect data 2015/16.

Child Health Clinical Outcomes Programme

N/A N/A Did not collect data 2015/16.

Chronic Kidney Disease in Primary Care

N/A N/A Not applicable to secondary care providers.

Congenital Heart Disease - Paediatric

N/A N/A Service not provided at KCH.

Head and Neck Oncology N/A N/A Service not provided at KCH.

National Audit of Dementia N/A N/A Did not collect data 2015/16.

National Audit of Intermediate Care


Mental Health Clinical Outcome Review Programme:


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Audit Title Reporting period Participation Number (%) of cases submittNational Confidential Inquiry into Suicide and Homicide for people with Mental Illness

Non-Invasive Ventilation - Adults

N/A N/A Did not collect data 2015/16.

Paediatric Pneumonia N/A N/A Did not collect data 2015/16.

Prescribing Observatory for Mental Health


Pulmonary Hypertension Audit


Trust participation in NCEPOD Studies

NCEPOD Title Reporting period Participation % of cases submitted

Acute Pancreatitis 01/01/14 – 30/06/14 Yes Clinical Questionnaire returned = 10/10 (100%). Case notes returned = 8/10 (80%); Organisational questionnaire returned =2/2 (100%)

Mental Health in General Hospitals

13/10/14 – 13/11/14 Yes Due to be published Oct-16.

Clinical audit projects reviewed by the Trust Key: King’s National Clinical Audit Rating Symbol Definition

Positive analysis: Outcome measures better than or within expected range, underperformance against <50% process targets with no demonstrable impact on patient outcome.

Neutral analysis: Outcome measure within expected range, underperformance against >50% process targets with no demonstrable impact on patient outcome.

Negative analysis: Outcome measure outside (below) expected range - negative outlier, underperformance against significant key process targets.

Not applicable – service not provided at this location. National Audit Data source Summary of analysis Rating

DH PRUH

National Neonatal Audit Programme

Royal College of Paediatrics and Child Health (RCPCH), Nov-15

KCH performs above average for 3/5 process criteria. Reduced proportion of babies receiving mother’s milk on DH site – action is in progress.

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National Audit Data source Summary of analysis Rating DH PRUH

Rheumatoid and Early Inflammatory Arthritis

British Society for Rheumatology, Jan-16

Reduction in Disease Activity Score by at least 1.2 – KCH achieved 71% for this key outcome measure – above national average (62%). 79% of patients were seen within 3 weeks (national average 38%). Similar to national average for referral, treatment initiation, educational support and treatment target achieved. Data quality issues in completing Rheumatoid Arthritis Impact of Disease score (RAID) – action in progress.

(ICNARC) Case Mix Programme


ICNARC, 02/04/15 – 30/06/15

PRUH is within expected range for survival.

(ICNARC) Case Mix Programme


ICNARC, 01/01/15 – 31/03/15

DH is within expected range for survival.

National Emergency Laparotomy Audit (NELA)

Royal College of Anaesthetists, Jun-15

KCH is below national average against many criteria, significantly influenced by data collection issues. Actions are being taken to improve data collection in the current cycle. This is a Trust Quality Priority for 2016/17.

Audit of Patient Blood Management in Adults undergoing Elective, Scheduled Surgery

NHS Blood and Transplant, Oct-15

KCH performed in line with or above the national average for 8/11 key indicators.

UK Inflammatory Bowel Disease (IBD) Audit:

National Clinical Audit of Biological Therapies

- Adult

Royal College of Physicians, Sep-15

Numbers too small to make quality of care conclusions from results (small numbers nationally). Actions taken at DH and PRUH demonstrate improved data capture across sites.

IBD Audit: National Clinical Audit of Biological Therapies – Paediatric


DH demonstrated compliance with NICE Technology Appraisal 187.

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National Oesophago-Gastric Cancer Audit

Health and Social Care Information Centre (HSCIC), published Nov-15

DH and PRUH patients receive treatment at GSTT. The complication rate achieved by GSTT, at 5.2%, is the lowest achieved by a London Trust. The adjusted 30-day and 90-day mortality rates achieved by GSTT are within expected range at 1.4% and 2.9% respectively.

King’s adjusted emergency re-admission rate of 23% has been incorrectly assigned a green rating in the audit report - it should have received a red rating and is currently under investigation.

(ICNARC) Case Mix Programme - Liver Intensive Care Unit (LITU)

ICNARC, 01/07/15 – 31/09/15


Liver Transplantation Audit – Adults and Paediatrics

NHS Blood & Transplant, Apr-15

KCH has the highest 90-day survival rate nationally for elective liver transplants in adults. KCH within expected range for all indicators.

Annual Report on Liver Transplantation – Adult

NHS Blood and Transplant, Sep-15

DH has the highest 1-year risk-adjusted survival rate nationally for super-urgent transplants. DH within expected range for survival.

Annual Report on Liver Transplantation – Paediatric

NHS Blood and Transplant, Sep-15


Renal Registry Renal Registry, Dec-16

KCH one-year-after-90-day incident survival (adjusted to age 60) from the start of renal replacement therapy is similar to the national average (KCH 90.0%, national average 91.8%), even though King’s has the 2nd highest rate in England of patients starting on renal replacement therapy who have diabetes, and the highest in London, at 39.2%.

National Bowel Cancer Audit

Health and Social Care Information Centre, Dec-15

KCH (and network) adjusted 90-day and 2 year mortality rates are within expected range, 90-day unplanned readmission and 18-month stoma rate within expected range.

National Bowel Health and Social The Trust achieved a lower risk adjusted

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Cancer Audit – Consultant-level Outcomes

Care Information Centre, Dec-15

90-day mortality than the national average.

Falls and Fragility Fractures Programme: National Hip Fracture Database (NHFD) Annual Report 2015 – published report (based on Jan – Dec 2014 data).

National Hip Fracture Database, Sep-15

The published report, based on 2014 data, shows both sites below national average against many criteria. At the PRUH the rates for patients sustaining a hip fracture as an in-patient and the 30 day mortality rate are reported as being above the NHFD average.

NHFD online, however (based on data to Dec-15), shows that both sites have performed above the national average from August 2015. Hip Fracture was a Trust Quality Priority 2015/16, focusing on improving the achievement of all 9 best practice criteria – significant improvements have been achieved at both Trust sites (see Quality Priorities section).

Falls and Fragility Fractures Programme: National Audit of Inpatient Falls

National Hip Fracture Database, Oct-15

KCH has the lowest rate of falls per 1,000 occupied bed days (OBDs) in London and the 3rd lowest rate nationally. KCH has the 3rd lowest rate of falls leading to moderate/ severe harm or death per 1,000 OBDs in London.

KCH is below national average against a number of process measures. Actions already planned across sites to improve practice.

National Joint Registry – Enhanced Surgeon and Hospital Information

National Joint Registry, May-15

KCH is within expected range for patient-reported outcomes for hip and knee replacement surgery.

Orpington

National Joint Registry

National Joint Registry Centre, Sep-15

KCH is within expected range for 90-day mortality following hip and knee replacement and for hip and knee revision rate.

Orpington

National Joint Registry – Enhanced Surgeon and Hospital Information

National Joint Registry – online, Nov-15

Patient-Reported Improvement Measures, 90-day mortality and revision rates are within expected range for hip and knee replacement. Consent rate is

Orpington

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better than expected at Denmark Hill and Orpington.

National Prostate Cancer Audit – a) Organisational

Audit, and b) Clinical Audit

National Prostate Cancer Audit, Feb-15

Treatment is provided by an integrated Guy’s and St Thomas’ (GSTT) & King’s College Hospital (KCH) team – KCH provides all recommended diagnostic and support service facilities.

Results are reported by GSTT.

Adherence to British Society for Clinical Neurophysiology (BSCN) and Association of Neurophysiological Scientists (ANS) Standards for Ulnar Neuropathy at Elbow (UNE) testing

British Society for Clinical Neuro-physiology (BSCN) and Association of Neurophysiological Scientists (ANS), Nov-15

DH achieved 100% for 10/11 criteria.

The recording of hand temperature requires improvement, which is consistent with the national picture.

Adult Cardiac Surgery

Society for Cardiothoracic Surgery in Great Britain & Ireland (SCTS), Sep-15

Mortality rates are within expected range.

National Audit of Cardiac Rhythm Management Ablation Audit

National Institute Cardiac Outcomes & Research, Mar-15

DH undertakes in excess of the minimum number of procedures and is therefore not identified as an outlier.

Congenital Heart Disease Audit

British Congenital Cardiac Assoc, Jun-15


Percutaneous Coronary Intervention (PCI) Audit

British Cardiovascular Intervention Society (BCIS), Oct-15

DH performed better than expected for freedom from in-hospital major adverse cardiac and cerebrovascular events. DH is within expected range for 30-day post-PCI survival.

National Heart Failure Audit

National Institute Cardiac Outcomes & Research, Sep-15


Neurosurgical National Audit

Society of British Neurological

KCH is within expected range for 30-day standardised mortality rate.

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Programme Surgeons, Dec-15

Sentinel Stroke National Audit Programme – Hyper Acute Stroke Unit (HASU)

Royal College of Physicians, Jun-15

DH HASU 3rd highest score compared to national peers; PRUH HASU 2nd highest.

Sentinel Stroke National Audit Programme - Hyper Acute Stroke Unit (HASU) data


PRUH HASU achieved the 2nd highest score compared to national peers; DH HASU 3rd highest.

Vascular Outcomes – Abdominal Aortic Aneurysm Repair and Carotid Endarterectomy Outcomes

NHS England Consultant Outcomes Publication, Sep-15


College of Emergency Medicine Audit - Assessing for Cognitive Impairment in Older People in the Emergency Department

Royal College of Emergency Medicine, Jun-15

DH performed better or similar to national average for 3/6 standards, and PRUH for 5/6. Cognitive assessment at DH was recorded in 5% of cases (PRUH 60%, national average 11%).

College of Emergency Medicine Audit - Initial Management of the Fitting Child in the Emergency Department


Both sites performed at 98-100% against 4/5 standards. The provision of written safety information provided at discharge requires improvement, which is consistent with national picture.

College of Emergency Medicine Audit - Mental Health in the Emergency Department


DH performed better than national average for 7/8 standards, and PRUH for 6/8. Assessment by mental health practitioner within 1 hour: DH = 39%, PRUH = 0%, national average = 0%.

Documentation requires improvement.

Emergency Oxygen Audit

British Thoracic Society, Nov-15

61% of DH patients and 41% of PRUH patient did not have a prescription or bedside order in place. An action plan is in place.

National Adult Community Acquired

British Thoracic Society, Jun-15

Fewer in-patient deaths were reported compared to national average (but small

Enc.3.1.1

47


Pneumonia Audit numbers). Median length of stay at KCH was similar to national average (DH = 6 days, PRUH = 4 days, national average = 5 days).

National Lung Cancer Audit (NCLA)

The Royal College of Physicians, Dec-15

King’s performance equals or exceeds the level suggested in the NLCA report 2014, and is statistically better than the national average for: Anticancer treatment Non-small-cell lung cancer (NSCLC)

stage IIIB/IV and PS 0–1 having chemotherapy

3 out of 4 process, imaging and nursing measures equal or exceed the level suggested in the NLCA report. King’s performance is statistically similar to the national average for: NSCLC having surgery Small-cell lung cancer (SCLC)

patients having chemotherapy.

King’s is below the level suggested for ‘Patient seen by nurse specialist’, achieving 51.1% for this measure, compared to 80% recommended by the NLCA.

National Chronic Obstructive Pulmonary Disease Audit Programme - Clinical Audit

Royal College of Physicians, Feb-15

DH performed in line with or above the national average for 26/30 measures linked to national standards. PRUH performed in line with or above the national average for 18/30 measures. (4.3%).

National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme: Resources and Organisation of Pulmonary Rehabilitation Services in England and Wales

Royal College of Physicians and British Thoracic Society, Nov-15

Both DH and PRUH met all 10 organisational Quality Standards specified by the British Thoracic Society.

National Chronic Obstructive Pulmonary Disease (COPD) Audit

Royal College of Physicians, Feb-16

KCH performance was above national average for all key functional outcomes measures.

Enc.3.1.1

48


Programme: Pulmonary Rehabilitation Services in England and Wales Clinical Audit

Trauma Audit & Research Network (TARN) - Clinical Report Core Measures for All Patients: Thoracic and Abdominal Injuries/ Patients in Shock

TARN, Mar-15 South East London, Kent and Medway Trauma Network is the best performing network in comparison to all other Trauma Networks nationally.

DH survival is within expected range.

TARN - Major Trauma Dashboard

TARN, Jun-15 DH performance is better than or similar to national average for 7/8 criteria. The underperforming criteria relate to admission delays, mainly for stable spinal injury cases, due to in-patient capacity, flow and rehab capacity, which is on the Trust Risk Register.

TARN - Online Survival Data

TARN, Jul-15 More trauma patients admitted to KCH are surviving compared to the number expected, based on the severity of their injury.

TARN - Clinical Report II Core Measures for all patients: BOAST 4 eligible fractures, Open limb fractures, Severe pelvic fractures

TARN, Aug-15 South East London, Kent and Medway Trauma Network is the best performing network in comparison to all other Trauma Networks nationally. DH survival is within expected range.

TARN - Major Trauma Dashboard

TARN, Aug-15 DH performed better than previous for 5/10 process criteria.

UK Cystic Fibrosis Registry 2014 Annual Data Report: Strength in Numbers a) Adults, and b) Paediatrics

Cystic Fibrosis Trust, Aug-15

The number of patients with chronic pseudomonas aeruginosa at KCH is below the national average; and KCH has the 2nd highest proportion of adult patients using preventative inhaled medication DNase, 8th highest for children.

National Cardiac Arrest Audit (NCAA)

ICNARC, Sep-15

KCH survival is within expected range.

Enc.3.1.1

49


National Paediatric Diabetes Audit Report 2013 - 14: Part One, Care Processes and Outcomes

Royal College of Paediatrics and Child Health (RCPCH), Sep-15

PRUH performed better than national average for 6/7 process criteria. DH and PRUH performed within NICE target range. DH performed better than national average for 3/7 process criteria. No patients received all process criteria.

Paediatric Intensive Care Audit Network (PICANet)

PICANet, Nov-15 The standardised mortality ratio at DH is one of the lowest nationally and the lowest compared to all London peer trusts.

Potential Donor Audit NHS Blood & Transplant

All process targets were exceeded.

The total number of organ donors fell, in line with the national picture.

Surgical Outcomes Audit - Nephrectomy

British Association of Urological Surgeons, Sep-15

DH is below the national average for the risk-adjusted complication, transfusion and mortality rates.

Surgical Outcomes Audit - Radical Prostatectomy

British Association of Urological Surgeons, Sep-15

DH achieved a 0% transfusion and complication rate.

Local Audits – CP to provide

Enc.3.1.1

50

Reporting against core indicators

All trusts are required to report against a core set of indicators, for at least the last two reporting periods, using a standardised statement set out in the NHS (Quality Accounts) Amendment Regulations 2012. Only indicators that are relevant to the services provided at King’s are included in the tables below.

Performance Measures Foundation Trusts Comparable Value

Ind

icat

or

Mea

sure

Cu

rren

t P

erio

d

Val

ue

Pre

vio

us

Per

iod

Val

ue

Hig

hes

t

Lo

wes

t

Nat

ion

al

Ave

rag

e

So

urc

e

Reg

ula

tory

S

tate

men

t

Su

mm

ary

Ho

spit

al

Mo

rtal

ity

Ind

ex

(SH

MI)

%01 July 2014 - 30 June 2015

89 01 July 2013 - 30 June 2014

91 TBC TBC TBC NHS IC

The [name of trust] considers that this data is as described for the following

reasons [insert reasons]. The [name of trust] [intends to take/has taken] the

following actions to improve this [percentage/proportion/score/rate/number], and so the quality of its services,

by [insert description of actions].

Pat

ien

ts d

eath

s w

ith

pal

liati

ve c

are

cod

ed a

t ei

ther

d

iag

no

sis

or

spec

ialit

y le

vel

%

01 October 2014 - 30

September 2015

41.84

01 October 2013 - 30

September 2014

34.3 TBC TBC TBC NHS IC





Enc.3.1.1

51


Ind

icat

or

Mea

sure

Cu

rren

t P

erio

d

Val

ue

Pre

vio

us

Per

iod

Val

ue

Hig

hes

t

Lo

wes

t

Nat

ion

al

Ave

rag

e

So

urc

e

Reg

ula

tory

S

tate

men

t

Pat

ien

ts a

ged

0-

15 (

emer

gen

cy)

read

mit

ted

w

ith

in 2

8 d

ays

of

bei

ng

d

isch

arg

ed

%01 April 2015 -

31 January 2016

1.6 01 April - 31 December

2014 3.9 TBC TBC TBC

PiMS (2015/16), CHKS (2014)





Pat

ien

ts a

ged

16

+ o

r o

ver

(em

erg

ency

) re

adm

itte

d

wit

hin

28

day

s o

f b

ein

g

dis

char

ged

%01 April 2015 -

31 January 2016

8.7 01 April - 31 December

2014 4.5 TBC TBC TBC

PiMS (2015/16), CHKS (2014)





Ad

mit

ted

pat

ien

ts

wh

o w

ere

risk

as

sess

ed f

or

ven

ou

s th

rom

bo

emb

olis

m

%01 April 2015 - 31 December

2015 96.53

01 April 2014 - 31 March

2015

97.28

TBC TBC TBC VTE returns





Enc.3.1.1

52


Ind

icat

or

Mea

sure

Cu

rren

t P

erio

d

Val

ue

Pre

vio

us

Per

iod

Val

ue

Hig

hes

t

Lo

wes

t

Nat

ion

al

Ave

rag

e

So

urc

e

Reg

ula

tory

S

tate

men

t

Cas

es o

f C

dif

fici

le

infe

ctio

n r

epo

rted

fo

r p

atie

nts

ag

ed 2

or

ove

r

Rat

e pe

r 10

0K b

ed d

ays

KCH APR15 - FEB16

Reportable cases rate

/100,000 bed days

(80) 18.49%

KCH 2014/15 Reportable cases rate

/100,000 bed days

(75) 15.43%

TBC TBC TBC

C-diff cases/KH03 G&A + Obs per 100,000.

Note: KH03

excludes Well

babies & Critical Care





Enc.3.1.1

53

Responsiveness to patients personal needs National 2014 Scores

Ind

icat

or

Mea

sure

Cu

rren

t P

erio

d

Val

ue

Pre

vio

us

Per

iod

Val

ue

Hig

hes

t

Lo

wes

t

Nat

ion

al

Ave

rag

e

Dat

a S

ou

rce

Reg

ula

tory

S

tate

men

t

Wer

e yo

u in

volv

ed

as m

uch

as

you

w

ante

d t

o b

e in

d

ecis

ion

s ab

ou

t yo

ur

care

an

d

trea

tmen

t?

Sco

re o

ut o

f 10

trus

t-w

ide 2014

National Inpatient Survey

7.0

2013 National Inpatient Survey

7.5 9.2 6.1

Not

ava

ilabl

e

CQC



following actions to improve this [percentage/proportion/score/rate/number], and so the quality of its services, by

[insert description of actions].

Did

yo

u f

ind

so

meo

ne

on

th

e h

osp

ital

sta

ff t

o

talk

to

ab

ou

t yo

ur

wo

rrie

s an

d

fear

s?

Sco

re o

ut o

f 10

trus

t-w

ide 2014


5.2


5.5 8.2 4.3 CQC





Wer

e yo

u g

iven

en

ou

gh

pri

vacy

w

hen

dis

cuss

ing

yo

ur

con

dit

ion

o

r tr

eatm

ent?

Sco

re o

ut o

f 10

trus

t-w

ide 2014


8.0


8.7 9.4 7.5 CQC





Enc.3.1.1

54

Responsiveness to patients personal needs National 2014 Scores

Ind

icat

or

Mea

sure

Cu

rren

t P

erio

d

Val

ue

Pre

vio

us

Per

iod

Val

ue

Hig

hes

t

Lo

wes

t

Nat

ion

al

Ave

rag

e

Dat

a S

ou

rce

Reg

ula

tory

S

tate

men

t

Did

a m

emb

er o

f st

aff

tell

you

ab

ou

t m

edic

atio

n s

ide

effe

cts

to w

atch

fo

r w

hen

yo

u w

ent

ho

me?

Sco

re o

ut o

f 10

trus

t-w

ide


4.3


4.7 7.6 3.7 CQC

The [name of trust] considers that this data is as described for the following reasons [insert reasons]. The [name of trust] [intends to take/has taken] the following actions to improve this [percentage/proportion/score/rate/number], and so the quality of its services, by [insert description of actions].

Did

ho

spit

al t

ell y

ou

w

ho

to

co

nta

ct if

yo

u

wer

e w

orr

ied

ab

ou

t yo

ur

con

dit

ion

or

trea

tmen

t af

ter

you

left

h

osp

ital

?

Sco

re o

ut o

f 10

trus

t-w

ide


7.3


7.8 9.7 6.5 CQC


Enc.3.1.1

55

Patient Friends & Family Tests Comparable

Foundation Trust Value

Ind

icat

or

Mea

sure

Cu

rren

t P

eri

od

Val

ue

Pre

vio

us

Per

iod

Val

ue

Hig

hes

t

Lo

wes

t

Nat

ion

al

Ave

rag

e A

pri

l 15

- J

an 1

6

Dat

a S

ou

rce

Reg

ula

tory

S

tate

men

t

Pat

ien

ts d

isch

arg

ed f

rom

A

ccid

ent

& E

mer

gen

cy

(typ

es 1

/2)

wh

o w

ou

ld

reco

mm

end

th

e T

rust

as

a p

rovi

der

of

care

to

th

eir

fam

ily o

r fr

ien

ds.

%

April 2015 - Jan 2016

(latest available data)

82

Oct 2014 March 15 (scoring

changed Oct 14)

80 100 52 86 NHS

England

The [name of trust] considers that this data is as described for the following reasons [insert reasons]. The [name of trust] [intends to take/has taken] the following actions to improve this [percentage/proportion/score/rate/nu

mber], and so the quality of its services, by [insert description of

actions].

Inp

atie

nts

th

e T

rust

as

a p

rovi

der

of

care

to

th

eir

fam

ily o

r fr

ien

ds?

%

April 2015 - Jan 2016

(latest available data)

94

Oct 2014 March 15 (scoring

changed Oct 14)

94 100 73 96 NHS

England

The [name of trust] considers that this data is as described for the following reasons [insert reasons]. The [name of trust] [intends to take/has taken] the following actions to improve this [percentage/proportion/score/rate/nu

mber], and so the quality of its services, by [insert description of

actions].

Enc.3.1.1

56

Staff – Friends & Family Test and National Staff Surveys

Comparable Foundation Trust

Value

Ind

icat

or

Mea

sure

Cu

rren

t P

eri

od

Val

ue

Pre

vio

us

Per

iod

Val

ue

Hig

hes

t

Lo

wes

t

Nat

ion

al

Ave

rag

e

Dat

a S

ou

rce

Reg

ula

tory

S

tate

men

t

Sta

ff e

mp

loye

d b

y, o

r u

nd

er c

on

trac

t w

ho

w

ou

ld r

eco

mm

end

th

e T

rust

as

a p

rovi

der

of

care

to

th

eir

fam

ily o

r fr

ien

ds.

%*

2015 National Staff Survey (Quarter 3)

3.7

2014 National Staff

Survey (Quarter 3)

3.88 4.10 3.3 3.76

NHS Annual Staff

Survey Results

The Trust considers that this data is as described as it has been taken from the nationally published staff survey results: http://www.nhsstaffsurveys.com/Caches/Files/NHS_staff_survey_2015_RJZ_full.pdf

Sta

ff e

xper

ien

cin

g

har

assm

ent,

bu

llyin

g o

r ab

use

fro

m s

taff

in t

he

last

12

mo

nth

s.

%*


29

2014 National Staff

Survey (Quarter 3)

25 16 42 26

NHS Annual Staff

Survey Results

The Trust considers that this data is as described as it has been taken from the nationally published staff survey results: http://www.nhsstaffsurveys.com/Caches/Files/NHS_staff_survey_2015_RJZ_full.pdf

Enc.3.1.1

57

Staff – Friends & Family Test and National Staff Surveys

Comparable Foundation Trust

Value

Ind

icat

or

Mea

sure

Cu

rren

t P

eri

od

Val

ue

Pre

vio

us

Per

iod

Val

ue

Hig

hes

t

Lo

wes

t

Nat

ion

al

Ave

rag

e

Dat

a S

ou

rce

Reg

ula

tory

S

tate

men

t

Sta

ff b

elie

vin

g t

he

Tru

st

pro

vid

es e

qu

al

op

po

rtu

nit

ies

for

care

er

pro

gre

ssio

n o

r p

rom

oti

on

%*


84

2014 National Staff

Survey (Quarter 3)

79 96 76 87

NHS Annual Staff

Survey Results

The Trust considers that this data is as described as it has been taken from the nationally published staff survey results: http://www.nhsstaffsurveys.com/Caches/Files/NHS_staff_survey_2015_RJZ_f

ull.pdf

*30% (255 staff responsed from a sample of 850 staff)

Enc.3.1.1

58

Patient Reported Outcomes Comparable


Ind

icat

or

Mea

sure

Cu

rren

t P

eri

od

Val

ue

Pre

vio

us

Per

iod

Val

ue

Hig

hes

t

Lo

wes

t

Nat

ion

al

Ave

rag

e

Dat

a S

ou

rce

Reg

ula

tory

S

tate

men

t

Pat

ien

t re

po

rted

o

utc

om

es m

easu

res

gro

in h

ern

ia s

urg

ery


Pat

ien

t re

po

rted

o

utc

om

es m

easu

res

vari

cose

vei

n

surg

ery


Enc.3.1.1

59

Patient Reported Outcomes Comparable


Ind

icat

or

Mea

sure

Cu

rren

t P

eri

od

Val

ue

Pre

vio

us

Per

iod

Val

ue

Hig

hes

t

Lo

wes

t

Nat

ion

al

Ave

rag

e

Dat

a S

ou

rce

Reg

ula

tory

S

tate

men

t

Pat

ien

t re

po

rted

o

utc

om

es m

easu

res

hip

rep

lace

men

t su

rger

y


Pat

ien

t re

po

rted

o

utc

om

es m

easu

res

knee

rep

lace

men

t su

rger

y


Enc.3.1.1

60

Part 3: Other information

Access & Performance - Quality of care indicators Comparable

Foundation Trust values (as at Q3 or

Feb 16)

Ind

icat

or

Mea

sure

Cu

rren

t P

erio

d

Val

ue

Pre

vio

us

Per

iod

Val

ue

Hig

hes

t

Lo

wes

t

Nat

ion

al

Ave

rag

e

Dat

a S

ou

rce

Reg

ula

tory

S

tate

men

t

6-w

eek

dia

gn

ost

ic

wai

ts

% March 2016 5.8 March 2015 5.5 0 9.3 1.3 PiMs/ CRIS

The Trust has a weekly diagnostic waiting list meeting which reviews the breach portfolio and signs off action

plans for the test modality as appropriate.

Max

imu

m w

aiti

ng

ti

me

of

62 d

ays

fro

m

urg

ent

GP

ref

erra

l to

fi

rst

trea

tmen

t fo

r ca

nce

rs

% Jan-March

2016 88.8

Jan-March 2015

84.2 93.5 55.5 83.5 Open Exeter

The Trust discusses all the cancer metrics weekly at the Performance

Improvement Group and monthly at the Patient Access Board where key

actions are reviewed and updated.

Enc.3.1.1

61

Access & Performance - Quality of care indicators Comparable

Foundation Trust values (as at Q3 or

Feb 16)

Ind

icat

or

Mea

sure

Cu

rren

t P

erio

d

Val

ue

Pre

vio

us

Per

iod

Val

ue

Hig

hes

t

Lo

wes

t

Nat

ion

al

Ave

rag

e

Dat

a S

ou

rce

Reg

ula

tory

S

tate

men

t

Per

cen

tag

e o

n in

com

ple

te

pat

hw

ay w

ith

in 1

8 w

eeks

fo

r p

atie

nts

on

inco

mp

lete

p

ath

way

at

the

end

of

the

rep

ort

ing

per

iod

% March 2016 80.4 March 2015 92.2 98 73.8 92.1 PiMs/ Oasis

The Trust took a reporting holiday with the agreement of local commissioners

and Monitor during the period. The Trust returned to reporting in March

2016. Auditors will conduct a review of the Trust’s data as part of the external

assurance process for the Quality Report. The Trust has taken robust

action during the period to improve the quality of its data for this indicator and to ensure that longer waiting patients

are cared for in the short-term.

Enc.3.1.1

62

Patient Safety - Quality of care indicators Comparable

Foundation Trust values

Ind

icat

or

Mea

sure

Cu

rren

t P

erio

d

Val

ue

Pre

vio

us

Per

iod

Val

ue

Hig

hes

t

Lo

wes

t

Nat

ion

al

Ave

rag

e

Dat

a S

ou

rce

Reg

ula

tory

S

tate

men

t

Pat

ien

t sa

fety

inci

den

ts r

epo

rted

to

th

e N

RL

S w

her

e d

eg

ree

of

har

m is

rec

ord

ed a

s ‘s

ever

e h

arm

or

dea

th’ a

s a

per

cen

tag

e o

f al

l pat

ien

t sa

fety

inci

den

ts

rep

ort

ed

% Oct 2014 – Mar 2015

0.96 Apr-Sept

2014 0.6 5.19 0.5 0.6 NRLS

The data for Oct 2014 to Mar 2015 shows that King’s College Hospital is a slight outlier in terms of the proportion of incidents with severe harm or death. King’s considers that the data overestimates the proportion of severe harm/death incidents because a significant proportion of incidents graded in this way will be downgraded post-investigation. This is not always reflected in the NRLS data as it is taken at a point in time.

Rat

e p

atie

nt

safe

ty

inci

den

ts

Num

ber/

1000

be

d da

ys

Oct 2014-Mar 2015

36.06 Apr-Sept

2014 40.7 82.21 3.57 37 NRLS

Kings College Hospital’s rate of reporting compares favourably with most of its peer hospitals

Nu

mb

er o

f p

atie

nt

safe

ty

inci

den

ts

Num

ber

Oct 2014-Mar 2015

8350 Apr-Sept

2014 9844 12784 443 4572 NRLS

Data for the period Apr 2015 – Sep 2015 shows that the total number of incidents has risen to around 10,000 which suggest that reporting is improving on an already solid baseline.

Enc.3.1.1

63

Patient Safety - Quality of care indicators Comparable

Foundation Trust values

Ind

icat

or

Mea

sure

Cu

rren

t P

erio

d

Val

ue

Pre

vio

us

Per

iod

Val

ue

Hig

hes

t

Lo

wes

t

Nat

ion

al

Ave

rag

e

Dat

a S

ou

rce

Reg

ula

tory

S

tate

men

t

The Trust considers that the data is as described because it was taken directly from the National Reporting & Learning System database and relates to acute non-specialist trusts.

Enc.3.1.1

64

Scorecard – latest version with text

Enc.3.1.1

65

Trust actions on duty of candour (incidents/actions)

Initial Implementation: Policy ratified and published on 30th

September 2014. Standardised documentation for

recording Duty of Candour conversations

‘Candour Guardian’ role identified - Dr Rob Elias, Consultant Nephrologist

Presentations at Consultant Development Mornings, Audit Days, Divisional Governance meetings, Nursing for and significant Trust committees were facilitated by the Candour Guardian and the Patient Safety Team.

A series (~10) of Candour drop in sessions were organised across all KCH sites to allow staff to find out more information.

KWIKI webpages developed (accessed over 4000 times to date)

Ongoing work to embed best practice in Candour: Candour Working Group: a team of

interested senior clinicians meet 2-3 monthly to review complicated/difficult cases and assess ways of improving the pathway in future and supporting the clinicians involved

Development of standardised Duty of Candour Letters

Changes to the Duty of Candour form in line with feedback from staff

Roll out of EPR duty of candour form for DH & Orpington and access through the Clinical Portal for PRUH and QMS (‘How to Guides’ developed)

Development of standardised letters to feedback the outcome of investigations into falls, pressure ulcers and hospital acquired thrombosis.

Education, focussed mainly on process, continued. As of February 2015, it was estimated that >800 staff had received face to face training.

Collaborative presentation on with KHP colleagues at National Safety Connections event

Plans for 2016 Duty of Candour Lead is in discussion

with a Human Factors training group to develop a ½ day and 1 day training course for KCH staff

KCH is now involved in the HIN Communities of Practice about Duty of Candour ( first meeting in November 2015, next meeting Jan 2016)

Development of FAQ based on comments from the Survey

Update of the KWIKI page to include some case studies from complex cases

Publication of the Audit Results Develop a methodology in conjunction

with PPI to get feedback from patients involved in Duty of Candour conversations to evaluate their experience.

March 2015 audit - This included a review of 50 cases showed: In 83% of confirmed candour cases

there was documented evidence that a candour discussion had occurred

The requirement to have a candour discussion within 10 working days was not always met (75%) – this was often due to the fact that the level of harm was not clear and was being discussed within clinical teams

In 91% of cases senior staff held the candour conversation

Enc.3.1.1

66

Trust action plan for Sign-Up to Safety Campaign

Campaign Pledges Trust Patient Improvement Plans

1. Putting safety first. Committing to reduce avoidable harm in the NHS by half through taking a systematic approach to safety and making public your locally developed goals, plans and progress. Instil a preoccupation with failure so that systems are designed to prevent error and avoidable harm

To follow

2. Continually learn. Reviewing your incident reporting and investigation processes to make sure that you are truly learning from them and using these lessons to make your organisation more resilient to risks. Listen, learn and act on the feedback from patients and staff and by constantly measuring and monitoring how safe your services are

To follow

3. Being honest. Being open and transparent with people about your progress to tackle patient safety issues and support staff to be candid with patients and their families if something goes wrong

To follow

4. Collaborate. Stepping up and actively collaborating with other organisations and teams; share your work, your ideas and your learning to create a truly national approach to safety. Work together with others, join forces and create partnerships that ensure a sustained approach to sharing and learning across the system

To follow

5. Being supportive. Be kind to your staff, help them bring joy and pride to their work. Be thoughtful when things go wrong; help staff cope and create a positive just culture that asks why things go wrong in order to put them right. Give staff the time, resources and support to work safely and to work on improvements. Thank your staff, reward and recognise their efforts and celebrate your progress towards safer care.

To follow

Enc.3.1.1

67

Annex 1: Statements from commissioners, local Healthwatch organisations and Overview and Scrutiny Committees To follow

Enc.3.1.1

68

Annex 2: Statement of directors’ responsibilites for the quality report The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations to prepare Quality Accounts for each financial year. Monitor has issued guidance to NHS foundation trust boards on the form and content of annual quality reports (which incorporate the above legal requirements) and on the arrangements that NHS foundation trust boards should put in place to support the data quality for the preparation of the quality report. In preparing the Quality Report, directors are required to take steps to satisfy themselves that: the content of the Quality Report

meets the requirements set out in the NHS Foundation Trust Annual Reporting Manual 2015/16 and supporting guidance

the content of the Quality Report is not inconsistent with internal and external sources of information including:

board minutes and papers for the period April 2015 to [the date of this statement]

papers relating to Quality reported to the board over the period April 2015 to [the date of this statement]

feedback from commissioners dated XX/XX/20XX

feedback from governors dated XX/XX/20XX

feedback from local Healthwatch organisations dated XX/XX/20XX

feedback from Overview and Scrutiny Committee dated XX/XX/20XX

the trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated XX/XX/20XX

the [latest] national patient survey XX/XX/20XX

the [latest] national staff survey XX/XX/20XX

the Head of Internal Audit’s annual opinion over the trust’s control environment dated XX/XX/20XX

CQC Intelligent Monitoring Report dated XX/XX/20XX

the Quality Report presents a balanced picture of the NHS foundation trust’s performance over the period covered

the performance information reported in the Quality Report is reliable and accurate

there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Report, and these controls are subject to review to confirm that they are working effectively in practice

the data underpinning the measures of performance reported in the Quality Report is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review and

the Quality Report has been prepared in accordance with Monitor’s annual reporting manual and supporting guidance (which incorporates the Quality Accounts regulations) as well as the standards to support data quality for the preparation of the Quality Report.

Enc.3.1.1

69

The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Report. By order of the board

NB: sign and date in any colour ink except black

Lord Kerslake, Chair

Nick Moberly, Chief Executive Officer

Date

Enc.3.1.1


2015 NHS Staff Survey

Results

04 May 2016Council of Governors

Enc. 3.2.1

1

Report to: Council of Governors

Date of meeting: 04 May 2016

Subject: 2015 Annual Staff Survey Results

Author(s): Rob Eames, Associate Director of HR

Presented by: Dawn Brodrick, Executive Director of Workforce Development

Status: Information and discussion

2

Summary of ReportThe purpose of this report is to update the Council of Governors on the 2015 NHS Staff Survey results for the Trust. This report should be read in conjunction with Appendix 1 attached which, is a two side summary of the results of the staff survey.

The reports provides the results and the next steps following the publication of the national staff survey data.

ActionThe Council is asked to note contents of this report which was discussed by the Board of Directors on 06 April 2016.

Enc. 3.2.1

2

• National staff survey open between October and December 2015• National results for 2015 survey were published on 23rd February

2016• Random sample of 850 staff (sample size set nationally)• 255 staff responded• The survey closed with a 30% response rate (national average for

Acute Trusts is 40.6%)• This is a small representation of the workforce, although the results

have been modified to ensure they are statistically sound• In comparison to the 2014 staff survey results only four key findings

have had a significant statistical change, with two findings improving and two getting worse (please see appendix 1)

Response ratesEnc. 3.2.1

3

Key Finding Kings 2015

Kings 2014

Average National Score ‘15

Best National Score ‘15

KF1 Staff recommendation of the organisation as a place to work or receive treatment 3.69 3.86 3.76 4.10

KF2 Staff satisfaction with the quality of work and patient care they are able to deliver 3.88 / N/A 3.93 4.29

KF3 % agreeing that their role makes a difference to patients/ service users 91% / N/A 90% 95%

KF4 Staff motivation at work 3.97 3.80 3.94 4.14

KF5 Recognition and value of staff by managers and the organisation 3.49 / N/A 3.42 3.73

KF6 % reporting good communication between senior management and staff 34% 28% 32% 51%

KF7 % able to contribute towards improvements at work 74% 69% 69% 79%

KF8 Staff satisfaction with the level of responsibility and involvement 3.92 3.88 3.91 4.08

KF9 Effective team working 3.77 / N/A 3.73 3.96

KF10 Support from immediate managers 3.78 3.67 3.69 3.96

KF11 % appraised in last 12 months 73% 65% 86% 95%

KF12 Quality of appraisals 3.16 / N/A 3.05 3.39

KF13 Quality of non-mandatory training, learning or development 4.01 / N/A 4.03 4.18

KF14 Staff satisfaction with resourcing and support 3.19 / N/A 3.30 3.66

KF15 % staff satisfied with the opportunities for flexible working patterns 40% / N/A 49% 58%

KF16 % working extra hours 79% 74% 72% 61%

KF17 % suffering work related stress 45% 41% 36% 24%

KF18 % feeling under pressure in last 3 mths to attend work when feeling unwell 63% 66% 59% 46%

KF19 Org and mgmt interest in and action on health/ wellbeing 3.48 / N/A 3.57 3.97

KF20 % experiencing discrimination at work in last 12 mths 12% 20% 10% 5%

KF21 % believing the organisation provides equal opportunities for career progression/ promotion 84% 79% 87% 96%

KF22 % experiencing physical violence from patients, relatives or the public in last 12 mths 12% 12% 14% 10%

KF23 % experiencing physical violence from staff in last 12 mths 1% 1% 2% 0%

KF24 % reporting most recent experience of violence 46% 58% 53% 72%

KF25 % of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months 33% 34% 28% 19%

KF26 % of staff experiencing harassment, bullying or abuse from staff in last 12 months 29% 25% 26% 16%

KF27 % staff/ colleagues reporting most recent experience of harassment, bullying or abuse 45% 51% 37% 52%

KF28 % staff witnessing potentially harmful errors, near misses or incidents in last month 36% 41% 31% 21%

KF29 % of staff reporting errors, near misses or incidents witnessed in the last month 89% 98% 90% 97%

KF30 Fairness and effectiveness of procedures for reporting errors, near misses and incidents 3.75 N/A 3.70 3.92

KF31 Staff confidence and security in reporting unsafe clinical practice 3.65 3.70 3.62 3.93

KF32 Effective use of patient/ service user feedback 3.83 3.84 3.70 3.97

Staff Engagement Score 3.81 3.77 3.79 4.03

Overview of all results (Please see Appendix 1)

Top 5 Scores Bottom 5 Scores Key Findings most relevant to Francis Report Largest statistically significant change since 2014

Improved since 2014 (could be through chance) Worsened since 2014 (could be through chance) / No 2014 comparator (New 2015 Key Finding)

Enc. 3.2.1

4

• There have been some positive results around staff motivation and commitment to King’s and the overall level of staff engagement has improved (although further work is still required in this area)

• The results from 255 respondents show that line management, communication and staff involvement is good and team working is effective

• The results have again highlighted some areas for improvement that we are already in the process of developing initiatives for, as part of the King’s BEST strategy and workforce strategy development process (e.g. appraisals, equality, staff engagement/morale, health and wellbeing and line management capability etc)

• We are also using other workforce metrics locally such as turnover rate, stability rate, exit questionnaires and leaver data to triangulate the health of our workforce and we will use and develop these combined metrics further in the future

SummaryEnc. 3.2.1

5

• Due to the low numbers of staff responding we are not proposing to develop specific Divisional or Occupational Group Staff Survey action plans for this year

• A significant increase in staff feedback through the staff survey is required to get a better understanding of staff views. In 2016 the survey will be open for all staff to participate and we also need to increase the overall Trust response rate

• Staff engagement will be key as part of our vision/strategy and organisational design and development (ODD) work

• We will continue to embed the strategic narrative/direction of the Trust in all that we do

• We will use “2-way“ communication and feedback mechanisms to listen and involve staff in the decisions that affect them as part of the strategy and the ODD work

• We will lead staff in a way that drives accountabilities, ways of working and delivers a culture that aligns to the BEST strategy

Next steps Enc. 3.2.1

6

STAFF SURVEY 2015 HEADLINES

OVERVIEW: The survey closed with a 30% (national average is 40.6%) response rate (255 staff) from a random sample of 850 staff. This is a small representation of the workforce; the results have been modified to ensure they’re statistically sound. In comparison to the 2014 staff survey results only four key findings have significantly changed. The overall staff engagement score has positively improved since 2014 however this was brought down by lower than average scores in staff recommending the Trust as a place to work or be treated. This will be monitored in the Q4 FFT. Despite this staff believe that patient and service user feedback is effectively used putting Kings in the best 20%. The results show that 14 of the 32 key findings for King’s are above average with 5 in the top 20% of acute Trusts. Staff are motivated at work which has significantly increased since last year; when appraisals happen they are of good and above average quality; staff are involved in improvements at work with good communication between them and senior management; line managers are supportive which is also reflected in effective team working. Staff also feel confident to report harassment, bullying or abuse and unsafe clinical practice, their view is that the procedures for reporting near misses and incidents are fair and effective, however despite this the results indicate that staff are not reporting incidents as much as they should be. Physical violence between staff is also low. In contrast 17 of the 32 key findings are worse than the average of acute trusts with 9 of these being in the worst 20%. Areas of concern include staff feeling the pressure to work extra hours, reporting stress at work, a lack of flexible working and appraisals not being completed. The quality of non-statutory and mandatory training on offer is considered worse than average. There is an increase in staff witnessing potentially harmful errors, near misses or incidents which are not being reported. Staff are not satisfied with the quality of care they are able to deliver and they have a low view of the organisations and management’s commitment to their health and wellbeing. The view is that discrimination exists alongside a lack of equal opportunity for career progression/promotion.

IN THE BEST 20% OF ACUTE TRUSTS BETTER THAN AVERAGE OF ACUTE TRUSTS

KF7. Staff ability to contribute toward improvements at work (best)

KF10. Support from immediate managers (best) KF27. % reporting most recent experience of

harassment, bullying or abuse (best) KF32. Effective use of patient / service user

feedback (best) KF23. % experiencing physical violence from staff

in last 12 mths (lowest)

KF3. % agreeing that their role makes a difference to patients / service users

KF4. Staff motivation at work (significantly since 2014)

KF5. Recognition and value of staff by managers and the organisation

KF9. Effective team working KF12. Quality of appraisals KF22. % experiencing physical violence from patients,

relatives or the public in last 12 mths KF6. % reporting good communication between senior

management and staff KF30. Fairness and effectiveness of procedures for

reporting errors, near misses and incidents KF31. Staff confidence and security in reporting unsafe

clinical practice

WORST 20% OF ACUTE TRUSTS NATIONALLY WORSE THAN AVERAGE OF ACUTE TRUSTS KF11. Percentage of staff appraised in last 12

months KF14. Staff satisfaction with resourcing and support KF15. Percentage of staff satisfied with the

opportunities for flexible working patterns KF16. Percentage of staff working extra hours KF17. Percentage of staff suffering work related

stress in last 12 months KF19. Org and mgmt. interest in and action on

health/ wellbeing KF24. % reporting most recent incident of violence KF25. % experiencing harassment, bullying or

abuse from patients, relatives or the public in last 12 months

KF28. Percentage of staff witnessing potentially harmful errors, near misses or incidents in last month

KF1. Staff recommendation of the organisation as a place to work or receive treatment (significantly since 2014)

KF2. Staff satisfaction with the quality of work and patient care they are able to deliver

KF13. Quality of non-mandatory training, learning or development

KF18.% feeling pressure in last 3 mths to attend work when feeling unwell

KF26.% experiencing harassment, bullying or abuse from staff in last 12 mths

KF20.% experiencing discrimination at work in last 12 mths (significantly since 2014)

KF21.believing the organisation provides equal opportunities for career progression/promotion

KF29. % reporting errors, near misses or incidents witnessed in last 12 mths (significantly since 2014)

Enc.3.2.1 Appendix 1

TRUST 2015 STAFF SURVEY RESULTS

Key Finding Kings 2015

Kings 2014

Average National score ‘15

Best National Score ‘15

KF1 Staff recommendation of the organisation as a place to work or receive treatment 3.69 3.86 3.76 4.10

KF2 Staff satisfaction with the quality of work and patient care they are able to deliver 3.88 / N/A 3.93 4.29

KF3 % agreeing that their role makes a difference to patients/ service users 91% / N/A 90% 95%

KF4 Staff motivation at work 3.97 3.80 3.94 4.14

KF5 Recognition and value of staff by managers and the organisation 3.49 / N/A 3.42 3.73

KF6 % reporting good communication between senior management and staff 34% 28% 32% 51%

KF7 % able to contribute towards improvements at work 74% 69% 69% 79%

KF8 Staff satisfaction with the level of responsibility and involvement 3.92 3.88 3.91 4.08

KF9 Effective team working 3.77 / N/A 3.73 3.96

KF10 Support from immediate managers 3.78 3.67 3.69 3.96

KF11 % appraised in last 12 months 73% 65% 86% 95%

KF12 Quality of appraisals 3.16 / N/A 3.05 3.39

KF13 Quality of non-mandatory training, learning or development 4.01 / N/A 4.03 4.18

KF14 Staff satisfaction with resourcing and support 3.19 / N/A 3.30 3.66

KF15 % staff satisfied with the opportunities for flexible working patterns 40% / N/A 49% 58%

KF16 % working extra hours 79% 74% 72% 61%

KF17 % suffering work related stress 45% 41% 36% 24%

KF18 % feeling under pressure in last 3 mths to attend work when feeling unwell 63% 66% 59% 46%

KF19 Org and mgmt interest in and action on health/ wellbeing 3.48 / N/A 3.57 3.97

KF20 % experiencing discrimination at work in last 12 mths 12% 20% 10% 5%

KF21 % believing the organisation provides equal opportunities for career progression/ promotion

84% 79% 87% 96%

KF22 % experiencing physical violence from patients, relatives or the public in last 12 mths 12% 12% 14% 10%

KF23 % experiencing physical violence from staff in last 12 mths 1% 1% 2% 0%

KF24 % reporting most recent experience of violence 46% 58% 53% 72%

KF25 % of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months

33% 34% 28% 19%

KF26 % of staff experiencing harassment, bullying or abuse from staff in last 12 months 29% 25% 26% 16%

KF27 % staff/ colleagues reporting most recent experience of harassment, bullying or abuse

45% 51% 37% 52%

KF28 % staff witnessing potentially harmful errors, near misses or incidents in last month 36% 41% 31% 21%

KF29 % of staff reporting errors, near misses or incidents witnessed in the last month 89% 98% 90% 97%

KF30 Fairness and effectiveness of procedures for reporting errors, near misses and incidents

3.75 N/A 3.70 3.92

KF31 Staff confidence and security in reporting unsafe clinical practice 3.65 3.70 3.62 3.93

KF32 Effective use of patient/ service user feedback 3.83 3.84 3.70 3.97

Staff Engagement Score 3.81 3.77 3.79 4.03

Key

Top 5 Scores Bottom 5 Scores Key finding most relevant to the Francis report Statistically significant change since 2014 Improved since ‘14 (could be by chance) Worsened since ‘14 (could be by chance) / No Comparison from 2014 ( A new 2015 KF)

Enc.3.2.1 Appendix 1

Governor Elections2016

Council of Governors04 May 2016

Enc.3.3.1

1

Report to: Council of Governors

Date of meeting: 04 May 2016

Subject: Governor Elections

Author(s): Tamara Cowan, Board Secretary

Presented by: Judith Seddon, Acting Director of Corporate Affairs & Trust Secretary

Sponsor: Judith Seddon, Acting Director of Corporate Affairs & Trust Secretary

History: previously considered KE and verbal update at Council of Governors

Status: For Information/Endorsement

2

Summary of Report

• This reports provide Board od Directors with information about the 2016 Governor elections.

Action required• The Board is ask to note the forthcoming governor elections and note the process to be undertaken.

Enc.3.3.1

2

3

Legal: The Council of Governors are part of the Trust’s governance framework and the Trust is required to hold elections for governors.

Financial: The election will cost the Trust circa £11,000

Assurance: Having an effective governing body in place will provide assurance to the Trust.

Clinical: No direct implications

Equality & Diversity: No direct implications

Performance: No direct implications

Strategy: No direct implications

Workforce: No direct implications

Estates: No direct implications

Reputation: No direct implications

Other:(please specify) No direct implications

Key implicationsEnc.3.3.1

3

• Council is made up of 34 Governors– 13 elected from public constituencies of

Lambeth, Lewisham, Southwark and Bromley;

– 6 elected from the patient constituencies;

– 5 elected from the staff constituencies; and

– 10 appointed from key stakeholders

BackgroundEnc.3.3.1

4

• Public, Patient and Staff Governors are elected by the Members of the Trust

• Public and Patient Members are required to sign-up to membership of the Trust

• Staff are automatically opted-in as Members, they do have option to opt-out

Background cont’d.Enc.3.3.1

5

• The following governor terms will come to an end November 2016:– 2 Patient Governors– 1 Staff (Nursing & Midwifery) Governor

• The following governor terms will come to an end January 2017:– 4 Bromley Governors– 1 Lewisham Governor

2016 ElectionsEnc.3.3.1

6

Current Governor Term Details Eligible for Re-Election

Interested in Re-election?

Anoushka de Almeida-Carragher First, 3 year Yes No

Eniko Benfield First, 3 year Yes Yes

Paul Corben First, 3 year Yes Yes

Penny Dale First, 3 year Yes Yes

Tim Bradley Replaced Alan Hall (01/10/2015)

Yes Yes

Tom Duffy Last, 2 year No N/A

Jan Thomas Last, 2 year No N/A

Nicky Hayes Last, 2 year No N/A

2016 Elections, Current Postholders

Enc.3.3.1

7

• Elections are: – In line with Monitor’s Model Election Rules, enshrined

in Trust’s Constitution (formal timeframe of 40 days between Notice and Close of Poll;

– Run by independent scrutineers, Electoral Reform Services

• NEW this year – Electronic Information & Online Voting which will:– Save the Trust money;– Improve engagement with wider audience– More lead time to publicise this new process

2016 Elections ProcessEnc.3.3.1

8

High Level TimetableEvents When What

Rai

sing

Ele

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n A

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enes

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Pu

blic

ity

Apr

il-S

epte

mbe

r 201

6

Presentation & Flyers at Trust Community Events

Presentations & Flyers by governors at Trust Health Talks & Staff Induction

Notices on Trust external and internal websites

Notices & flyers around Trust sites

Notices, flyers and presentations though stakeholder

Messages in Trust’s Membership bulletin

Governor Awareness Sessions

Form

al E

lect

ion

Proc

ess

May

–S

epte

mbe

r 20

16

Notice of Election (formal)

Nominations & Publication of Statements

Notice of Poll

Voting Period (end-August – end-September)

Gov

erno

r Ind

uctio

ns &

Tr

aini

ngs

Clo

se o

f Pol

l -Te

rm

com

men

cem

ent

Shadow Governor Meetings

Attend Board Meetings

Buddying Current Governors

Attend Governor Development Day

Attend Governor Workshops

Site Tours

Enc.3.3.1

9


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Pre

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OR INFOR

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Enc. 3.3.2

2

1. | Engagement & Involvement Opportunity During the Period Governors have attended the following scheduled meetings for the period 10 March 2016 – 27 April 2016: Date Activity 17 March Council of Governors Meeting

31 March Review Session

06 April Board of Directors Meeting (Public)

14 April Membership and Community Engagement Committee Meeting

14 April Governor Strategy Committee Meeting

19 April Patient Experience and Safety Committee Meeting

Governors have also been busy undertaking the initiatives outlined in the Governor Engagement & Involvement Register as follows: Involvement Activity Governor Attendee(s) Governors Attended

During the Period Members Health Talk Penny Dale Yes Breakfast Meeting with Chairman Penny Dale

Chris North Fiona Clark Roger Paffard Jan Thomas Andrew McCall Helen Ahmet Victoria Silvester

Yes

Community Events Andrew McCall Fiona Clark

Yes

Go See Visits Chris North Penny Dale Fiona Clark

Yes

Southwark & Lambeth Citizens Forum Andrew McCall Yes Council of Governors Planning Meeting with Chairman

Chris North Yes

Corporate Induction Roger Engwell Yes Internal Audit Appointment Committee Helen Ahmet Yes Bromley Health & Well Being Board Meeting

Penny Dale Yes

Nutrition in Elderly Patients Meeting Penny Dale Yes PLACE Visits Penny Dale

Fiona Clark Yes

Public Health Committee Fiona Clark Yes End of Life Committee Fiona Clark Yes Nominations Committee Fiona Clark Yes

Enc. 3.3.2

3

Involvement Activity Governor attendee(s)

Trust Lead Meeting Date Meeting Time Meeting Venue Additional Information

Public Health Committee

Tom Duffy Pida Ripley Victoria Silvester Grace Okoli Sue Gallagher Fiona Clark

Chair: John Moxham (Organiser Mika Kuszai)

There is no limit to governor attendance for these meetings. Should any other governors wish to attend, please advise the Foundation Trust Office

21/04/2016 10:00-11:30 TBC 28/07/2016 10:00-11:30 Dulwich Room 27/10/2016 10:00-11:30 Dulwich Room Staff Commendation Panel

Jan Thomas Fiona Clark Penny Dale

Chair: John Karani Contact: Linda Flay

09/05/2016 07/11/2016

11:00 11:00

Dulwich Room

9 May 11:00 Dulwich Room 7 November 11:00 Dulwich Room Improving King’s Patient Food Service – Food Service and Nutrition Group

Victoria Silvester Jan Thomas

Chair/Lead: Jan Flint

TBC TBC TBC Reserve Governor: Roger Engwell Comes under the Nutrition Support Steering Group (NSSG) which is a sub-group of the Patient Safety Committee.

Patient Food Audits (DH)

Victoria Silvester Fiona Clark Jan Thomas

Chair/Lead: Jan Flint

TBC TBC TBC Reserve Governor: Roger Engwell

Organ Donor Committee

Jan Thomas Chair/Lead: Ben Rhodes

The committee meets quarterly, the next date is yet to be agreed

Community Events (DH & PRUH)

No limit to attendance

Lead: Sally Lingard

Detail provided in the monthly stakeholder calendar

Patient Experience Committee

Victoria Silvester Pida Ripley

Lead: Jessica Bush

Reserve Governor: Tom Duffy

23/03/2016 14:30-16:30 Dulwich Room 25/05/2016 14:00-16:00 Board Room, PRUH 27/07/2016 14:00-16:00 Dulwich Room 27/09/2016 11:00-13:00 Board Room, PRUH

Enc. 3.3.2

4



29/11/2016 10:00-12:00 Dulwich Room National Governors’ Forum (FTN Network)

Tom Duffy Jan Thomas

n/a TBC TBC TBC

NHS providers Focus Group

Tim Bradley n/a 20 April 2016 10:00-15:30 28 Great Russell Street

Serious Complaints Committee

Pida Ripley Lead: Judith Seddon

Reserve Governor: Fiona Clark

12/05/2016 10:00-12:00 Dulwich Room 14/07/2016 11:30-13:30 TBA 13/10/2016 13:00-15:00 Dulwich Room End of Life Care Steering Group

Fiona Clark Jan Thomas

Contact: Wendy Prentice, Xan Neethling

Reserve Governor: Penny Dale

1 April 10:00-11:30 Dulwich Room 6 May 10:00-11:30 Dinwoodie 1 & 2 10 June Dulwich Room 22 Jul 10:00-11:30 Dulwich Room 26 Aug 10:00-11:30 Dulwich Room 30 Sep 10:00-11:30 Dulwich Room 4 Nov 10:00-11:30 Dinwoodie 1 & 2 9 Dec 10:00-11:30 Dulwich Room Maternity Services Liaison Group

Anoushka de Almeida-Carragher

Lay Chair: Joanna Brien

29 Jan 12:30-14:30 Jenny Lee House Remaining dates and venues TBC

Go See Visits All Governors Geraldine Walters (Helen Day)

Monthly following Board meetings

Denmark Hill and Princess Royal University Hospital sites

Please advise the Foundation Trust Office should you wish to attend the Go See Visits following the Trust Board of Directors meeting

PLACE Visits All Governors Various Adhoc Dignity Visits All Governors Nicky Hayes TBC King’s In Conversations All Governors Jenny Steele TBC Quality Accounts Engagement

All PESC Members Adhoc See governor sub-committee

Enc. 3.3.2

5



Denmark Hill Phlebotomy Focus Group

1 required Phil Brown/ Althea Haye (Linda Akkad PA)

TBC TBC TBC This group is looking for one governor to attend discussion on the present services at the King’s site and be a source of consultation for improvements.


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1

Meeting: Governor Strategy Committee

Meeting Date: 04 May 2016

Action: For Information

SUMMARY OF KEY DISCUSSION POINTS NHS Performance Measurement The Committee received and noted the presentation from Sam Benghiat focusing on possible ways to measure NHS performance. The National Health Service (NHS) is a broad system of numerous healthcare organisations trying to achieve good healthcare for current and future generations. The development of ‘perfect’ data for all clinical services is hard to achieve due to direct impact of external factors on the entire healthcare industry. The current performance measures do not always encourage the outcomes sought by most organisations as these systems assess the overall performance of processes and do not target specific clinical elements.

Strategic Planning Update (Where Are We Now?) The Committee received a brief overview of the current strategic planning goals and related issues. It was highlighted that the Trust aims to move towards a place-based commissioning where healthcare providers would deliver best value patient services through collaborative planning. KHP Update The Committee noted the King’s Health Partners (KHP) update and it was highlighted that work continues on the development of the Strategic Outline Cases (SOC) for both Haematology and Cardiovascular. There are ongoing discussions that the KHP Institutes plans would be woven into the Sustainability and Transformation Plan (STP). Horizon Scan The Committee noted the horizon scan and the relevant strategic issues. The Public Accounts Committee report on acute finances emphasises the need to develop adequate plans to meet the £22bn efficiency challenges. The healthcare providers are aiming to introduce enhanced workforce plans to reduce the agency overspend. The Trust has taken appropriate actions to minimise the impact of junior doctors’ strikes on service delivery and staff morale. 2016/17 Final Operational Plan The Committee received and noted the latest update on the 2016/17 Operational Plan. The Operational Plan has been constructed using a set of assumptions for income, expenditure, capital and financing; and stretch performance targets for improvements to patient waiting times.

Enc. 3.3.3.2

2

The financial ‘bridge’ shows that with support from STP funding, tariff growth and investments from local Clinical Commissioning Groups (CCGs), the Trust expects to improve its revenue deficit position by £57m to a projected £8m deficit in 2016/17. The Trust acknowledges that further access to distressed funding will be required to improve creditor payment performance and to fund the capital schemes required to meet the core facilities maintenance and re-equipping needs.

Commercial Services Performance Update The Committee received and noted an update on commercial services performance. NHS is entering a period of unprecedented change. The combination of aging population, increased levels of complex diseases and greater patient expectations have increased the demand for services and healthcare providers need to find viable ways for funding. The Trust has the potential to raise additional funds to support clinical services and financial stability through a number of commercial opportunities, which would be closely aligned with its core strengths and points of differentiation. Clinical Academic Site Strategy The Committee noted the clinical academic site strategy update. The Trust is currently exploring various options for the implementation of a clinical academic site strategy, which would improve capacity performance and transform current clinical processes. Finance and Performance Reports (M10) The Committee received and noted the month 10 Finance and Performance reports. Committee members have expressed thanks to Executive colleagues for their candour and openness. KEY ACTIONS FROM MEETING Action Who Progress The Committee agreed that the strategy objectives would be discussed at the next meeting.

GSC Completed

The Committee agreed that Governors will have an opportunity to input into the Operational Plan via the NEDs/Governors Review Session or another forum.

Govs Completed

Enc. 3.3.3.3

1

`Meeting: Patient Experience & Safety Committee

Meeting Date: 4 May 2016

Action: For Information

SUMMARY OF KEY DISCUSSION POINTS Patient Story The Committee welcomed Irene Karrouze(IK), Continence Nurse, who presented a patient case on the successful implementation of a passports. IK relayed the story of the patient Mr X who had been catheterised in the Trust and the challenges he faced in getting adequate community care on issues relating to his catheter.

Mr X, aged 77, was catheterised and discharged with a urinary catheter. Mr X lived alone, with no family and had other illnesses. Following his discharge the patient was sent home with a catheter. Over the next few weeks the patient attended the Trust’s emergency departments ten times with catheter related issues;

During his last visit the patient was very distressed about the catheter and refused to leave the ward until the issues were resolved. Following a review with the Continence team and discussions with the consultant a decision was made to start the patient on alfa blockers and also to conduct trial without catheter (TWOC);

On his discharge Mr X was provided with a catheter passport which can help staff easily ascertain his history and also empower district nurses to provide the right care to the patient in his home as opposed to calling an ambulance and bring the patient to the emergency department every time there was an issue;

The patient was much happier and expressed his gratitude to the Trust for the use of the catheter passport in his case; and

The Committee agreed that the catheter passport was an excellent tool and that if possible its use should be extended to other medical conditions.

Safeguarding Adults

The Committee received the annual safeguarding children’s report.

Following significate changes to caselaw legislation relating to deprivation of liberty safeguards (DoLS). The Trust had to quickly understand and apply the new rules to its patients. The implications of the caselaw was that there are now considerably more patients to whom DoLS applications are applicable.

2

The Trust had a learning period in relation to appropriate applications, the safeguarding team is now skillful in preparing applications. The Denmark Hill team holds a weekly meeting with social sector partners and doctors. The meetings at the Princess Royal are held monthly with different partners; and

1.

The Trust is below the 80% target on staff training relating to DoLS. It should however be noted that the nursing staff group are on target on DoLS training. The safeguarding team is working toward improving training levels for all other professional staff groups.

Safeguarding Children

The Committee received the annual safeguarding children’s report.

The safeguarding team was able to recruit to the key position of safeguarding Doctor for the Denmark Hill site in March 2016. Funds were also secured to recruit a fulltime specialist midwife for women with mental-ill health at the Princess Royal University Hospital, this post is currently advertised;

Midwives were also provided with training on female genital mutilation at their annual children’s safeguarding update. The Havens and the young person’s midwifery group attended additional training on child sexual exploitation; and

The Trust will be opening a new Havens facility close to the Denmark Hill site shortly.

CQC Action Plan Update

The Committee received an update on the Trust’s compliance with the Care Quality

Commission actions plan.

The Trust was inspected by the Care Quality Commission(CQC) between 13 to 17 April 2015. The inspection report was published at the end September 2015. The Trust was rated as ‘requires improvement’;

The inspection report identified a number of actions the Trust must correct. An action

plan was drafted with identified timeline to correct the ‘must do’ items in the report.

Progress on the action plan is monitored via the Trust’s CQC Steering Group with

issues escalated to King’s Executive (KE) and Board of Directors where appropriate;

The Trust invited KPMG to undertake a review of action plan development in March

2016. The review identified that progress on the action plan was very good with the

greater proportion of the of the ‘must do’ items completed. However a small number of

new concerns were identified; and

The Trust will continue to work on the action plan and increase accountability and

ownership of actions to ensure that changes in practice embed and the Trust is

compliant with all CQC standards of care.

Enc. 3.3.3.3

3

Governor Involvement Updates

The Quality and Governance Committee indicated that the Trust has a few deep rooted

problems which remain difficult to solve. The Chair noted at the last meeting on 17 March

that "we are always making the same points about complaints but things don’t seem to

improve", similarly with falls in the hospital. The Committee will continue to address these

issues within the Trust.

The Committee of the Commissioners (CQRG) has a long membership list. It is a very

different Committee compared to Trust committees and there is no consistency of attendees.

The last committee meeting focused on Antimicrobial Stewardship and the proposed review

by NHS London relating to the length of time patients had to wait before they were informed

they do not have cancer.

Month 10 Finance and Performance Reports

The Committee noted the reports.

Decisions from the Metting

The Committee decided it would no longer receive copies of the Trust monthly finance and

performance reports as part of its pack of papers, because these are circulated regularly to

all Governors with the monthly Board of Directors papers.


REGISTER OF GOVERNOR ATTENDANCE (PUBLIC)

CONSTITUENCY REASON FOR ABSENCE

1 2 3 4 5

Prof Sir George Alberti Chair Retired on 31/03/2015

Lord Robert Kerslake Chair √ √

Ms Anoushka de Almeida-Carragher Bromley √ √

Ms Eniko Benfield Bromley

Mr Paul Corben Bromley

Ms Penny Dale Bromley √

Mr Alan Hall Lewisham Resigned on 10/09/2015

Ms Fiona Clark Lambeth

Mr Christopher North Lambeth

Mr Nandakumar Ratnavel Lambeth

Dr Grace Okoli Lambeth

Ms Barbara Pattinson Southwark

Ms Pam Cohen Southwark

Mr Andrew McCall Southwark

Mrs Victoria Silvester Southwark

Miss Jo Millett Staff - Nurses and Midwives

Ms Nicky Hayes Staff - Nurses and Midwives

Mr CV Praveen Staff - Medical and Dentistry Resigned on 07/03/2016

Dr Cornelius Lewis Staff - Allied Health Professionals Resigned on 01/04/2016

Mr Roger Engwell Staff - Administration and Clerical

Mr Anand Arya Staff - Medical and Dental Staff Group

Mr Daniel BeazleyStaff - Allied Health Professionals, Scientific & Technical

Joined on 02/04/2016

Ms Helen Ahmet Patient

Mr Derek St Clair Cattrall Patient

Mr Thomas Duffy Patient

Mrs Catriona Ogilvy Patient Governor role terminated. Replaced by Craig Jacobs

Mrs Pida Ripley Patient

Ms Jan Thomas Patient

Mr Craig Jacobs Patient Joined on 25/09/2015

Mr Tim Bradley Patient Joined on 25/09/2015

Cllr Robert Evans Bromley Council

Ms Diane Summers Guy's & St Thomas' Hospital NHS Foundation Trust

Mrs Phidelma Lisowska Joint Staff Committee √ √

Mr Chris Mottershead King's College London √

Ms Sue Gallagher Lambeth CCG Resigned on 24/10/2015

Mr Richard Gibbs Southwark CCG Resigned on 22/10/2015

Mr Jim Gunner Bromley CCG Resigned on 29/04/2015

Cllr Jim Dickson Lambeth Council √ √

Cllr Kieron Williams Southwark Council √ √

Mr Roger Pafford South London and Maudsley NHS FT Joined on 02/01/2015

Dr Sadru Kheraj Lambeth CCG √ Joined on 01/01/2016

Mr Noel Baxter Southwark CCG Joined on 01/02/2016

NAME MEETINGS ATTENDED

Meeting Dates Key: (1) 10 December 2015; (2) 17 March 2016;

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Appendix 1: Board Declaration

Board Response

For finance, that: 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. Rationale for signing not confirmed The Trust is still reliant on the working capital facility from Monitor. The Trust Continuity of Service Risk Rating of 1 at the end of Quarter 4.

NOT CONFIRMED

For governance, that: 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. Rationale for signing not confirmed The Trust self-certified that there was a risk it would not meet the following targets in its Annual Plan:

Referral to treatment targets – 18 weeks for admitted/non-admitted/incomplete; and

A&E 4-hour target; and 62-day cancer waits; and C.Diff – Quarters 1-4

In quarter 4 the Trust did not meet the following targets:

18 weeks in aggregate incomplete pathway; and A&E 4-hour target; and The number of cases of c.diff is above trajectory The 2 week Wait breast target is currently an unvalidated position

NOT CONFIRMED

Otherwise: The board confirms that there are no matters arising in the quarter requiring an exception report to Monitor (per the Risk Assessment Framework, Diagram 6) which have not already been reported. Rationale for signing confirmed

The Trust is not aware of any other matters arising that Monitor is not already aware.

CONFIRMED

Consolidated subsidiaries: Number of subsidiaries included in the finances of this return. This template should not include the results of your NHS charitable funds.

1

Click to go to index

Summary of Financial Statements for King’s College Hospital NHS Foundation Trust

units sense

Audited For

PrevYE ending

31-Mar-15

Plan For

Month ending

31-Mar-16

Actual For

Month ending

31-Mar-16

Variance For

Month ending

31-Mar-16

Plan For

YTD ending

31-Mar-16

Actual For

YTD ending

31-Mar-16

Variance For

YTD ending

31-Mar-16

Plan For

Year ending

31-Mar-16

Summary Income and Expenditure Account

Operating income (inc in EBITDA)NHS Clinical income £m (+ve) 880.626 71.363 - (71.363) 860.388 825.345 (35.044) 860.388 Non-NHS Clinical income £m (+ve) 16.345 1.569 - (1.569) 19.783 21.240 1.457 19.783 Non-Clinical income £m (+ve) 186.811 11.819 - (11.819) 141.844 123.200 (18.644) 141.844 Total £m 1,083.782 84.750 0.000 (84.750) 1,022.015 969.785 (52.230) 1,022.015

Operating expenses (inc in EBITDA)Employee expense £m (-ve) (620.182) (49.776) - 49.776 (628.355) (575.133) 53.222 (628.355) Non-Pay expense £m (-ve) (401.385) (27.350) - 27.350 (345.619) (362.770) (17.151) (345.619) PFI / LIFT expense £m (-ve) (51.173) (4.931) - 4.931 (53.891) (50.781) 3.110 (53.891) Total £m (1,072.740) (82.057) 0.000 82.057 (1,027.865) (988.684) 39.181 (1,027.865)

EBITDA £m 11.042 2.693 - (2.693) (5.850) (18.899) (13.049) (5.850) EBITDA Margin % % 1.02% 3.18% 0.00% (3.18%) (0.57%) (1.95%) (1.38%) (0.57%)

Operating income (exc from EBITDA)Donations and Grants for PPE and intangible assets £m (+ve) - 0.134 - (0.134) 0.900 1.103 0.203 0.900

Operating expenses (exc from EBITDA)Depreciation & Amortisation £m (-ve) (22.152) (1.954) - 1.954 (23.446) (18.182) 5.264 (23.446) Impairment (Losses) / Reversals £m (+/-ve) (4.535) (0.459) - 0.459 (5.500) (5.039) 0.461 (5.500) Restructuring costs £m (-ve) - - - - - - - -Total £m (26.687) (2.413) 0.000 2.413 (28.946) (23.221) 5.725 (28.946)

Non-operating incomeFinance income £m (+ve) 0.969 0.228 - (0.228) 2.500 0.092 (2.408) 2.500 Gain / (Losses) on asset disposals £m (+/-ve) (0.285) (0.039) - 0.039 (0.350) (0.111) 0.239 (0.350) Gain on transfers by absorption £m (+ve) - - - - - - - -Other non - operating income £m (+ve) - - - - - - - -Total £m 0.684 0.189 0.000 (0.189) 2.150 (0.019) (2.169) 2.150

Non-operating expensesInterest expense (non-PFI / LIFT) £m (-ve) (1.809) (0.337) - 0.337 (3.670) (3.490) 0.180 (3.670) Interest expense (PFI / LIFT) £m (-ve) (17.279) (1.413) - 1.413 (16.962) (15.553) 1.409 (16.962) PDC expense £m (-ve) (11.272) (0.961) - 0.961 (11.523) (8.961) 2.562 (11.523) Other finance costs £m (-ve) (0.153) (0.012) - 0.012 (0.150) (0.121) 0.029 (0.150) Non-operating PFI costs (e.g. contingent rent) £m (-ve) (6.163) (0.537) - 0.537 (6.452) (6.017) 0.435 (6.452) Losses on transfers by absorption £m (-ve) - - - - - - - -Other non-operating expenses (including tax) £m (-ve) (0.250) - - - - - - -Total £m (36.926) (3.260) 0.000 3.260 (38.757) (34.142) 4.615 (38.757)

Surplus / (Deficit) after tax £m (51.887) (2.657) 0.000 2.657 (70.503) (75.179) (4.676) (70.503)

Profit/(loss) from discontinued Operations, Net of Tax £m (+/-ve) - - - - - - - -

Surplus / (Deficit) after tax from Continuing Operations £m (51.887) (2.657) 0.000 2.657 (70.503) (75.179) (4.676) (70.503)

Memorandum Lines:

Surplus / (Deficit) before impairments and transfers £m (47.352) (2.198) - 2.198 (65.003) (70.140) (5.137) (65.003)

One off income/costs £m (4.820) (0.498) - 0.498 (5.850) (5.150) 0.700 (5.850) Normalised Surplus / (Deficit) £m (47.067) (2.159) - 2.159 (64.653) (70.029) (5.376) (64.653) Normalised Surplus / Deficit Margin % % (4.34%) (2.54%) 0.00% 2.54% (6.31%) (7.21%) (0.91%) (6.31%)

Summary Statement of Financial Position

Non-current AssetsIntangible assets £m (+ve) 3.495 2.704 - (2.704) 2.704 - (2.704) 2.704 Property, Plant & Equipment £m (+ve) 365.304 375.295 - (375.295) 375.295 - (375.295) 375.295 On-balance sheet PFI £m (+ve) 247.392 258.148 - (258.148) 258.148 - (258.148) 258.148 Other £m (+ve) 11.659 13.410 - (13.410) 13.410 - (13.410) 13.410 Total £m 627.850 649.557 0.000 (649.557) 649.557 0.000 (649.557) 649.557

Current AssetsCash and cash equivalents £m (+ve) 43.445 2.000 - (2.000) 2.000 - (2.000) 2.000 Other current assets £m (+ve) 115.307 112.578 - (112.578) 112.578 - (112.578) 112.578 Total £m 158.752 114.578 0.000 (114.578) 114.578 0.000 (114.578) 114.578

Current LiabilitiesOverdrafts and drawdowns in committed facilities £m (-ve) - (26.494) - 26.494 (26.494) - 26.494 (26.494) PFI / LIFT leases £m (-ve) (3.550) (3.898) - 3.898 (3.898) - 3.898 (3.898) Other borrowings £m (-ve) (4.074) (63.774) - 63.774 (63.774) - 63.774 (63.774) Other current liabilities £m (-ve) (175.701) (134.804) - 134.804 (134.804) - 134.804 (134.804) Total £m (183.325) (228.970) 0.000 228.970 (228.970) 0.000 228.970 (228.970)

Non-current LiabilitiesPFI / LIFT leases £m (-ve) (155.109) (151.211) - 151.211 (151.211) - 151.211 (151.211) Other borrowings £m (-ve) (67.462) (63.386) - 63.386 (63.386) - 63.386 (63.386) Other non-current liabilities £m (-ve) (6.295) (4.995) - 4.995 (4.995) - 4.995 (4.995) Total £m (228.866) (219.592) 0.000 219.592 (219.592) 0.000 219.592 (219.592)

Reserves £m (+ve) 374.413 315.394 291.744 (23.650) 315.394 291.744 (23.650) 315.394

Summary Statement of Cash Flows

Surplus (Deficit) from Operations £m (15.645) 0.414 - (0.414) (33.896) (41.018) (7.122) (33.896)

Operating activitiesNon-operating and non-cash items in operating surplus/(deficit) £m (+/-ve) 26.648 1.697 - (1.697) 17.350 14.955 (2.395) 17.350 Operating Cash flows before movements in working capital £m 11.003 2.111 0.000 (2.111) (16.546) (26.063) (9.517) (16.546)

Movements in working capital £m (+/-ve) 48.424 2.246 (7.173) (9.419) (29.445) (35.551) (6.106) (29.445) Increase/(Decrease) in non-current provisions £m (+/-ve) - (0.434) (6.295) (5.861) (1.300) (6.295) (4.995) (1.300) Net cash inflow/(outflow) from operating activities £m 59.427 3.923 (13.468) (17.391) (47.291) (67.909) (20.618) (47.291)

Investing activitiesCapital Expenditure (Accruals basis) £m (-ve) i (49.147) (3.262) - 3.262 (38.903) (23.883) 15.020 (38.903) Increase/(decrease) in Capital Creditors £m (+/-ve) (1.669) 0.100 - (0.100) 1.200 (0.051) (1.251) 1.200 Proceeds on disposal of PPE, intangible assets and investment property £m (+ve) 0.012 0.002 - (0.002) 0.021 0.001 (0.020) 0.021 Other cash flows from investing activities £m (+/-ve) 0.213 0.038 - (0.038) 0.220 (0.247) (0.467) 0.220 Net cash inflow/(outflow) from investing activities £m (50.591) (3.122) 0.000 3.122 (37.462) (24.180) 13.282 (37.462)

Financing activitiesPublic Dividend Capital repaid £m (-ve) - - - - - (9.400) (9.400) -Repayment of borrowings £m (-ve) i (1.285) - - - (3.883) (3.884) (0.001) (3.883) Capital element of finance lease rental payments £m (-ve) i (3.199) (0.296) - 0.296 (3.550) (3.253) 0.297 (3.550) Interest element of finance lease rental payments £m (-ve) i (23.443) (1.952) - 1.952 (23.414) (19.929) 3.485 (23.414) Interest paid on borrowings £m (-ve) (1.452) - - - (2.908) (3.546) (0.638) (2.908) Other cash flows from financing activities £m (+/-ve) 9.462 (1.787) - 1.787 50.561 89.606 39.045 50.561 Net cash inflow/(outflow) from financing activities £m (19.917) (4.035) 0.000 4.035 16.806 49.594 32.788 16.806

Opening cash and cash equivalents less bank overdraft £m (+/-ve) 54.526 (21.269) 14.418 35.687 43.453 43.445 (0.008) 43.453 Net cash increase / (decrease) £m (11.081) (3.234) (13.468) (10.234) (67.947) (42.495) 25.452 (67.947) Changes due to transfers by absorption £m (+/-ve) - - - - - - - -Closing cash and cash equivalents less bank overdraft £m 43.445 (24.502) 0.950 25.452 (24.494) 0.950 25.444 (24.494)

Financial Sustainability Risk Rating

Capital Service CoverRevenue Available for Capital Service £m 11.761 (3.350) (25.007) (21.657) (3.350) Capital Service £m (41.160) (46.190) (41.279) 4.911 (46.190) Capital Service Cover metric 0.0x 0.29 (0.07) (0.61) (0.53) (0.07) Capital Service Cover rating Score 1 1 1 1

LiquidityWorking Capital for FSRR £m (+/-ve) (41.663) (131.482) - 131.482 (131.482) Operating Expenses within EBITDA, Total £m (1,072.740) (1,027.865) (988.684) 39.181 (1,027.865) Liquidity metric Days (13.982) (46.050) - 46.050 (46.050) Liquidity rating Score 2 1 4 1

I&E MarginNormalised Surplus/(Deficit) £m (+/-ve) (47.067) (64.653) (76.229) (11.576) (64.653) Adjusted Total Income for FSRR £m (+ve) 1,084.751 1,025.415 964.779 (60.636) 1,025.415 I&E Margin % (4.34%) (6.31%) (7.90%) (1.60%) (6.31%)I&E Margin rating Score 1 1 1 1

I&E Margin VarianceI&E Margin % (6.31%) (7.90%) (1.60%) (6.31%)I&E Margin Variance From Plan % -4.37% (4.37%) -1.60% (4.37%)I&E Margin Variance From Plan rating Score 1 2 1

Overall Financial Sustainability Risk Rating Score 1 2 1

Continuity of Service Risk Rating Score 2

CIPs

CIPs as a percentage of opex within EBITDA less PFI expenses % 1.94% 12.62% 0.00% (12.62%) 7.43% 4.46% (2.97%) 7.43%CIPs £m (+ve) 20.160 11.141 - (11.141) 78.143 43.749 (34.394) 78.143

Appendix 1

Click to go to index

Targets and indicators as set out in the Risk Assessment Framework (RAF) - definitions per RAF Appendix ANOTE: If a particular indicator does not apply to your FT then please enter "Not relevant" for those lines.

Key:

Threshold or target YTD

Scoring Per Risk

Assessment Framework

Risk declared

Scoring Per Risk


Performance Declaration Comments / explanations

Scoring Per Risk



Scoring Per Risk



Scoring Per Risk



Scoring Per Risk


must completemay need to complete

Target or Indicator (per Risk Assessment Framework)

Referral to treatment time, 18 weeks in aggregate, incomplete pathways i 92% 1.0 Yes 1 0.0% Not met Data not submitted with agree 1 0.0% Not met Data not submitted with agree 1 0.0% Not met Data not submitted with agree 1 0.0% Not met Data not submitted with agree 1

A&E Clinical Quality - Total Time in A&E under 4 hours i 95% 1.0 Yes 1 89.9% Not met 1 91.8% Not met 1 89.3% Not met 1 83.4% Not met 1

Cancer 62 Day Waits for first treatment (from urgent GP referral) - post local breach re-allocation i 85% 1.0 Yes 84.6% Not met 86.4% Achieved 86.3% Achieved 89.4% Achieved

Cancer 62 Day Waits for first treatment (from NHS Cancer Screening Service referral) - post local breach re-allocation i 90% 1.0 No 95.5% Achieved 92.6% Achieved 97.5% Achieved 92.9% Achieved

Cancer 62 Day Waits for first treatment (from urgent GP referral) - pre local breach re-allocation i 0.0% 0.0% 0.0% 0.0%

Cancer 62 Day Waits for first treatment (from NHS Cancer Screening Service referral) - pre local breach re-allocation i 0.0% 0.0% 0.0% 0.0%

Cancer 31 day wait for second or subsequent treatment - surgery i 94% 1.0 No 98.8% Achieved 95.3% Achieved 98.8% Achieved 98.2% Achieved

Cancer 31 day wait for second or subsequent treatment - drug treatments i 98% 1.0 No 99.5% Achieved 100.0% Achieved 100.0% Achieved 100.0% Achieved

Cancer 31 day wait for second or subsequent treatment - radiotherapy i 94% 1.0 No 100.0% Achieved 100.0% Achieved 99.4% Achieved 99.1% Achieved

Cancer 31 day wait from diagnosis to first treatment i 96% 1.0 No 0 98.4% Achieved 0 99.3% Achieved 0 99.3% Achieved 0 98.1% Achieved 0

Cancer 2 week (all cancers) i 93% 1.0 No 97.0% Achieved 97.5% Achieved 95.1% Achieved 93.1% Achieved

Cancer 2 week (breast symptoms) i 93% 1.0 No 99.1% Achieved 99.2% Achieved 98.7% Achieved 91.6% Not met

Care Programme Approach (CPA) follow up within 7 days of discharge i 95% 1.0 N/A 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant

Care Programme Approach (CPA) formal review within 12 months i 95% 1.0 N/A 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant

Admissions had access to crisis resolution / home treatment teams i 95% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0

Meeting commitment to serve new psychosis cases by early intervention teams OLD measure - use until Q1 2016/17 i 95% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0

Ambulance Category A 8 Minute Response Time - Red 1 Calls i 75% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0

Ambulance Category A 8 Minute Response Time - Red 2 Calls i 75% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0

Ambulance Category A 19 Minute Transportation Time i 95% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0

C.Diff due to lapses in care (YTD) i 72 1.0 Yes 1 28 Not met 1 47 Not met 1 67 Not met 1 82 Not met 1

Total C.Diff YTD (including: cases deemed not to be due to lapse in care and cases under review) i 0 0 0 0

C.Diff cases under review i 0 0 0 0

Minimising MH delayed transfers of care i <=7.5% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0

Meeting commitment to serve new psychosis cases by early intervention teams NEW measure (scored from Q4 2015/16) i 50% 1.0 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant 0

Improving Access to Psychological Therapies - Patients referred within 6 weeks NEW measure (scored from Q3 2015/16) i 75% 1.0 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant 0 0.0% Not relevant 0

Improving Access to Psychological Therapies - Patients referred within 18 weeks NEW measure (scored from Q3 2015/16) i 95% 1.0 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant 0 0.0% Not relevant 0

Data completeness, MH: identifiers i 97% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0

Data completeness, MH: outcomes i 50% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0

Compliance with requirements regarding access to healthcare for people with a learning disability i N/A 1.0 No 0 N/A Achieved 0 N/A Achieved 0 N/A Achieved 0 N/A Achieved 0

Community care - referral to treatment information completeness i 50% 1.0 N/A 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant

Community care - referral information completeness i 50% 1.0 N/A 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant

Community care - activity information completeness i 50% 1.0 N/A 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant

Risk of, or actual, failure to deliver Commissioner Requested Services N/A N/A No No No No

Date of last CQC inspection i N/A N/A 13/04/2015 13/04/2015 13/04/2015 13/04/2015

CQC compliance action outstanding (as at time of submission) N/A N/A No Final CQC Inspection Report pending Yes Yes Yes

CQC enforcement action within last 12 months (as at time of submission) N/A N/A No No No No

CQC enforcement action (including notices) currently in effect (as at time of submission) N/A N/A No Final CQC Inspection Report pending No No No

Moderate CQC concerns or impacts regarding the safety of healthcare provision (as at time of submission) i N/A N/A No Final CQC Inspection Report pending No We have requirement notices in place and must do's which we ar No We have requirement notices in place and must do's which we ar No We have requirement notices in place and must d

Major CQC concerns or impacts regarding the safety of healthcare provision (as at time of submission) i N/A N/A No Final CQC Inspection Report pending No No No

Overall rating from CQC inspection (as at time of submission) i N/A N/A N/A Final CQC Inspection Report pending Requires improvement Requires improvement Requires improvement

CQC recommendation to place trust into Special Measures (as at time of submission) N/A N/A No No No No

Trust unable to declare ongoing compliance with minimum standards of CQC registration N/A N/A No No No No

Trust has not complied with the high secure services Directorate (High Secure MH trusts only) N/A N/A N/A N/A N/A N/A

Results left to complete:0 i 0 0 0 0

Checks Count:0 i

Checks left to clear:0 i OK

Service Performance Scorei 4 4 3 3 4

0

0

0

Report by Exception

0

1

0

0

0

Quarter 2

0

0

0

0

0

0

Quarter 3

0

0

0

Declaration of risks against healthcare targets and indicators for 201516 by King’s College Hospital NHS Foundation Trust

1

0

0

0

0

0

0

Quarter 4

1

Annual Plan Quarter 1

Appendix 2

1

Governors’ Membership & Community Engagement Committee Minutes of the meeting held at 11:30 on 18 February 2016, in the Dulwich Meeting Room, King’s College Hospital, Denmark Hill

Members: Fiona Clark (FC) Public Governor/ Committee Chair Penny Dale (PD) Public Governor Chris North (CN) Public Governor (Lead Governor) Pida Ripley (PR) Patient Governor Tom Duffy (TD) Patient Governor Barbara Pattinson (BP) Public Governor Jan Thomas (JT) Patient Governor In attendance: Tim Bradley Patient Governor Jessica Bush (JB) Head of Engagement and Patient Experience Petula Storey (PS) Head of Volunteering Sally Lingard (SL) Director of Communications Sarah Willoughby (SW) Stakeholder Relations Manager Tamara Cowan (TC) Board Secretary Jane Badejoko (JB1) Corporate Governance Officer (minutes) Nicola Kingston (NK) External Speaker (SLIC)- Item 2.1 only Valerie Dinsmore (VD) Integrated lead for Customer Engagement, Health and Wellbeing

Board - Item 2.1 only Rachel Rundquist PPI & Membership Team Intern Apologies: Andrew McCall (AM) Public Governor Phidelma Lisowska (PL) Joint Staff Governor

Item

Subject

Action

016/01 Welcome and apologies Apologies for absence were noted.

016/02 Minutes of the Previous Meeting The minutes of the previous meeting were approved as a correct record.

016/03 Action Tracker The action tracker was noted.

016/04 MEMBERS IN FOCUS

016/05 External Speakers from the Citizens Forum The Committee welcomed Nicola Kingston and Valerie Dinsmore from Southwark and Lambeth Integrated Care (SLIC) citizens’ forum.

Enc. 4.3.1

2

Item Subject

Action

The following key points were reported: SLIC is a partnership organisation between the local GP Federations, the

three local NHS Foundation Hospital Trusts which include Guy’s and St Thomas’ (GSTT) NHS Foundation Trust, South London & Maudsley NHS Foundation Trust and King’s College Hospital NHS Foundation Trust and Southwark and Lambeth Clinical Commissioning Groups and Southwark and Lambeth local authorities and people in Southwark and Lambeth localities with support and funding from the GSTT Charity;

The organisation was created 3 years ago to form a common discussion

platform between health, social care providers, voluntary sector organisations and local people, with the aim to work together on integrated care and improve the way care is delivered in the community;

SLIC was given start-up funding from the GSTT charity which will end in

March 2016. But there are plans for the organisation to continue under in new format of a Strategic Partnership. The work on integrated care is ongoing and there is need for continued co-operation between local health and social care providers and the public;

SLIC is governed by a citizens Board which is composed of 19 members

who are a mix of volunteer citizens from Southwark and Lambeth, Healthwatch Lambeth and Southwark staff and CCG staff, they meet monthly with Sir Ron Kerr serving as the meeting Chair;

The meetings include discussions on various health issues and detailed

discussions on how to best redesign the whole system to make it fit for purpose;

The following key points were discussed and noted: SLIC as an independent organisation has been providing a unique benefit

to the local community by collecting information on services available locally and passing this onto on to members of the public when required;

South East London as sector must work together to improve healthcare and

provision to local residents that will include cooperation between hospital, General Practitioners (GP), community care providers, the voluntary sector and social housing organisations;

Lessons on joint up working can be learned from the voluntary and faith

sectors which are an excellent source of learning provide all partners are willing to work together; and

It was noted that SLIC citizens Board has no influence over how services

are provided or run but it does feedback public views/experiences to providers via its open meetings.

016/06 Stakeholder Update The Committee received the stakeholder update from Sarah Willoughby.

Enc. 4.3.1

3

Item Subject

Action

The following key points were reported: The stakeholder team attended a number of events at Lambeth, Lewisham and Southwark in November 2015. Also in attendance were local authority staff, Clinical Commissioning Group (CCG) staff and NHS England representatives, the main topic was strategic updates and discussions on the future of healthcare; and

The team also scheduled a number of face to face meetings between Nick

Moberly, Chief Executive Officer and Ministers of Parliaments (MP) and the new the Chief Executive Officer for NHS improvement agency Jim Mackey.

016/07 Update on Transport Matters

The Committee received the Transport update from Sarah Willoughby. The following key points were reported: Transport for London (TFL) published a commissioner report at the end of

2015 indicating their proposed intensions to proceed with the Bakerloo line extension via Old Kent Road and not via Camberwell which was considered as a possible line extension. The announcement did not include a start date for the construction work. However, the report does state that there is need to improve South East London travel links and reduce the congestion on Walworth Road;

The Trust will be liaising with TFL and putting forward an evidence based case to support the Bakerloo line extension via Camberwell, which would be beneficial to local residents and provide easy access to the Denmark Hill site and improved transport links to the whole area;

Southwark Council has announced it will be developing a business case for the proposed re-opening of Camberwell Rail station which was closed in 1916; and

Bromley bus services are running a consultation on proposed bus route

changes to buses R11 and R3. The changes will bring about ease of travel between the Princess Royal University Hospital (PRUH) and the Orpington site.

The following key points were discussed: Previously the Trust’s ran a transport feeder group which reported into this

Committee. The feeder group discussed transport matters but was disbanded in 2014 due to low Governor attendance.

The oversight function for all transport matters then reverted to this Committee. Accordingly, transport matters has been a regular feature on the Membership & Community Engagement Committee (MCEC).

A detailed discussion ensued with options such as reinstating the transport group or amending the name of MCEC to include the word ‘transport’. It was agreed that the word ‘community’ in MCEC embraced transport matters and that the current coverage of transport matters was sufficient and not necessitating re-establishing a separate transport group;

Enc. 4.3.1

4

Item Subject

Action

The Trust is currently running a short survey jointly with SLAM and local interest groups open to all staff, patients and local people who visit the site. The aim of the survey is to form part of the evidence based case that will be presented to TFL in the attempt to lobby for the Bakerloo line extension via Camberwell; To ensure the survey provides a true reflection of patient’s opinions the Trust will be holding an onsite survey day at Denmark Hill on 25 February 2016. Paper based surveys will be available to patients and the Trust volunteers will be available to assist patients and visitors; and The Bromley bus consultation will close at the end of March 2016, further updates will be provided to the Committee in due course.

It was agreed that the Committee would: 1) Receive the results from the transport survey and a written report on

transport matters; and

2) Retain its current name and transport matters would be a feature of each meeting.

SW

016/08 Membership Update The Committee received the Membership Update Report from Jessica Bush. The following key points were reported: The Trust’s membership remains stable and annual targets have largely

been met. The Trust will be looking to increase its membership numbers in Lambeth constituency and young members from all constituencies; and

The Trust will be submitting the annual membership report to Monitor at the

end of March 2016. The report will be accompanied by a narrative summary, this is a new reporting feature.

016/09 Young Person’s Involvement at Bromley College The Committee received the Young person’s report from Jessica Bush. The following key points were reported: The Trust interacted with students at Bromley College in 2015, this was

brought about following the successful collaboration between the Trust and Lambeth College;

The collaboration proved to be successful and provided the Trust with an

insight into young adults’ interest. Students were divided into 5 teams and asked to update the Trust’s young adult members recruitment poster; and

The results were very encouraging and the Trust was delighted that they all

selected the NHS blue as the colour of preference. They also suggested the poster should include social media links and list the benefits of being a member examples, work experience, voluntary possibilities and any discounts available.

Enc. 4.3.1

5

Item Subject

Action

The following key points were discussed: The Trust has taken all the useful information on board and the next stage

would be to produce the poster. There are also discussions taking place on the possibility of advertising the fact that NHS Discounts national scheme is available to Trust members;

It was noted that members of NHS Trusts are able to register and receive the benefits of NHS discounts scheme; and

The Trust will be doing a call out to all members, asking for anyone with design skills who would like to assist with the production of the new posters.

016/10 Update on Volunteers The Committee received an update of Trust Volunteers from Jessica Bush. The following key points were reported: The Trust volunteers are not automatically enrolled as Trust members, they

have to complete a form to requesting to become members. This is different from staff who are automatically enrolled as members;

The Trust’s Volunteer programme is being reviewed as a whole to make

sure all information is stored at a single point and volunteer numbers and placements are easily accessible; and

The volunteer programme review will also look at the possibility of an option

to register as a Trust member on the volunteer application form at the earliest stage of the application process.

016/11 Governor Contribution to @King’s Magazine The Committee received an update on @King’s magazine from Sally Lingard. The following key points were reported: The Trust will publish 3 @King’s magazine per financial year, this means

that the next issues of @King’s magazine will be in the new financial year post April 2016; and

The next issue will focus on the upcoming Governor election. The following key point was discussed: It was noted that in the past Governor contributions to the magazine had

been re-written, it was agreed that while in some circumstances the Trust may need to edit and reduce the governor contribution to ensure it fits in with the permitted wording count but if this is done the contributing Governor will always be consulted prior to publication.

016/12 Governor Engagement & Involvement Report The Committee noted the governor engagement and involvement report.

Enc. 4.3.1

6

Item Subject

Action

016/13 Membership Community Event The Committee received information about the Trust upcoming Community events from Sally Lingard. The following key points were reported:

The Trust will be holding 2 community events in March, with the first taking place on Thursday 3 March from 5pm at Bromley Central Library, High St, Bromley BR1 1EX.

The second event will be held on Wednesday 9 March from 5pm Cambridge House, 1 Addington Square, London SE5 0HF;

The events are an opportunity for the Trust to interact with Trust members

and patients and have discussion sessions on key issues and developments over the past year and Trust plans for the year ahead; and

The Trust requires Governors to attend the event to engage with members

and give a short presentation on the role of a Governor.

016/14 Committee Work Plan 2016 The Committee approved the work plan.

016/15

Month 9 Finance and Performance Reports

The Committee received and noted the finance and performance reports for month 9. The Committee decided to no longer receive the Finance and Performance reports as these reports are presented at the monthly Trust Board of Directors meeting.

016/16 Any Other Business

There were no items of any other business raised for discussion.

016/17

Date of Next Meeting The next meeting will be held on Thursday, 14 April 2016, from 11:30-13:30 in Dulwich Committee Room.

Enc. 4.3.1

1

Governor Strategy Committee Minutes of the meeting of the Governors’ Strategy Committee held at 15:30-17:30 on Monday, 15 February 2016 in the Dulwich Committee Room, King’s College Hospital, Denmark Hill. Members: Andrew McCall (AM) Committee Chair Barbara Pattinson (BP) Public Governor Chris North (CN) Public Governor Fiona Clark (FC) Public Governor Nanda Ratnavel (NR) Public Governor Penny Dale (PD) Public Governor Phidelma Lisowska (PL) Joint Staff Governor Pida Ripley (PR) Patient Governor Tom Duffy (TD) Patient Governor In attendance: Alan Goldsman (AG) Acting Director of Strategy David Dawson (DD) Deputy Director of Strategy Colin Gentile (CG) Chief Financial Officer Joe Farrington-Douglas (JFD) Senior Strategy Advisor Tamara Cowan (TC) Board Secretary Tim Bradley (TB) Public Governor Cllr Jim Dickson (JD) Cabinet Member for Health & Wellbeing, London Borough of

Lambeth (Item 2.1 only) Sarah Willoughby (SW) Stakeholder Relations Manager Silviyana Yankova (SY) Corporate Governance Assistant (Minutes) Apologies: Lord Kerslake (BK) Trust Chair Trudi Kemp (TK) Director of Strategy Judith Seddon (JS) Acting Director of Corporate Affairs Jill Solly (JS1) Head of Primary/Secondary Care Interface Jan Thomas (JT) Patient Governor

Item

Subject Action

16/1 Welcome and Apologies The Committee Chair welcomed members and attendees to the Governor Strategy Committee meeting and the apologies for absence were noted.

16/2 Minutes of the Previous Meeting The minutes of the meeting held on 22 October 2015 were approved as a correct record.

16/3 Action Tracker The Committee noted the action tracker and the following updates: Action Item 15/04, Aims and Forward Plan of the Committee - It was

Enc. 4.3.2

2

Item Subject Action

agreed that this item would be removed from the action tracker as the Committee Chair received feedback from Committee members;

Action Item 15/37, 7-Day Working – It was noted that it would be useful to

have contribution from Prof. Julia Wendon relating to 7-day working at a future Governor Workshop.

JW

16/4 Integration of Health and Social Care Services in Lambeth The Committee received and noted the presentation from Cllr Jim Dickson relating to the integration of health and social care services in Lambeth. The following key points were reported: The integration initiative aims to improve the outcomes for vulnerable adults in

Lambeth and deliver cashable savings best achieved by integrating commissioning and services supported by wider partnerships with health providers;

The purpose of the Southwark and Lambeth Strategic Partnership is to align

key strategies and build a shared vision of integrated care as well as sharing best practices;

The partnership aims to address various matters of people using or working in

health and social care services in Lambeth and Southwark; The Committee in Common has been established with a shared governance

framework looking at how budgets are spent and commissioning for Mental Health and Older People;

The integrated reablement has been commissioned in partnership with Guy’s

and St Thomas’ NHS Foundation Trust (GSTT) ensuring people well-being and independence;

The partnership is creating a unified point of access for health and care

community independent services via locality care networks; Another focus of the initiative is to mainstream successful Southwark and

Lambeth Integrated Care (SLIC) projects and continue to test locality geriatricians and primary care holistic assessments;

Various approaches to support residents have been implemented in particular

improving mental healthcare deals for BME residents; The following key points were discussed: Appropriate actions have been taken to minimise delays in transfer of care by

providing people with the right care as well as offering appropriate health packages; and

Over the past few years facilities for disabled people have been closed or

consolidated into one improved and integrated centre.

16/5 Strategic Planning Update (Where Are We Now?) The Committee received an overview of the current strategic planning aims and related issues.

Enc. 4.3.2

3

Item Subject Action

The following key points were reported: In accordance with Monitor requirements, the Trust has to produce a 2016/17

operational plan which will be submitted on 11 April 2016. The key issue is that the organisation needs to achieve a better alignment across the healthcare sector as a whole;

The NHS is moving towards a place-based system of commissioning where

NHS commissioners and providers come together to deliver best value through collaborative planning;

An affordability gap of £818m has been identified across the healthcare sector

over the next five years. Key emerging strategies to address the affordability gap include three broad

approaches: - There is an expectation that individual organisations will scrutinise costs,

limiting waste and applying good business practices which should help achieve 2% efficiency;

- The productivity at scale approach is looking at using the combined power

of the South East London health sector to improve clinical and non-clinical services; and

- Ensuring organisations are optimising workforce across the sector.

There are significant strategic planning initiatives across the healthcare sector

and the Trust needs to participate actively in the alignment process and ensures that its strategy is in alignment with the external healthcare environment.

16/6 Trust Strategic Vision/Mission (Triangle) The Committee received and discussed the Emerging Trust Strategy. The report provides clear strategic objectives allowing the Trust to transform into an organisation that is financially sustainable, operationally efficient and offering outstanding care for patients across all services. The following key points were reported: The Trust aims to articulate a shared understanding of key principles to set

clear organisational purpose and forward strategy. The overall goals will be translated into annual operational objectives at each level of the organisation, clearly communicating them so they are owned at the frontline;

The Trust is moving very determinately towards the deficit target of £65m by

the end of the financial year and there has been a significant proportion of cost improvement plans (CIPs) delivered to date;

The organisation has improved working across sites and management teams

are developing a new organisational structure;

It is vital to maintain and improve “grip” by gaining control of finances and continue addressing key clinical and operational performance issues;

Enc. 4.3.2

4

Item Subject Action

The Trust needs to continue implementing significant systemic changes by strategic alignment, building skills and transforming services;

It was highlighted that the long-term sustainability across South East London

healthcare system can be achieved by working closely; The Trust will attract and retain outstanding people across clinical and non-

clinical services by offering great development opportunities and talent management;

The introduction of a “clean sheet” approach aims to systematically redesign

clinical services and consistently deliver outstanding quality that is ‘best in class’ and efficient;

The “Triangle” is a tool which will support clarity of the Trust’s mission, forward

objectives and support delivery of the best quality of care. The following key points were discussed: The Committee responded positively to the Trust’s forward initiatives and

noted that the changes will boost staff morale and organisational culture; and The Trust is aiming to embed performance management culture and systems

across the wards and offer staff opportunities for training and continuous development.

It was agreed that the objectives and milestones underpinning the “Triangle” would be discussed further at the Council of Governors meeting.

DD

16/7 Update on Financial Plan, CIPs & Transformation The Committee received and noted the Financial Plan, CIPs and Transformation update. The following key points were reported: The Trust remains focused on delivering its £65m deficit target for 2015/16; The Trust is £71.9m overspent at month 9; The organisation is aiming to implement a mitigation plan to successfully

manage the deficit target. The success of the plan will require particular emphasis on CIPs delivery and managing the risk of penalties from NHS England;

Current mitigation plans will generate between £19m to £22.6m of financial improvement;

It is crucial for the Trust to deliver its £65m deficit target which would unlock

goodwill;

A letter was sent from the system out to large acute Trusts delivering care offering a proportion of £1.6bn sustainability and transformation funding;

The proposed plan does not require funding to be spent on waiting lists and other related issues. The funding would be distributed to the bottom line to improve providers’ position;

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The Trust has been offered £30m funding however the underlying condition is that the Trust would be required to deliver £4m surplus and operational improvements are required primarily on waiting times and A&E;

The Trust realises that achieving financial and service delivery as well as good

quality and patient experience is challenging especially with further cost savings;

It was agreed that Governors will have an opportunity to input into the Operational Plan at the Council of Governors meeting.

SY

16/8 KHP Update The Committee received and noted the KHP update. It was highlighted that a session on KHP Institutes would be organised at a later date.

16/9 Horizon Scan The Committee noted the Horizon Scan update and the relevant strategic issues. The following key points were reported: There have been significant changes across the external healthcare

environment mainly focusing on financial, regulatory and planning frameworks. The front-loaded funding has been taken away from the frontline and healthcare providers need to meet certain criteria to obtain the additional funding;

For the first time Commissioners and NHS providers are working on the same

framework and timetables for annual planning and must demonstrate robust plans to meet financial control targets in order to qualify for additional financial support; and

The newly implemented regulatory framework across the healthcare sector is closely aligned with the system for Commissioners and NHS England which is aiming to bring together quality and finance.

16/10 Draft Work Plan for Governors’ Strategy Committee for 2016 The Committee noted the draft work plan for 2016 and the Committee Chair thanked members for their contribution.

16/11 Finance and Performance Reports (M09) The Committed received and noted the Finance and Performance reports for month 9.

16/12 Any Other Business There were no matters of any other business to discuss.

16/13 Date of Next Meeting The Governor Strategy Committee meeting will be held on 14 April 2016 at 14:30 in the Dulwich Committee Room, Denmark Hill.

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Governors’ Patient Experience & Safety Committee Minutes of the meeting held at 9.00am on 18 February 2016 in the Dulwich Committee Room, King’s College Hospital Members:

Tom Duffy (TD) Patient Governor, Committee Chair Pida Ripley (PR) Patient Governor Jan Thomas (JT) Patient Governor Penny Dale (PD) Public Governor – Bromley Chris North (CN) Public Governor – Lambeth Tim Bradley (TB) Public Governor – Lewisham Victoria Silvester (VS) Public Governor – Southwark Roger Engwell (RE) Staff Governor – Admin & Clerical Nicky Hayes (NH) Staff Governor – Nursing Midwifery In attendance:

Judith Seddon (JS) Associate Director of Governance Jessica Bush (JB) Head of Public & Patient Involvement Maxine Spencer (MS) Director of Midwifery & Head of Gynae Nursing Geraldine Walters (GW) Executive Director of Nursing & Midwifery Richard Hinckley (RH) Head of Patient Safety & Risk Management Tooba Ahmadi (TA) Corporate Governance Officer (minutes) Apologies:

Derek St Clair Cattrall (DC) Patient Governor Craig Jacobs (CJ) Patient Governor Jo Millett (JM) Staff Governor – Nursing & Midwifery Phidelma Lisowska (PL) Joint Staff Committee Faith Boardman (FB) Non-Executive Director Item Subject Action

016/00 Welcome, introduction and apologies

Apologies for absence were noted.

016/01 Minutes of the previous meeting – 08/10/2015

The minutes of the previous meeting were approved as a correct record subject to amending the constituency for Tim Bradley to Public Governor – Lewisham.

016/02 Action Tracker/Matters Arising

The Committee noted the action tracker.

PATIENT EXPERIENCE

016/03 Patient Experience/ Video Story

The Committee watched a video of a patient relaying her experience following the birth of her two children. The patient’s story highlighted issues with the

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Item Subject Action

lack of professionalism, communication and attention from the midwife during her first labour.

The patient also described her positive experience through the ‘caseload midwifery’ care, which provided continued care throughout her pregnancy. The patient felt satisfied of her care following the birth of her second child and suggested that patients should be asked for feedback about their experience during labour and how the midwives performed soon after birth, whilst the experience is still fresh.

Governors raised the following points in discussions:

It is important patient video stories are shared with staff so lessons can be learnt;

There are some powerful themes coming from this patient story and it is important patient stories are shared with staff so lessons can be leant, in particular with those staff directly involved with the care;

It was highlighted that the maternity team works very hard to drive improvements through various initiatives with limited resources. There has been significant improvement in the vacancy rates and the Trust is continuing to ensure the core staff are in post;

Governors commented that the patient video stories should be shorter and snappier. Governors also appreciated the hard work that goes into producing the video from a raw recording with limited resources, time and media expertise;

However, the external review of the Communication’s team, which is

currently being undertaken, should consider providing support to internal patient communication and information such as video stories;

Governors noted the ‘whose shoes’ initiative, which was launched at

the recent Stakeholder Events. The responses from the event were collected and transferred into a poster to bring maternity patient experiences to live; and

The Trust is also in the process to address a number of issues and

pledges that were identified from the ‘whose shoes’ initiative. This is the beginning of a significant strategy to transform care.

016/04 National Maternity Survey Results 2015

Maxine Spencer, Director of Midwifery presented the results of the Care Quality Commission (CQC) 2015 National Maternity Survey and the Trust’s performance. This was the first maternity survey results as an enlarged

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organisation where all women (excluding under 16s) who had live births at the Trust in February 2015 were surveyed.

The following key points were noted:

The Trust’s response rate was 38% compared to 41% nationally and the overall performance was rated Amber ‘same as expected’;

Out of 24 comparable indicators, the Trust improved on 14, performed same on one indicator and scored less well for eight indicators;

Overall DH performed slightly better than the PRUH. The Oasis

birthing centre at the PRUH is performing well and the Trust is pushing the use of this facility further;

The top performing trust scored an overall rating of 49, lowest

performing trust 43 and King’s overall rating was 46. Therefore, there is a very small margin that the Trust could push to improve and initiatives such as ‘continuity of care’ and ‘whose shoes’ are important to help the Trust drive further improvements;

Governors raised concern on scores relating to ‘care in hospital after birth’ question, which was rated Red. The Trust is working to address a number of issues and streamline various processes, in particular reducing the unproductive admin processes that a very busy team is encumbered with; and

The Trust is also providing five midwives a two day accredited course to improve their skills and help new mothers with their breastfeeding.

The Committee commended and thanked MS for presenting the patient video story and the maternity survey results as well as her transformational work in ‘whose shoes’ initiative.

PATIENT SAFETY & RISK MANAGEMENT

016/05 Patient Safety Update and Safer Surgical Checklist

The Committee received a comprehensive report on patient safety at the Trust, highlighting the safety culture and systems that are embedded within the Trust to ensure patient safety. The following key points were noted:

The Adverse Incident (AI) reporting rate is relatively high and consistent between sites with the proportion of low grade incidents increasing;

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The proportion of AIs with significant harm is decreasing and the 2014 staff survey results indicated strong performance in AI management with 99% of staff knowing how to report an AI;

Surgical Safety was chosen as a Quality Priority for 2015-16 and

there has been significant improvement following the implementation of a number of initiatives. There are fewer surgical never events occurring in theatre settings now;

However, further improvements can be delivered; therefore surgical

safety will be carried forward as a quality priority for 2016-17;

Improvements will be measured against a number of Key Performance Indicators including zero surgical never events and 100% compliance with completion of safer surgical checklist;

Medication safety was another quality priority in 2015-16. All outcome

measures were achieved with the exception of ‘reducing incidents involving 10-fold errors’;

Medication Safety will be taken forward as a quality priority for 2016-17. A number of improvement initiatives such as the introduction of an escalation pathway when drug is not available timely have been identified to drive further improvement;

Falls and pressure ulcers continue to remain an issue and this is

reflective of increased complexity and acuity of the patients at the Trust;

VTE is another area of concern and further work in relation to VTE

risk assessment in elective orthopaedics is underway; and

There had been a decrease in the number incidents involving deteriorating patients. However, this has increased at the PRUH during the reporting period and a number of actions are being taken to mitigate against the risk. This includes tracking of emergency laparotomy post-operative and the pilot of iMobile referral pathway at DH.

In response to Governors comments the following key points were noted: The feedback from the recent CQC inspection found the Trust to

have robust governance structures to investigate AIs. However, communicating learnings to staff was flagged as an issue;

This has been added as a ‘should do action’ and a number of improvement initiatives have already been put in place to ensure learnings from complaints and AIs are part of the culture;

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Item Subject Action

Grip socks are provided to patients at risk of falls and pressure ulcers are assigned to the community, if the patient comes to the Trust with a pre-existing pressure ulcers;

In ophthalmology changes have been made to improve the service.

This includes appointing a Clinical Director for the service who is driving cohesive behaviours and standardisation of IT systems and equipment across sites;

It is difficult to bench mark ‘10-fold errors’ as allergy data are not

coordinated nationally and information is not easily accessible; and

Never Event will form part of the doctors’ appraisal and revalidation process. A list of all surgeons with zero never events are published to encourage peer pressure improvement; and

Staff are informed about never events through speciality, safety and

local ward level meetings to ensure key messages reach all front line staff. There is also staff alert through regular newsletters and bulletins.

016/06 Trust Quality Priorities 2016/17

The Committee received the review of the Trust performance against the 2015-16 quality priorities and the proposed quality priorities for 2016-17.

The following key points were noted: On the whole performance against 2015-16 priorities have been

mixed with most of the objectives in progress;

The Committee noted the detailed performance and Red Amber Green (RAG) rating against each objective in each of the quality priority domains;

Governors noted the proposed long list of priorities in each quality

domain for 2016-17 as outlined below. This has been sent to stakeholders for their input and the Committee was also asked for their comments and suggestions; Outcomes

o Improving outcomes for patients with sepsis o Improving outcomes for patients undergoing emergency

abdominal surgery o Improving outcomes for patients following planned major

surgery Safety

o Never Events –“improve safety in invasive procedures”.

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Item Subject Action

o Sepsis – “improvement of its recognition, management and escalation”

o Reduce Medication Omissions Experience

o Improving staff health and wellbeing to improve patient experience

o Improving outpatient experience o Improving accessible information for disabled people

Governors were supportive of all the proposed priorities for 2016-17. The following additional comments and suggestions were noted:

The Trust should avoid lighter life style changes such as smoking and alcohol. There should be more focus on clinical issues;

Issues in relation to front line services were raised at the Annual Members Meeting in September. Therefore, the Trust should consider front line services such as administration and appointment process issues as a quality priority to improve patient experience;

It was commented the front line service issues could possibly tie in with accessible information but there should be greater focus on getting the communication right;

Accessible information should be available for all patients and not just the disabled patients; and

The Trust’s performance in infection control is satisfying and as infection control is given a key focus at the weekly Executive meetings and in balancing with other priorities, it may not be appropriate as a priority this year.

The Committee recommended the proposed priorities to the Council of Governors and it was noted that the Council will be asked to select and ratify the mandated quality priority at its meeting on 17 March 2016.

GOVERNOR INVOLVEMENT UPDATES

016/07 Serious Complaints Committee (SCC)

The Committee received and noted the agenda from the Serious Complaints Committee (SCC), which is attended by a Governor representative on regular basis. The SCC met on 15 October 2015 and discussed the response time to complaints in detail, which is still a significant issue for the Trust. The Committee also received a presentation and case study on Networked Services.

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Item Subject Action

016/08 Patient Experience Committee (PEC)

The Governor representatives of the Patient Experience Committee (PEC) reported that the Committee met on 27 January 2016 and it was highlighted that the PRUH performance in the national maternity survey was in par with DH site.

There are a number of unregistered maternity patients that end up at the Trust, in particular at the PRUH. The Trust is aware of the issues in relation to maternity service and a number of actions are being undertaken to address the issue and improve performance.

016/09 Commissioners Quality Review Group (CQRG)

The Governor representative of the Commissioner Quality Review Group (CQRG) reported that the Group met in January and discussed a number of items including an update from the Trust on the CQC action plan. The CQRG is a Committee of the Commissioners with a long membership list, which includes GPs. It is a very different Committee compared to any Trust committees and there is no consistency of attendees.

016/10 Quality and Governance Committee (QGC)

This was the first Board Committee attended and observed by a Governor. It was a very useful meeting and provided the opportunity to observe the Non-Executive Director (NED) in action. There was a significant amount of challenge from the NEDs on various issues including lack of isolation facility at NICU, providing training to non-compliant staff and complaints performance. It was suggested that there should be a nominated clinical lead for each patient complaint and this should form part of their continued professional development (CPD).

FOR INFORMATION

016/11 Governor Involvement Activities

The Committee received and noted the Governor Engagement Report for the period 1 November 2015-11 February 2016.

016/12 Finance & Performance Report

The Committee received and noted the month 9 Finance and Performance Report.

016/13 Monthly Patient Experience Report

The Committee received and noted the monthly Patient Experience Report for December 2015.

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Item Subject Action

016/14 Committee Workplan 2016

The Committee received and noted its work plan for 2016.

016/15 ANY OTHER BUSINESS

There were no matters of any other business raised for discussion.

016/16 DATE OF NEXT MEETING

Tuesday, 19 April 2016, 17:30-19:30 in the Dulwich Committee Room

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