TRUST BOARD MEETING IN PUBLIC AGENDA · 2017. 12. 4. · Page 1 of 2 TRUST BOARD MEETING IN PUBLIC AGENDA 07 December 2017 at 9.30am ± 12.00noon Terrace Executive Meeting Room, Spice

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TRUST BOARD MEETING IN PUBLIC

AGENDA

07 December 2017 at 9.30am – 12.00noon

Terrace Executive Meeting Room, Spice of Life Restaurant, Watford Hospital

Apologies should be conveyed to the Trust Secretary, Jean Hickman on [email protected] or call 01923 436 283

Item ref

Title Objective Previously presented

Lead Paper or verbal

01/54 Opening and welcome

To note N/A Chair Verbal

02/54 Integrated diabetes service To receive N/A Chief Nurse Presentation

ADMINSTRATION

03/54 Apologies for absence Katie Fisher


04/54 Conflict of interests To note N/A Chair Paper

05/54 Minutes of the meeting held on 02 November 2017

For approval

N/A Chair Paper

06/54 Board action log from 02 November 2017 and previous meetings and decision log

To note N/A Chair Paper

07/54 Chair’s report

For information

N/A Chair Paper

08/54 Chief Executive’s report For information

N/A Chief Executive

Paper

PERFORMANCE

09/54 Integrated performance report – month 7

For information

Trust Executive Committee

Chief Operating Officer

Paper

10/54 Winter readiness briefing For information



Paper

SAFE EFFECTIVE CARE (BAF RISK 1)

11/54 Quality improvement plan update

For information

and assurance


Chief Nurse

Paper

12/54 Annual maternity establishment review

For information

and assurance

Patient and Staff Experience Committee

Chief Nurse Presentation

AGENDA

1 of 125Trust Board Meeting in Public-07/12/17

Page 2 of 2

DELIVER A LONG TERM STRATEGY (BAF RISK 9)

13/54 Strategy update – month 8 For information


Deputy Chief Executive

Paper

COMMITTEE REPORTS

14/54 Assurance report from the Finance and Investment Committee

For information

and assurance

Finance and Investment Committee

Committee Chair/ Chief Financial

Officer

Paper

15/54 Assurance report from the Patient and Staff Experience Committee

For information

and assurance


Committee Chair/Director of

Human Resources

Paper

16/54 Assurance report from the Clinical Outcomes and Effectiveness Committee

For information

and assurance

Clinical Outcomes and Effectiveness Committee

Committee Chair/Chief Nurse

Verbal

GOVERNANCE

17/54 Corporate governance meeting schedule

For information


Trust Secretary Paper

REPORT TO CORPORATE TRUSTEE

18/54 Assurance report from the Charitable Funds Committee

For information

and assurance

Charitable Funds

Committee

Committee Chair/ Director of

Communications

Verbal

ANY OTHER BUSINESS

19/54 Any other business previously notified to the Chairman

N/A N/A Chair Verbal

QUESTION TIME

20/54 Questions from Hertfordshire Healthwatch

To receive

N/A

Chair Verbal

21/54 Questions from our patients and members of the public

To receive N/A Chair Verbal

ADMINISTRATION

22/54 Draft agenda for next board meeting

To approve N/A Chair Paper

23/54 Date of the next board meeting in public:11 January 2018, Terrace Executive Meeting Room, Watford Hospital


AGENDA

2 of 125 Trust Board Meeting in Public-07/12/17

Acronyms and abbreviations

AGENDA


A AAA Abdominal Aortic Aneurysm AAU Acute Admissions Unit A&E Accident and Emergency ABPI Association of the British Pharmaceutical Industry AC Audit Commission ACS Adult Care Services ADM Assistant Divisional Manger AGS Annual Governance Statement AHP Allied Health Professional

B BAF Board Assurance Framework BAMM British Association of Medical Managers BAU Business as usual BC Business Continuity BCP Business Continuity Plan BGAF Board Governance Assurance Framework B&H Bullying and Harassment BISE Business Integrated Standards Executive BMA British Medical Association BME Black and ethnic minorities BSI Bloodstream infection

C CAB/C&B Choose and Book Caldicott Guardian The named officer responsible for delivering and implementing the

Confidentiality and patient information systems CAMHS Child and adolescent mental health services CAS Central Alert System CCG Clinical Commissioning Groups

CCIO Chief Clinical Information Officer CCORT Clinical Care Outreach Team CCU Critical Care Unit CD Clinical Director C.Diff Clostridium Difficile CEO Chief Executive Officer CfH/CFH Connecting for Health CFO Chief Financial Officer CHD Coronary heart disease CIO Chief Information Officer CIP Cost improvement programme CIS Care Information Systems CMO Chief Medical Officer CNO Chief Nursing Officer CNS Clinical Nurse Specialist CNST Clinical Negligence Scheme for Trusts COI Central Office of Information COO Chief Operating Officer COPD Chronic Obstructive Pulmonary Disease COSHH Control of Substances Hazardous to Health CPA Clinical Pathology Accreditation

AGENDA


CPD Continuing Professional Development CPOP Clinical Policy and Operations CFPG Capital Finance Planning Group CPR Cardiopulmonary resuscitation CQC Care Quality Commission CQUIN Commissioning for Quality & Innovation CRS Care Records Service CSE Child sexual exploitation CSSD Central Sterile Service Department CSU Clinical Support Unit CT Computerised Tomography

D DCC Direct Clinical Care DD Divisional Director DGH District General Hospital DGM Divisional General Manager DM Divisional Manager DIPC Director of Infection Prevention and Control DH or DoH Department of Health DNA Did Not Attend DNR Do Not Resuscitate DO Developing our Organisation DoC Duty of Candor DoLS Deprivation of Liberty Safeguards DPH Director of Public Health DQ Data Quality DTA Decision to admit DTOC Delayed Transfers of Care DQ Data Quality

E EA Executive Assistant EADU Emergency Assessment and Discharge Unit ECG Echocardiogram ECIP Emergency Care Improvement Programme ED Emergency Department ED Executive Director EDD Expected Date of Discharge EDS Equality Delivery System EIA Equality Impact Assessment ENHT East & North Herts NHS Trust ENT ear, nose and throat EoE East of England EoL End of Life EPAU Early Pregnancy Assessment Unit EPRR Emergency Preparedness, Resilience and Response ERAS Enhanced Recovery Programme after Surgery ESR Electronic Staff Record EWTD European Working-Time Directive

AGENDA


F FBC Full Blood Count FBC Full Business Case FCE Finished Consultant Episode FFT Friends and Family Test FD Finance Director FGM Female genital mutilation FOI Freedom of Information FRR Financial Risk Rating FSA Food Standards Agency FT Foundation Trust FY Full Year

G GDC General Dental Council GGI Good Governance Institute GMC General Medical Council GP General Practitioner GUM Genito-urinary medicine GOO General other outcome

H H&S Health and Safety HAI Hospital Acquired Infection HAPU Hospital Acquired Pressure Ulcer HCAI Healthcare-Associated Infections HCC Hertfordshire County Council HCT Hertfordshire Community NHS Trust HDA Health Development Agency HDD Historical Due Diligence HDU High Dependency Unit HEE Health Education England HHH Hemel Hempstead Hospital HES Hospital Episode Statistics HIA Health Impact Assessment HITP Hertfordshire Integrated Transport Partnership HON Head of Nursing HPA Health Protection Agency HPFT Hertfordshire Partnership NHS Foundation Trust HR Human Resources HRG Health Related Group HSC Health Service Circular; (House of Commons) Health Select Committee HSC Health Scrutiny Committee, sub-committee of Overview and Scrutiny

Committee, Hertfordshire County Council HSE Health and Safety Executive HSMR Hospital Standardised Mortality Ratio (Rates) HSO Health Service Ombudsman HTM 00 Health Technical Memorandum HUC Herts Urgent Care HVCCG Herts Valley Clinical Commissioning Group

AGENDA


I IBP Integrated Business Plan IC Information Commissioner ICAS Independent Complaints Advocacy Service ICNs Infection Control Nurses ICO Information Commissioners Office ICT Information, Communications and Technology IDT Integrated Discharge Team IVF In Vitro Fertilisation ICU Intensive Care Unit IDVA Independent domestic violence advisors IG Information Governance IMAS Interim Management Service IM&T Information Management and Technology IP Inpatient IPR Integrated Performance Report IRGC Integrated Risk and Governance Committee ISE Integrated Standards Executive IST Intensive Support Team IT Information Technology ITFF Independent trust financial facility ITU Intensive Treatment Unit

J JSNA Joint Strategic Needs Assessment

K KLOE Key Line of Enquiry KPI Key Performance Indicator

L LAs Local authorities LABV Local Asset Backed Vehicle LAT Local Area Team (of NHS England) LCFS Local Counter Fraud Service L&D Learning and Development LDB Local delivery board LGBT Lesbian Gay Bisexual and Transgender LHCAI Local Health Care Associated Infections LHRP Local Health Resilience Partnerships LMC Local Medical Committee LSMS Local Security Management Specialist LSP Local Service Provider LTFM Long Term Financial Model

AGENDA


M MCA Mental Capacity Act MD Medical Director MDA Medical Device Agency MDT Multi-Disciplinary Team MEWS Modified Early Warning Score MHAC Mental Health Act Commission MHRA Medicines and Healthcare Products Regulatory Agency MIU Minor Injuries Unit MMC Modernising Medical Careers MMR Measles, mumps, rubella MRET Marginal rate emergency tariff MRI Magnetic resonance imaging MRSA Methicillin-resistant Staphylococcus aureus MSSA Methicillin-sensitive Staphylococcus aureus

N NE Never Event NED Non Executive Director NHS National Health Service NHS CFH NHS Connecting for Health NHSE NHS England NHSLA NHS Litigation Authority NHSTDA NHS Trust Development Agency NHSP NHS Professionals NHSP Newborn Hearing Screening Programme NICE National Institute for Health and Clinical Excellence NIHR National Institute for Health Research NMC Nursing and Midwifery Council #NoF Fractured Neck of Femur NPSA National Patient Safety Agency NSF National Service Framework NTDA NHS Trust Development Agency

O OBC Outline Business Case OD Organisational Development OJEU Official Journal of the European Union OLM Oracle Learning Management OMG Operational Management Group ONS Office for National Statistics OOH Out of Hours Service OP Outpatient OSC (local authority) Overview and Scrutiny Committee OT Occupational Therapist/Therapy

AGENDA


P PA Programmed Activities PAC Public Accounts Committee PACS Picture Archiving and Communications System PALS Patient Advice and Liaison Service PAM Premises Assurance Model PAS Patient Administration System PAS 5748 Publicly Available Specification 5748 - provides a framework for the

planning, application and measurement of cleanliness in hospitals PbR Payment by Results PCC Primary Care Centre PCT Primary Care trust PEG Patient Experience Group PFI Private Finance Initiative PHO Public Health Observatory PID Project Initiation Document PLACE Patient Led Assessment of the Care Environment PMO Programme Management Office PMR Provider Management Regime PPI Proton Pump Inhibitors PPI Patient and Public Involvement PR Public Relations PSED Public Sector Equality Duty PSQR Patient Safety, Quality and Risk Committee PTL Patient Tracker List

Q QA Quality Assurance Q&A Questions and Answers QG Quality Governance QGAF Quality Governance Assurance Framework QIA Quality Impact Assessment QIP Quality Improvement Plan QIPP Quality, Improvement, Prevention and Promotion QRP Quality Risk Profile QSG Quality and Safety Group

R R&D Research and Development RA Registration Authority RAG Risk and Governance/Red Amber Green RCA Root Cause Analysis RCN Royal College of Nursing RCP Royal College of Physicians RCS Royal College of Surgeons RES Race Equality Scheme RFH Royal Free Hospitals NHS Foundation Trust RIDDOR Reporting of Injuries, Diseases and Dangerous Occurrences Regulations RSRC Risk Summit Response Committee RTT Referral to Treatment RTTC Releasing Time to Care

AGENDA


S SACH St Albans City Hospital SCBU Special Care Baby Unit SES Single Equality Scheme SFI Standing Financial Instructions SHMI Standardised Hospital Mortality Index SHO Senior House Officer SI Serious Incident SIC Statement of Internal Control SIRG Serious Incident Review Group SIRI Serious Incident Requiring Investigation SIRO Serious Incident Risk Officer SLA Service Level Agreement SLR Service Line Reporting SLM Service Line Management SMG Strategic Management Group SMS Security Management Service SOC Strategic Outline Case SQ Safety and Quality SPA Supporting Professional Activity SRG System Resilience Group STEIS Strategic Executive Information System ST & M Statutory and Mandatory STP Sustainability and Transformation Programme SUI Serious Untoward Incident (same as Serious Incident, more commonly

used).

T T&D Training and Development TDA Trust Development Authority (also known as NTDA) TEC Trust Executive Committee TLEC Trust Leadership Executive Committee T&O Trauma and Orthopaedic TOP Termination of Pregnancy TOR Terms of Reference TPC Transformation Programme Committee

T TSSU Theatre Sterile Service Unit TUPE Transfer of Undertakings (Protection of Employment) Regulations TVT Tissue Viability Team

U UCC Urgent Care Centre

V VFM Value For Money VTE Venous Thromboembolism

AGENDA


W WACS Women’s and Children’s Services WBC Watford Borough Council WFC Workforce Committee WGH Watford General Hospital WHHT West Hertfordshire Hospitals NHS Trust WHO World Health Organisation WRVS Women’s Royal Voluntary Service WTD Working-time directive WTE Whole Time Equivalent (staffing)

Y YTD Year to date YCYF Your care, your future

AGENDA


Last updated 30 November 2017

Declaration of Board members and attendees conflicts of interest 07 December 2017

Agenda item: 04/54

Name Role Description of interest Relevant dates

From To

Professor Steve Barnett Trust Chair Chair and Client Partner of SSG Health Ltd

Non-Executive Chairman of Finegreen Associates

Trustee and Director of the Institute of Employment Studies

Wife is CEO of Rotherham NHS Foundation Trust

Visiting Professor University of West London Business School

Honorary Visiting Professor Cranfield University School of Management

Member of the East Midlands Regional Committee for Clinical Excellence Awards

Present Present Present Present Present Present Present

Andy Barlow Divisional Director, Women’s and Children’s Services Barlow Medical Services Ltd Present

John Brougham Non-Executive Director Non-Executive Director and Chair of the Audit Committee of Technetix Ltd

2010

Present

4

Tab 4 C

onflict of interest

1 of 125T

rust Board M

eeting in Public-07/12/17


Helen Brown Deputy Chief Executive None

Professor Tracey Carter Chief Nurse and Director of Infection Prevention and

Control None

Paul Cartwright Non-Executive Director Treasurer for St Peter’s Church

Trustee and Chair of Finance and Audit Committee for The Church Lands, St Albans.

Charitable Funds for West Hertfordshire Hospitals NHS Trust

Nov 2015 Nov 2015 Nov 2015

Present Present Present

Virginia Edwards Non-Executive Director Trustee Peace Hospice Care

Global Action Plan; providing support to their programme called Operation TLC

Director Edwards Consulting Ltd

Husband is CEO of Nuffield Trust

Husband is a non-remunerated member of the Strategy Committee of Guys and St. Thomas’s Charitable Trust

Husband is Director of Edwards Consulting Ltd

Charitable Funds for West Hertfordshire Hospitals NHS Trust

2011 2016 2011 2011 2011 2011 2014

Present Present Present Present Present Present Present

Katie Fisher Chief Executive None

Jeremy Livingstone Divisional Director of Surgery , Anaesthetics and

Cancer Jeremy Livingstone Ltd Present

4

Tab 4 C

onflict of interest

2 of 125T

rust Board M



Arla Ogilvie

Divisional Director for Medicine Private practice Present

Jonathan Rennison Non-Executive Director Kings College London

Rising Tides Ltd

The Yellow Chair Ltd

Edgecumbe Consulting

Association of NHS Charities

The Teatpot Trust

Swindon Museum and Art Gallery Trust

BNET (Britain-Nigeria Education Trust)

Centre for Sustainable Working Life, Birkbeck College

Evidence Aid

March 2017 May 2017 August 2012 April 2015 Sept 2015 June 2016 Dec 2016 Oct 2016 April 2017 January 2017

Present Present Present Present Present Present Present Present Present Present

Don Richards Chief Financial Officer Director of 7M Ltd April 2017

Phil Townsend Non-Executive Director None

Sally Tucker Chief Operating Officer None

Dr Mike van der Watt Medical Director

Owner and Director Heart Consultants Ltd

Private Practice

Wife is Director of Hearts Consultants Ltd

Present

4

Tab 4 C

onflict of interest

3 of 125T

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02 November 2017 at 9:30am Terrace Executive Meeting Room, Watford Hospital

Agenda item 05/54

Chair Title Attendance

Professor Steve Barnett Chair Yes

Voting members

John Brougham Non-Executive Director Yes

Helen Brown Deputy Chief Executive Yes

Professor Tracey Carter Chief Nurse and Director of Infection Prevention and Control

Yes

Paul Cartwright Non-Executive Director Yes

Ginny Edwards Non-Executive Director Yes

Katie Fisher Chief Executive Yes

Jonathan Rennison Non-Executive Director Yes

Don Richards Chief Financial Officer Yes

Phil Townsend Non-Executive Director Yes

Dr Mike van der Watt Medical Director Yes

Non-voting members

Dr Tammy Angel Divisional Director, Unscheduled Care No

Paul da Gama Director of Human Resources Yes

Lisa Emery Chief Information Officer Yes

Mr Jeremy Livingstone Divisional Director, Surgery, Anaesthetics and Cancer

No

Dr Arla Ogilvie Divisional Director, Medicine No

Sally Tucker Chief Operating Officer Yes

In attendance

Jean Hickman Trust Secretary Yes

Louise Halfpenny Director of Communications Yes

Ajitha Jayaratnam Representative for Medicine Division Yes

Sundera Kumara Moorthy Healthwatch representative Yes

1 member of the public N/A Yes

5

Tab 5 Minutes of the meeting held on 02 November 2017


Page 2 of 9

MEETING NOTES

Agenda item

Discussion Lead Dead-line


01.01 The chairman opened the meeting and welcomed the board and members of the public.

02/53 Briefing on the work of the paediatric carers support team

02.01 The chair introduced Becky Platt, matron for paediatric services and Suzanne Boon, manager of the carer support team (CST) and invited them to present a briefing of the work of the CST to the board. The board was informed on the background and key principles of the voluntary service which offered support to families with children on the paediatric ward. It was reported that engagement with ward staff was a key factor to the success of the service.

02.02 Ginny Edwards congratulated the team on its outstanding work which had been praised by the care quality commission (CQC) and asked what emotional support the team received. Suzanne Boon responded that there was wide support available to volunteers including regular meetings with senior staff and the safeguarding team and debriefings following particularly distressing cases.

02.03 John Brougham queried whether the model could be used in other service areas, such as care of the elderly. The board was advised that it was possible to develop a similar approach in other areas, however strong leadership was required. The chief nurse concurred with this view and said that the CST was a model of excellence which demonstrated how volunteer services should be run. She stressed the importance of volunteers being treated as members of staff and becoming integrated into a ward team. The chief nurse confirmed that the trust was investigating how to establish a similar model in other service areas.

02.04 Jonathan Rennison queried how long it had taken for the necessary culture and mind shift to be embedded which had allowed the voluntary service to become so effective. The board was advised that it had taken a number of years for the service to fully develop and embed and had required strong clinical engagement, clearly defined roles and good local management.

02.05 The chief information officer offered to meet with the team to discuss actions to address long standing information technology issues

LE 12/17

02.06 The chairman thanked Becky Platt and Suzanne Boon for their excellent, informative presentation and asked for the board’s thanks to be passed onto the team of volunteers.

OPENING

03/53 Apologies for absence

03.01 Apologies were received from the divisional director of unscheduled care and divisional director of medicine. The board was advised that Ajitha Jayaratnam was in attendance to represent the medicine division.

04/53 Conflicts of interests

04.01 No further conflicts of interest were noted than those previously circulated.

05/53 Minutes of the meeting held on 05 October 2017

05.01 Minute 05.03. It was noted that a decision to allow vaping on the trust estate had been taken in line with guidance issued by Public Health England.

5



Page 3 of 9

Agenda item


05.02 Minute 09.08. It was highlighted that the final sentence related to monthly data.

05.03 Subject to the amendments detailed above, the minutes were recorded as a true record of the meeting.

06/53 Board action log from 05 October 2017 and previous meetings and decision log

06.01 There were no outstanding actions.


07.01 The chair presented his report to the board and advised on a recent regional chair’s meeting which had focused on the importance of improving emergency department (ED) performance. The chair requested a report to be presented to the board at its December meeting on winter planning, in line with national guidance.

ST

12/17

07.02 The board was informed on NHS Improvement’s (NHSI) NExT director scheme and the chair advised that the trust would be supporting the scheme by offering a coaching programme to a potential future non-executive director.

07.03 The chairman advised the board that Dr Tammy Angel would be stepping down from the role of divisional director for unscheduled care. He thanked Dr Angel for her hard work and the expertise that she had brought to the divisional director role and to the board. He advised that Dr Andy Barlow, divisional director for women’s and children’s service would be attending future board meetings.

07.04 It was highlighted that a clinical and community engagement event in October 2017 had discussed which services could potentially be provided at a Hemel Hempstead healthcare hub.

07.05 The board discussed a new executive talent scheme which had been launched by NHSI to support trusts in recruiting to executive-level interim positions. The chief executive advised that a number of senior managers had completed a previous aspiring director course and confirmed that the trust would be nominating individuals to the latest talent scheme.

07.06 The board acknowledged and congratulated Ruth Connolly, assistant divisional manager for emergency care on being awarded runner up as volunteer of the year at Watford’s Audentior Awards 2017. The maternity team was also congratulated for being shortlisted in the workforce category of the HSJ awards.

07.07 Resolution: The board noted the report.

08/53 Chief Executive’s report

08.01 The board received the chief executive’s report and noted an update on the position regarding non-emergency transport. The chief executive cautioned that, although the east of England ambulance trust was endeavouring to ensure continuity of the transport service, it was currently in ‘rescue mode’ and issues continued to impact on the patient experience.

08.02 The chief executive reported that since the smoke-free policy had come into force at the beginning of October 2017 an improvement in the environment had been recognised. However, she noted that it was early days and assured the board that communication was ongoing to remind patients, visitors and staff of the policy.

5



Page 4 of 9

Agenda item


08.03 It was reported that the flu vaccination programme was well underway and performance was better than at the same period in 2016/17.

08.04 The current completion rate for the national staff survey was reported to be better than the same time the previous year; however the chief executive advised that more work was required to meet the target rate.

08.05 The board noted that Kevin Howell, director of environment, Phil Downing, head of nursing, Gloria Rowland, associate director of midwifery and gynaecology and Rachael Corser, deputy director of governance and associate chief nurse would be leaving the trust to take up promotional roles at other NHS trusts. The chief executive thanked them on behalf of the board for their hard work and dedication and said it was testament to the trust that staff were being successfully developed to be appointed to enhanced positions elsewhere.

08.06 The chief executive informed the board that Professor Steve Barnett’s tenure as chair had been extended to November 2019. The board thanked the chair for his work over the past two years and looked forward to working with him for a further two years.


PERFORMANCE

09/53 Integrated performance report - month 6

09.01 The chief information officer presented the integrated performance report (IPR) and highlighted the areas of good performance and the areas which require improvement.

09.02 Phil Townsend brought the board’s attention to a high staff turnover and vacancy rate and asked if this was a seasonal discrepancy. The board was assured by the director of human resources that if band five vacancy data was removed from the figures, the trust would be positioned around the national average. He also reported that the trust’s recruitment plans had been negatively impacted by Brexit, however work was ongoing to improve the turnover and vacancy rate.

09.03 John Brougham highlighted a decrease in cancer performance, however he reminded the board of the Trust’s year-to-date achievement in meeting the two week wait and breast symptomatic cancer standard. The chair welcomed this significant achievement, but asked for assurance that the decreasing trend in cancer performance was not expected to continue. The chief operating officer reminded the board that the trust had achieved the standard in quarter two and offered assurance that cancer performance was expected to improve slightly due to a focus on patient pathways and the recruitment of a new cancer lead. She advised that cancer performance was closely monitored at divisional performance review meetings and by the clinical outcomes and effectiveness and trust executive committees.

09.04 The medical director advised that due to issues with a community echocardiogram provider, the Herts valleys clinical commissioning group (HVCCG) had suspended the contract and requested the trust to pick up the work. The board was warned that, although the current work and backlog was being carried out, it was having a negative impact on the trust’s performance. Paul Cartwright asked whether similar issues were expected to arise from other community contracts and was advised by the medical director that this possibility had been raised with HVCCG.

5



Page 5 of 9

Agenda item


09.05 The board was updated on discussions with HVCCG regarding the re-definition of mixed sex accommodation. The chief nurse advised that this issue was reviewed regularly at quality contract meetings and a retrospective review of cases was expected to be completed by early December 2017. In response to a question by the chair, the chief nurse confirmed that the stroke unit was not an area where mixed sex breaches were required to be reported unless patients were admitted for non-clinical reasons.

09.06 Jonathan Rennison asked for an update on VTE assessments. The medical director replied that the rate was slowly improving and the chief executive assured the board that the trust executive committee (TEC) had recently been assured that best practice was being followed and was satisfied that the trust was providing safe management to patients. She further reported that TEC was certain that a higher percentage of VTE assessments were being undertaken and medication being offered than captured and she assured the board that various options were being considered to improve VTE reporting, including electronic solutions.

09.07 Jonathan Rennison asked for clarification on a recent never event and the lessons learnt from the incident. The chief nurse responded that an investigation was currently underway and confirmed that there had been a previous similar incident, both of which had involved human factors. She assured the board that the serious incident group would review cross divisional learning to ensure that it was embedded and underpinned.

09.08 Jonathan Rennison asked for clarification on the benefits of monitoring the friends and family test (FFT) response rate. The board was reminded that a higher response rate provided a platform for more reliable comments to be collated and used to improve services. The board was assured that work was underway to improve the response rate in maternity and in ED, where texting was being considered. Further assurance was offered that the FFT data triangulated with the outcome of the national ED survey.

09.09 The director of human resources reminded the board that a proactive decision had been taken not to ask staff to complete the FFT in August 2017 as it was close to the national staff survey in September 2017.

09.10 The chief financial officer reported that the first half year deficit of £24.7m was £10.2m worse than budget, and £9.7m higher than the £15m full year target. The board discussed the key causes for the current financial position and the actions needed to be taken to get back on track. It was noted that these actions would be discussed in detail in the private session of the meeting.

09.11 The board was advised that the trust had written to NHSI regarding the financial position and to offer a re-forecast and recovery plan. It was reported that the importance of achieving a balance between the ED target and the financial trajectory would be discussed in the private session of the meeting. The chief financial officer confirmed that the cash flow had eased and a successful loan application had helped to pay invoices. However, he cautioned that the trust had not yet received confirmation of an application of £15m for capital funding and it was likely that this would not be received until after the government’s autumn statement was published.

09.12 John Brougham asked the forecast I&E performance to be added to the IPR finance graph.

DR/LE 01/18

5



Page 6 of 9

Agenda item


09.13 The chair congratulated the trust on being invited to speak at a national conference on the actions it had taken which had achieved lower than expected mortality rates.



10/53 Quality improvement plan

10.01 The chief nurse presented the quality improvement plan (QIP) and advised that this was closely monitored by the safety and quality committee. The board was advised that the latest CQC report was expected to be received in November 2017 and the trust would have ten days to review it for factual accuracy before it was published in December 2017.

10.02 Phil Townsend asked whether the trust planned to link the QIP with the IPR. The chief nurse responded that the QIP had been developed with the aim of delivering CQC recommendations and wider improvements. She advised that the trust’s quality strategy was being developed using a proven methodology and the QIP would be ‘rebranded’ and launched as part of the quality strategy in February 2018. The chief information officer added that the IPR would continue to be developed in order to effectively track the results of the quality strategy.


UNDERDEVELOPED INFORMATICS INFRASTRUCTURE (BAF RISK 4)

11/53 General data protection regulation update

11.01 The board received a report from the chief information officer on future changes to the Data Protection Act. She reminded the board that the changes had been discussed in detail at a recent board development session and provided an outline of an implementation plan which would be monitored by TEC and the safety and compliance committee.

11.02 Paul Cartwright asked for clarification on the financial implications of implementing the changes. The chief information officer responded that it was difficult to accurately predict the financial impact and advised that an area of cost would be associated with the recruitment of a GDPR officer.

11.03 Jonathan Rennison noted some points relating to fundraising and the charity and advised the board that he would discuss these with the chief information officer outside of the meeting.

JR/LE

12/17



12/53 Strategy update

12.01 The deputy chief executive presented a paper which outlined progress of longer-term service changes and strategic developments. She advised that conversations were ongoing with HVCCG regarding integrated service pathways and contracts.

12.02 The board was advised that a meeting had been arranged with NHS England (NHSE) and NHSI to discuss how the strategic outline case (SOC) for the redevelopment of acute hospital services could be moved forward. The deputy chief executive advised that there was no firm timeline for the department of health to complete its review of the SOC.

12.03 It was reported that discussions were ongoing with HVCCG regarding the Hemel Hempstead SOC and the board was advised that it would receive a report in December 2017 on the outcome of a stakeholder

5



Page 7 of 9

Agenda item


workshop which had explored potential clinical models. The deputy chief executive explained that an urgent care centre model was fundamentally the same as for an urgent treatment centre; however minor changes would be required to equipment and IT in order to make the trust fully compliant with the urgent treatment centre model. The chief executive assured the board that no services would be removed from the current model and reminded the board that the urgent care centre remained closed overnight following a proactive decision to protect patient safety due to staffing issues.

12.04 The deputy chief executive advised that a joint work programme which set out the proposed work areas with the Royal Free London Hospital NHS Foundation Trust (RFL) was currently at an exploratory stage and would be discussed in the private session of the meeting. The chair assured the board that any major decisions would be presented to the board for discussion and approval.

12.05 With regard to sustainability and transformation partnership (STP), it was reported that the board would receive a proposed memorandum of understanding (MOU) to consider for approval in the private session of the board meeting. It was noted that the MOU formalised the trust’s commitment to work with STP partners to deliver the STP priorities

12.06 It was reported that a group of senior staff had recently visited the United States to gain a greater understanding into the benefits of group working and to learn how working across scale and standardisation could improve performance. The trust’s charity was thanked for supporting the trip and it was noted that feedback on the benefits of the visit would be presented to the charitable funds committee in November 2017.

12.07 The board thanked the deputy chief executive for her well written, concise report.


13/53 Hertfordshire health concordat

13.01 The board received a concordat which set out expected ways of managing changes in services in Hertfordshire. The concordat represented an agreement between NHS bodies in Hertfordshire, Healthwatch Hertfordshire and Hertfordshire county council’s overview and scrutiny committee with the core principle of ‘no surprises’.

13.02 The medical director asked whether the proposed service changes relating to body mass index would be covered by the concordat. The deputy chief executive advised that the county council was aware of the trust’s clinical concerns in relation to this issue and was in discussion with HVCCG about whether the changes met the best interests of the population.

13.03 Resolution: The board approved the concordat.

GOVERNANCE

14/53 Summary report on corporate risk register

14.01 The board reviewed the corporate risk register (CRR) and the non-executive directors pointed out a number of discrepancies to risk numbers 3503, 3892, 3896, 3120 and 3741.

14.02 Non-executive directors asked for clarification on risk number 3781 relating to gaps in the unscheduled care medical workforce. The director of human resources acknowledged that the description of the risk was unclear and agreed to redraft it.

PDG

12/17

5



Page 8 of 9

Agenda item



15/53 Board assurance framework update

15.01 The deputy chief executive presented an updated board assurance framework (BAF) and highlighted recommendations made by lead committees for board approval.

15.02 Ginny Edwards advised that, although the patient and staff experience committee (PSEC) had not recommended a change to the RAG rating of principal risk 2 at the current time, it would review the longer term strategic workforce risks at the next committee review. Paul Cartwright also noted that PSEC had considered whether PR8 should be divided to reflect a significant variation in risk between internal and external engagement.

15.03 The deputy chief executive reported that a more integrated format for the BAF and CRR was being investigated and the ‘new-look’ document would be explored at a board development session in January 2018 with a view to recommending the refreshed BAF/CRR for board approval in March 2018. The board acknowledged the improvements that had been made to the CRR and BAF and welcomed future developments.

15.04 Resolution: The BAF was approved.

COMMITTEE REPORTS

16/53 Assurance report from the Finance and Investment Committee

16.01 John Brougham presented an assurance report from the finance and investment committee. He asked the board to ratify a loan application to cover funding requirements in October 2017 and advised that the board would receive a SOC to transform pathology service in the private session of the meeting, together with a paper outlining plans and risks in achieving the £35m deficit forecast.

16.02 Resolution: The board noted the report for information and assurance and ratified an NHS revenue support loan for £3.3m.

17/53 Assurance report from the Audit Committee

17.01 An assurance report on the work of the audit committee was received from Paul Cartwright. He noted that the committee was pleased that a review of the corporate governance structure was underway and would review the outcome in January 2018.

17.02 Resolution: The board noted the report for information and assurance.

18/53 Assurance report from the Safety and Compliance Committee

18.01 Phil Townsend presented a report on the work of the safety and compliance committee. He highlighted areas of risk relating to fire safety, theatre ventilation and medical devices and advised that the committee had requested a deep dive into the processes and results of audits on medical devices.

18.02 Resolution: The board noted the report for information and assurance.


19.01 Due to the close timing of the meeting, Ginny Edwards gave a verbal update on the latest patient and staff experience committee meeting and advised that a formal report would be presented at the next board meeting.

ANY OTHER BUSINESS


20.01 No other business was raised.

5



Page 9 of 9

Agenda item


QUESTION TIME


21.01 Q. Does the trust plan to use the outcome of NHSI’s annual readmission audit to improve its 28 days readmission rate as had been successfully demonstrated by other NHS trusts? A. The chief executive confirmed that the trust regularly scrutinised its readmission rates. She confirmed that the trust’s rate was average when benchmarked nationally; however, she acknowledged that the trust should not be complacent and advised that it was employing a variety of measures to improve performance. This included a pilot in July 2017 of post admission calls, which unfortunately had not resulted in any significant change to readmission rates.


22.01 No questions were raised.

ADMINISTRATION


23.01 The draft agenda was approved.

24/53 Date of the next board meeting

24.01 The next board meeting will be held on 07 December 2017 in the terrace executive meeting room, Watford hospital.

5



Page 1 of 1

Agenda item 06a/54

Action log Part 1 – 07 December 2017 (from meeting held on 02 November 2017 and earlier Boards if outstanding)

Ref No.

Action from agenda item

Action Lead for completing the

action

Date to be completed

Update

1 09.02/52 The number of complaints over three months to be included in future safety and compliance committee integrated performance reports.

LE/TC 12/17 The data is now presented in the main IPR and in the safety and compliance committee IPR

2 09.03/52 Harm free care data to be presented in a clearer format in future reports. LE/TC 12/17 Completed.

3 02.05/53 Meeting with the paediatric carers support team to discuss actions to

address long standing information technology issues. LE 12/17 Arrangements are in place

for the chief information officer to visit the paediatric team in December 2017 to see the problems first hand and explore solutions

4 07.01/53 Board to receive a report on winter planning ST 12/17 On agenda

5 11.03/53 Jonathan Rennison and chief information officer to discuss specific points regarding fundraising and the charity in line with the General Data Protection Regulation (GDPR)

LE/JR 12/17 Discussion has taken place and agreement reached regarding a set of actions to be added to the Trust’s GDPR plan

6 14.02/53 The description of risk number 3781 in the corporate risk register relating to a staff loyalty scheme to be redrafted to ensure it was clearer

PDG 12/17 Completed. Risk description updated

7 09.12/53 The forecast I&E performance to be added to the IPR finance graph. DR/LE 01/18 Due January 2018

6

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oard action log from 02 N

ovember 2017 and previous m

eetings and decision log

1 of 125T

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Agenda item: 06b/53

Board

meeting/decision date

Decision reference

(from minutes)

Item presented to Board for action Comments/outcome

4/7/2016 16/36The Board received corporate aims and objectives for 2016/17 Approved, subject to inclusion of

comments from Board

4/7/2016 17/36The Board received a refreshed Board Assurance Framework for 2016/17 Approved

05/05/2016 17/37

The Board received the updated terms of reference and work plans for 2016/17 for the

Audit, Remuneration, Workforce, Finance and Performance, Charitable Funds and

Integrated Risk and Governance Committees

Approved

7/7/2016 .09/39 The quality account 2015/16 Approved

7/7/2016 16/39Funding for external advisory support to develop a strategy outline case (SOC) for the

configuration of acute hospital service

Approved

7/7/2016 17/39 Infection prevention and control annual report 2015/16 Approved for publication

7/7/2016 18/39 The end of life care strategy Approved

7/7/2016 19/39The Board received the updated terms of reference and work plans for the Safety and

Quality Committee and the Trust Board

Approved

7/7/2016 21/39 Updated Board Assurance Framework Approved

9/1/2016 21/40Charitable Funds annual report and annual accounts 2015/16 , £12,000 of funds of funds

to support a holistic service for patients and their carers

Approved

9/1/2016 23/40 Terms of reference for the Trust Executive Committee Approved

10/7/2016 07/41Recommendation to increase the number of scheduled Board meetings to eleven per

annum.

Approved

10/7/2016 14/41 Recommended changes to the BAF 2016/17. Approved

11/3/2016 12/42 Patient experience and carer strategy Approved

11/3/2016 13/42 Statutory annual public sector equality duty report 2015 Approved

11/3/2016 18/42 The gifts, hospitality and sponsorship policy Approved

11/3/201619/42a

Recommendation to reduce the frequency of Integrated Risk and Governance Committee

meetings

Approved

11/3/2016 19/42c Update to terms of reference for the Board Approved

11/3/2016 19/42b Draft Board and Committee meeting schedule 2017/18 Approved

12/1/2016 10/43 Nursing, midwifery and allied health professions strategy Approved

BOARD AND CORPORATE TRUSTEE

DECISION LOG PART 1

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1/12/2017 15.2/44 counter fraud policy Approved

2/2/2017

02.13/45

Recommendation that the Watford site continue to be the location for emergency and

specialised care and the St Albans site continue to be the location for planned care as

recommeded in the SOC

Approved

2/2/201712.01/45

An interim revenue support loan of £2.3m to cover February 2017 revenue cash

requirements

Approved

2/2/201712.01/45

The transfer of 0.29 hectares (0.72 of an acre), to Watford Borough Council in line with

the Trust's obligations under the Health Campus agreement

Approved

3/6/2017 13.07/46 A graded approach to workforce metrics for future reporting. Approved

3/6/201715.02/46

An interim loan of £4m to cover cash flow requirements in February and March 2017

Approved

Approved

3/6/2017 15.02/46 The conversion of an IRWCF loan of £26.8m to an ISLF loan. Approved

3/6/2017 17.02/46Recommendation to delegate responsibility to the Audit Committee to sign off the Annual

Accounts, Annual Report and Annual Governance Statement.Approved

3/6/2017 18.02/46 The 2017/18 Board and Committee structure and meeting schedule Approved

4/6/2017 11.04/47 Hospital Pharmacy Transformation PlanApproved as direction of travel for

pharmacy service.

4/6/2017 14.02/47 Aims, objectives and principle risks. Approved

4/6/2017 16.02/47 Interim capital support facility agreement £7.5m Rattified

4/6/2017 16.02/47 Deficit control totals for 2017/18 of £15.4m Approved

5/4/2017 15.02/48 An interim revenue support loan of £1.964k Approved

5/4/2017 20a.03/48 West Herts charity strategy Approved

5/4/2017 20b.02/48 Discretionary resources policy Approved

6/1/2017 14.04/49 Outline business case for theatre reconfiguration Approved option E

6/1/2017 15.03/49 Proposed monitoring arrangements for aims and objectives Approved the approach

6/1/2017 17.01/49 NHS self-certification 2017/18 Approved condition G6 (3)

6/1/2017 18.02/49 Assurance report from Finance and Investment CommitteeRatified the terms and conditions of a

£42m interim revenue support loan

7/6/2017 16.04/50 The terms of reference and work plans for the board and committees Approved

7/6/2017 18.02/50The board approved the annual accounts, annual report, governance statement and

quality account 2016/17. Approved

7/6/2017 22.05/50The corporate trustee approved the recommended way forward to the future management

of the charity Approved

9/7/2017 10.02/51The board aproved the NHS England emergency preparedness, resilience and response

annual assurance. Approved

9/7/2017 13.02/51The board approved the infection prevention and control annual report 2016/17 for

publication on the Trust website Approved

10/5/2017 13.03/52Assurance report from Finance and Investment Committee

Ratified a £1.4 interim revenue support

loan

10/5/2017 13.03/52Assurance report from Finance and Investment Committee

Approved £1m capital expenditure

funding for the redevelopment of the

A&E department

6

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11/2/2017 13.03/53The Board approved the Hertfordshire health concordat Approved

11/2/201715.04/53 Board assurance framework Approved

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Trust Board Meeting 07 December 2017

Title of the paper Chair’s report

Agenda item 07/54

Lead Executive Professor Steve Barnett, Chair

Author Jean Hickman, Trust Secretary

Executive summary (including resource implications)

The aim of this paper is to provide an update on items of national and local interest/relevance to the Board.

Where the report has been previously discussed, i.e. Committee/Group

N/A

Action required:

The Board is asked to receive the report for information.

Link to Board Assurance Framework (BAF)

[Please indicate which Principal Risk this paper relates to by double clicking on the corresponding box]

PR1 Failure to provide safe, effective, high quality care

PR2 Failure to recruit to full establishments, retain and engage workforce

PR3 Current estate and infrastructure compromises the ability to deliver safe, responsive and efficient patient care

PR4a

Underdeveloped informatics infrastructure compromises ability to deliver safe, responsive and efficient patient care – IM&T

PR4b

Underdeveloped informatics infrastructure compromises ability to deliver safe, responsive and efficient patient care – Information and information governance

PR5a

Inability to deliver and maintain performance standards for Emergency Care

PR5b

Inability to delivery and maintain performance standards for Planned Care(including RTT, diagnostics and cancer)

PR7a

Failure to achieve financial targets, maintain financial control and realise and sustain benefits from CIP and Efficiency programmes

PR7b

Failure to secure sufficient capital, delaying needed improvements in the patient environment, securing a healthy and safe infrastructure

7

Tab 7 Chairs report


PR8 Failure to engage effectively with our patients, their families, local residents and partner organisations compromises the organisation’s strategic position and reputation.

PR9 Failure to deliver a long term strategy for the delivery of high quality, sustainable care

PR10

System pressures adversely impact on the delivery of the Trust's aims and objectives PR6 – business continuity has been closed (incorporated into PR1)

Trust objectives [Double click on the box to mark as appropriate]

To deliver the best quality care for our patients

To be a great place to work and learn

To improve our finances

To develop a strategy for the future

Benefits to patients/staff from this project/initiatives

Risks attached to this project/initiatives and how these will be managed 7

Tab 7 Chairs report


Agenda Item: 07/54

Trust Board Meeting – 07 December 2017 Chair’s report Presented by: Professor Steve Barnett, Chair 1. Purpose

1.1. The aim of this paper is to provide an update on items of national and local

interest/relevance to the Board.

2. NATIONAL NEWS AND DEVELOPMENTS

Autumn budget 2017

2.1. On 22 November 2017 the Chancellor of the Exchequer, Philip Hammond, presented his Autumn Budget to Parliament. Acknowledging that the health service was under pressure, the chancellor announced £1.6bn in extra revenue for 2018/19; £3.5 billion in extra capital funding; an immediate £350m to help trusts prepare for winter and the end of the pay cap for staff on the agenda for change contracts, subject to recommendations from the pay review bodies.

New Department of Health non-executive directors

2.2. Health Secretary Jeremy Hunt has appointed a new team of non-executive directors to the Department of Health board, as below:

Kate Lampard is the chair of GambleAware, a former barrister and previously led the NHS investigations into Jimmy Savile

Professor Dame Sue Bailey is chair of the Children and Young People’s Mental Health Coalition and Honorary Professor of Mental Health Policy at the University of Central Lancashire. She serves as Chair of the Academy of Medical Royal Colleges

Sir Ron Kerr served as Chief Executive of Guy’s and St Thomas’ NHS Foundation Trust until October 2015 and remains with the Trust as executive vice chairman.

Michael Mire is the Chair of the Land Registry and senior independent director at the Care Quality Commission (CQC)

Gerry Murphy has served as a non-executive director and Chair of the Audit and Risk Committee at the Department of Health since 2015

Professor Sir Mike Richards was previously a physician for more than 20 years. In 1999 he was appointed as the department’s first National Cancer Director and was Director for Reducing Premature Mortality on the NHS Commissioning Board (now NHS England)

New National Chief Medical Officer 2.3. NHS England announced in November 2017 that Professor Stephen Powis had been

appointed as its new National Medical Director. Professor Powis, 57, is currently Group Chief Medical Officer at the Royal Free London NHS Foundation Trust, and will succeed Professor Sir Bruce Keogh in his national role in the New Year.

7

Tab 7 Chairs report


2.4. Professor Powis has served on the board of an NHS Clinical Commissioning Group, as chair of the Association of UK University Hospitals medical directors group and a board member of Medical Education England. He was also Director of Postgraduate Medical and Dental Education for UCLPartners from 2010 to 2013.

Care Quality Commission update

2.5. The CQC is seeking views on a proposed approach to working with NHS Improvement

(NHSI) to reflect its assessment of trusts’ use of resources in published CQC inspection reports and trust-level ratings.

2.6. NHSI began its use of resources assessments at non-specialist acute trusts in October 2017 using the resources assessment framework and methodology which was developed following public and stakeholder feedback and testing at a number of acute trusts earlier this year.

2.7. This work is part of wider changes the CQC is making to the way it monitors, inspects

and rates NHS trusts, which includes more inspections of the specific core services that individual trusts provide and fewer comprehensive inspections of whole trusts, as well as working more closely with partners to agree a ‘shared view of quality’.

2.8. Members of the public, healthcare providers and other stakeholders are invited to take

part in the consultation which can be accessed from the CQC website (www.cqc.org.uk).

2.9. The consultation will run until 10 January 2018. NHS Improvement update

2.10. Ian Dalton will take over the position of Chief Executive of NHSI from Jim Mackey on 04

December 2017. Ian has over 30 years’ experience in the NHS and the wider health sector. He joins NHSI from Imperial College Healthcare NHS Trust where he was Chief Executive Officer.

2.11. Ian has held a number of senior provider, regional and national NHS roles throughout his career including Chief Operating Officer and Deputy Chief Executive Officer at NHS England and Chief Executive of NHS North of England, the North East Strategic Health Authority and two acute hospital trusts.

Single oversight framework

2.12. The Single Oversight Framework (SOF) sets out how NHSI plans to oversee NHS trusts

and NHS foundation trusts, using one consistent approach. It helps to determine the type and level of support that trusts need to meet their requirements.

2.13. The objective of the SOF is to help providers attain and maintain CQC ratings of ‘good’ or ‘outstanding’, meet NHS constitution standards and manage their resources effectively, working alongside their local partners.

2.14. The first version of the SOF was published in September 2016. In November 2017 NHSI updated the SOF to reflect changes in national policy priorities and standards, to clarify certain processes and definitions and to improve the structure and presentation of the document.

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http://links.govdelivery.com/track?type=click&enid=ZWFzPTEmbXNpZD0mYXVpZD0mbWFpbGluZ2lkPTIwMTcxMTA4LjgwNTQ1MjUxJm1lc3NhZ2VpZD1NREItUFJELUJVTC0yMDE3MTEwOC44MDU0NTI1MSZkYXRhYmFzZWlkPTEwMDEmc2VyaWFsPTE3MTQ3MzIzJmVtYWlsaWQ9a2F0aWUuZmlzaGVyQHdoaHQubmhzLnVrJnVzZXJpZD1rYXRpZS5maXNoZXJAd2hodC5uaHMudWsmdGFyZ2V0aWQ9JmZsPSZtdmlkPSZleHRyYT0mJiY=&&&101&&&http://www.cqc.org.uk/get-involved/consultations/consultation-reporting-rating-nhs-trusts-use-resources

2.15. The framework will help to identify NHS providers' support needs across five themes:

quality of care finance and use of resources operational performance strategic change leadership and improvement capability

2.16. Performance is monitored under each of the themes and consideration given as to

whether a trust requires support to meet the standards in each area. Individual trusts are segmented into four categories according to the level of support each trust needs and where improvements in performance are required, NHSI develops a package of support with the provider to help them achieve this.

2.17. Future updates to the SOF will be aligned with the national planning cycle; the next

scheduled refresh is planned for 2019/20. 3. LOCAL NEWS AND DEVELOPMENTS

CQC inspection

3.1. The trust received a draft report from the CQC on 17 November 2017 following an

inspection in August 2017. It consists of three site reports and one overall report. The trust had 10 working days to check the report for factual accuracy and the CQC is currently considering the trust’s response.

3.2. The CQC has indicated that its final report is likely to be published around the middle of December 2017. Changes to services at Hemel Hempstead hospital

3.3. The Dacorum and Hemel Hempstead hospital project group met in November 2017 to

discuss progress with the development of the strategic outline case (SOC) for Hemel Hempstead. Led by David Evans from Herts Valleys Clinical Commission Group (HVCCG), the project group includes partners from Herts Community Trust, East and North Herts Clinical Commissioning Group, local councillors and patient representatives.

3.4. A public consultation on the Hemel Hempstead SOC will take place in spring 2018 and project group discussion focused on the need for joined up communications to support public engagement. The next meeting of the project group will be held on 14 December 2017.

3.5. HVCCG will be consulting a range of stakeholders, starting in January, on plans for services currently delivered out of Hemel Hempstead hospital. The consultation will include:

Early feedback on the urgent treatment centre at Hemel Hempstead Hospital which went live on 01 December 2017. This will cover patient experience and future plans for developing services (including opening hours) as part of a wider urgent care strategy.

Two options for the contract for the West Herts Medical Centre (GP surgery located adjacent to the urgent care centre at Hemel Hempstead Hospital) which is up for renewal in 2018. Option 1: Not to renew the contract, to integrate GP services provided to non-registered patients into the UTC and to support registered patients (approx. 2,000) in re-registering with other GP practices. Option 2: to put out the contract for a full commercial and competitive procurement

Discussion on the development of a strategic outline case for a significant new health facility serving Hemel Hempstead and Dacorum, possibly located on the Hemel Hempstead hospital site.

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3.6. HVCCG is investigating a range of options that may be included in the consultation on

the opening hours for the urgent treatment centre. These range from keeping to the temporary hours (8am to 10pm); extending the temporary hours to offer a service up to midnight and reintroducing a 24 hour service.

3.7. HVCCG acknowledges that issues remain relating to the availability of GPs to staff overnight shifts which led to the temporary overnight closure last December and, as the HVCCG work towards GP extended access, the pressure on GP time will increase. HVCCG has confirmed that it will only include options in the consultation if it is satisfied that the option is capable of being delivered and is sustainable.

3.8. This consultation and engagement will start by the end of January and will last between six and eight weeks.

3.9. The board will receive a paper on the future options for Hemel Hempstead hospital in the

private session of the meeting on 07 December 2017.

Antibiotic awareness day

3.10. The antimicrobial stewardship team launched an antibiotic awareness campaign on 17 November 2017 to mark European antibiotic awareness day and world antibiotic week. The team visited wards with quizzes and freebies and manned a stand in the restaurant at Watford to support the national campaign ‘keep antibiotics working’.

3.11. A grand round in November focused on ‘Bugs and Drugs’ and included an interactive

session with quizzes and prizes.

Christmas is coming!

3.12 Thank you to Hygiene Finishes who have donated the Christmas tree and Tri Electrics for the Christmas tree lights which will help to brighten up the hospital sites over the festive season.

3.12. I will be switching on the lights across the three hospital sites from 07 December 2017.

Activities programme for patients

3.13. A new activities programme for patients is being developed. This includes working with schools, colleges, theatres, community groups and individuals who have generously offered to give their time to provide a variety of services, entertainment and activities for patients, carers and staff.

3.14. Activities include visits from therapy dogs, theatre productions, singers, beauty therapists and student visitors. Charitable donations

3.15. A huge thank you to the following groups for their time and hard work which has led to their kind donations to the trust:

The Michael Green Diabetes Foundation donated £15,000 to the diabetes team in the Michael Clements Diabetes Centre at Watford hospital. This latest donation from the Foundation brings the total funds they have provided to the trust’s diabetes service to more than £60,000

The Herts Prems donated £26,000 to the Special Care Baby Unit at Watford

Christians across Watford donated £1,500 to aid staff health and wellbeing

A local family for the donation of 50 care bears to Sarratt ward to be given to end of life care patients, those with dementia or to patients who are lonely

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Recognising and celebrating our staff

3.16. Well done to the following staff and teams for their outstanding work since the last board

meeting:

The maternity unit for winning a prestigious health service journal 2017 award for its achievements in improving performance. The unit won the national workforce award for its successful drive to recruit and retain midwives and for turning around its CQC rating from ‘inadequate’ to ‘good’.

Michelle Soskin, Consultant Anaesthetist on being awarded the Evelyn Baker medal by the Association of Anaesthetists of Great Britain and Ireland. The prestigious Evelyn Baker medal is awarded for outstanding clinical competence, recognising the ‘unsung heroes’ of clinical anaesthesia and related practice.

Sarratt and Croxley wards at Watford for being commended by NHSI on innovation and successfully completing a rapid improvement project in end of life care. Staff on the two wards developed their own patient-centred tailored training, boosted their confidence and improved the care environment to create a better experience for patients and carers.

Emma Pope from the stroke unit on winning September’s team member of the month award for her excellent leadership which resulted in the stroke team maintaining the highest rating for their national SNAPP data and just recently they were the first ward to undertake the ACE ward accreditation programme, where they were awarded with a gold rating.

Children’s services for holding a successful ball in November 2017, which rasied £7,000, which will be used towards a new echo machine, TVs and for a Christmas party for paediatric patients.

Mike van der Watt, Medical Director for being invited to present at a national conference hosted by NHS Improvement on how the trust turned around from being one of the worst to one of the best trusts regarding mortality.

The memory support team for running a competition for the most imaginative and inventive Twiddlemuff! A twiddlemuff is a knitted aid which can help people with dementia settle on wards and receive stimulation by familiar tasks and sensations.

4. BOARD UPDATE

4.1. Welcome to:

Andy Barlow, Divisional Director for Women’s and Children’s services who will be in attendance at future board meetings

Natalie Edwards who will be observing future board meetings as part of NHSI’s NExT director scheme. Natalie has 20 years extensive HR experience working in both strategic and operational roles.

5. KEY MEETINGS

Attended a Midlands and East Chairs Networking Event

Met with Jackie Kelly Dean of University of Hertfordshire

Attended a diabetes day and received a cheque from Michael Green Diabetes Foundation with the Mayor Dorothy Thornhill

Attended an event at the House of Commons on the importance of addressing mental health during pregnancy

Attended a medical staffing committee meeting

Chaired an appointments panel to recruit a consultant urologist

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6. RECOMMENDATION

6.1. The Board is asked to receive the report for information.

Professor Steve Barnett Chair December 2017

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Page 1 of 9

Trust Board Meeting

07 December 2017

Title of the paper Chief Executive’s report

Agenda item 08/54

Lead Executive Katie Fisher, Chief Executive Officer



The aim of this paper is to provide an overview of the work and key decisions taken by the trust executive committee since the previous board meeting.


N/A

Action required: The Board is asked to receive the report for information.

8

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Page 2 of 9

Risk to Board Assurance Framework (BAF)





PR4a


PR4b


PR5a

Inability to deliver and maintain performance standards for Emergency Care

PR5b

Inability to delivery and maintain performance standards for Planned Care(including RTT, diagnostics and cancer)

PR7a

Failure to achieve financial targets, maintain financial control and realise and sustain benefits from CIP and Efficiency programmes

PR7b

Failure to secure sufficient capital, delaying needed improvements in the patient environment, securing a healthy and safe infrastructure



PR10

System pressures adversely impact on the delivery of the Trust's aims and objectives PR6 – business continuity has been closed (incorporated into PR1)







Risks attached to this project/initiatives and how these will be managed

8



Page 3 of 9

Agenda Item: 08/54

Trust Board Meeting – 07 December 2017 Chief Executive’s report Presented by: Katie Fisher, Chief Executive 1. PURPOSE

1.1. The aim of this paper is to provide an overview of the work and key decisions taken by

the Trust Executive Committee since the previous board meeting.

2. LOCAL NEWS AND DEVELOPMENTS

2.1. Professor Steve Barnett has been appointed for a further term of office as Chair of the trust. The appointment was made by NHS Improvement (NHSI) who is responsible for appointing all Chairs and Non-Executives to NHS Trusts throughout England.

2.2. The appointment has been extended for two years and will end on 08 November 2019.

New lung function lab 2.3. A new lung function lab has opened in Watford, helping patients get treated closer to

home and speeding up decisions on discharge or transfer to other centres. Previously patients with respiratory problems needed to travel to a lab in Hemel Hempstead which is difficult as many suffer from breathlessness and limited mobility.

2.4. The state of the art equipment allows the trust to see patients with more advanced respiratory disease and supports the introduction of cardio pulmonary exercise testing.

2.5. The new lab at Watford is also helping to save on travel costs and staff time accompanying inpatients Urgent care

2.6. The Urgent Care Centre in Hemel Hempstead became an urgent treatment centre on 01 December 2017 as part of a national change. NHS England wants to have 150 urgent treatment centres in place across England to ease the pressure on hospitals, and particularly A&Es, so that they are free to treat the most serious cases.

2.7. There is currently a range of walk-in centres for patients with different names so NHS England is introducing the new centres to standardise this confusing range of options and to simplify the system for patients.

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2.8. The Urgent Care Centre at Hemel Hempstead hospital will operate on much the same basis as the current Urgent Care Centre and will initially have the same opening hours from 8am-10pm every day (which is above the 12 hours specified by the government). However, the Herts Valley Clinical Commissioning Group (HVCCG) plans to revisit the question of opening hours with residents in the context of other urgent care services such as NHS111 and GP out-of-hours services.

Winter planning

2.9. To provide oversight of NHS service delivery, patient care and performance during

winter, NHS England (NHSE) will be establishing director-led winter rooms. These will be in operation 8am-6pm on weekdays from November through to Easter and during high pressure weekends (around Christmas and New Year; half-term and Easter).

2.10. NHSE and NHSI commenced a test run of the winter rooms in October 2017 and the Trust will be required to provide regular reports on the status of the system.

2.11. To support resilience in staffing in areas with high vacancy rates over the Christmas and

New Year period, the trust will be offering an incentive scheme to band 5 and 6 nurses and theatre ODP staff through the hospital bank from the 20 December 2017 until 15 January 2018.

2.12. The board will receive a paper providing further details on winter planning as part of the

meeting on 07 December 2017.

Fire safety 2.13. A phased programme of work has been developed to address issues identified in recent

surveys on fire prevention measures across the three hospitals. The programme will ensure that the Trust complies with its statutory fire obligations; focusing on the highest priority recommendations first.

2.14. The Board will receive a paper on 07 December 2017 which will provide further clarity around levels of fire safety assurance.

Car parking

2.15. The car parking permit criteria for staff parking across the three hospitals is changing to

ensure it is fair and equitable for all. This will require all staff to re-apply for a car parking permit, disabled parking bays will be increased and charges for disabled drivers introduced. The impact of these changes will be reviewed by the Trust Executive Committee in May 2018.

Employee benefits and health and wellbeing portal

2.16. A new employee benefits and health and wellbeing portal is being developed. The portal will be accessible to staff online and is designed to give staff the means to take care of their physical, financial and mental wellbeing.

Conflicts of interest

2.17. The Trust’s conflicts of interest policy has been updated in line with national guidelines. The guidance introduces common principles and rules for managing conflicts of interest, provides advice to staff and organisations on what to do in common situations and supports good judgement on how interests should be approached and managed.

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Medical records

2.18. The management of health records is vital in ensuring safe and effective care to patients. Therefore, the trust will be moving to a full electronic storage system for health records. A working group has been established which, in the first instance, will monitor the scanning of 100,000 health records and them to formalise options to move towards a full electronic records system.

Progress week

2.19. The Trust held a progress week in October 2017 to support earlier discharge and to understand the obstacles that prevent patients leaving hospital earlier. Progress week focused on eight wards which were visited throughout the week and board rounds were observed. The Clinical Trust Executive Committee has reviewed the outcome of the week and agreed some actions to improve the service. These include a more consistent approach to writing up discharge paperwork, better use of the discharge lounge and reducing variability in discharge practices in different wards. Flu campaign

2.20. All NHS trusts have been asked to show that every eligible member of staff has been

offered the flu vaccine. The Trust has sought to make it as easy as possible for all staff to receive their flu vaccination, with staff flu clinics at the three hospitals plus trained peer vaccinators on wards and in departments.

2.21. In November 2017, the Trust took part in the national #Jabathon campaign run by NHS

Employers. This involved running extra drop in clinics across all sites and at various times and tweeting pictures of flu fighters who had had their jab. A collage of photos used in the Trust’s communications campaign was awarded as a winner by NHS Employers.

Staff survey

2.22. The NHS staff survey closed at the beginning on 01 December 2107. The survey is one of the best ways that staff can share their views about their job and the NHS. Previous staff survey feedback has led to positive changes for staff across the Trust, for instance last year staff fed back that they were experiencing too much stress at work and communication and support is ongoing to remind staff to take regular breaks. A monthly relaxation day and a wide range of exercise classes have also been introduced.

2.23. In order to increase the response rate the communications and workforce team worked together on intensive and positive communications during November 2017. Staff have been assured that the survey is completely anonymous and encouraged to complete the survey by being given the opportunity to be entered into a prize draw.

Visiting times extended

2.24. Longer visiting hours have been introduced in order to improve the patients’ experience and to suit patients’ and families’ individual needs. There is now flexible visiting between 1pm and 9pm every day on all of adult wards with the exception of the Acute Admissions Unit (AAU level 1) that allows open visiting.

2.25. Carers and people visiting patients who are at the end of their life are welcome to visit at any time. Although, visitors may be asked to leave during personal care and doctors'

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ward rounds to maintain confidentiality of other patients and people are requested not to visit during protected mealtimes unless they are there to help their loved one to eat.

2.26. The visiting times for the Maternity and Children’s wards are open for parents and partners.

Smoke free

2.27. The Trust went smoke free in October 2017 and there has been a positive improvement

in the environment. However, as expected, there are still a small number of patients and visitors who continue to smoke on site and, since the removal of the smoking shelters, they have found other places to smoke. The Trust is focusing on these ‘hotspots’ and continuing to reinforce the message that smoking is not permitted in hospital grounds, including car parks.

Environmental update

2.28. The Trust has an ongoing comprehensive management programme to keep the estate as safe and secure as possible. In addition to the regular work, below is a brief summary of additional works carried out across the sites since the last Board report.

Works to the ED corridor at Watford have been completed

Continuing installation of additional air conditioning units across the Trust

New lighting installations in outpatient clinic at Watford

Improvements to high level car park and street lighting

Potholes filled throughout the estate, including car parks

Medical units installed in theatre 5 at Watford

Upgraded external lighting across the Trust

Ongoing works to a clinical decision unit at Watford

Staff meals

2.29. Medirest, who are commissioned by the Trust to supply patient and staff meals, has introduced a new range of meals which are available to staff who do not have time to eat in the restaurant or need a meal out of hours. A range of 12 various meals are available from the restaurant and from a chilled vending machine in the A&E department. All meals can easily and quickly cooked in a microwave.

3. COMMUNICATIONS REPORT

Media

3.1. The Trust received coverage on a variety of topics during October, notably the Hemel Hempstead Gazette’s report on plans to change the Urgent Care Centre (UCC) at Hemel Hempstead Hospital to an Urgent Treatment Centre (UTC).

3.2. Other articles in the media during October included:

The Watford Observer reported that the East of England Ambulance Service has taken over several non-emergency transport contracts after the Private Ambulance Service went into administration. The Guardian, The BBC and the Herts Advertiser all reported on the story.

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The Hemel Hempstead Gazette and Express reported that the Trust missed two out of its three targets for waiting times, according to NHS statistics. The Trust was one of the worst performing in the country for the number of A&E patients being seen within four hours.

The Herts Advertiser reported on a raft of proposed health cuts in Hertfordshire, including axing NHS-funded IVF and forcing smokers and obese patients to make bigger health improvements before surgery.

The Hertfordshire Mercury reported that Herts hospitals are among the most expensive in England for parking.

The Watford Observer reported that armed police, firefighters and NHS services will take part in a terrorism training exercise at Watford Football club.

Paul da Gama spoke live on BBC3 Counties radio about the impact of Brexit on recruiting and retaining nursing staff. Paul said that among other factors, including London weighting and more demanding language skill requirements, Brexit was definitely contributing to the number of people leaving the nursing workforce. The Trust was therefore continuing to recruit from further afield including the Philippines and India. Paul emphasised that the Trust valued all its nurses and that EU nurses were a vital part of the workforce.

Website

Top five pages visited on internet site (excluding home page and vacancy pages):

1. Watford > wards and departments

2. Travel information > parking

3. About > contact

4. Our services > pathology

5. About our sites > Watford

October 2017 Positive coverage Neutral coverage Negative coverage

National coverage 0 2 1

Coverage (Watford) 3 2 2

Coverage (Dacorum) 0 4 2

Coverage (St Albans) 0 0 0

Other local 2 0 1

Letters coverage 6 2 2

Month’s Figures 17/18

Month’s Figures 16/17

Total Quarter 1 (April –June)

Total Quarter 2 (July – Sept)

Running total 17/18

Total 16/17

Total Page Views 484,415 413,825 1,364,707 1,414,842 3,263,964 4,901,513

Number of unique visitors

42,330 37,238 106,195 107,937 256,462 370,658

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Internal Communications

October 17/18

Total Quarter 1 (April - June)


Running total 17/18

Number of e-newsletters (e-update) 8 15 26 67

Number of CEO briefings 6 12 19 50

Number of Herts & Minds newsletters 0 1 1 3

Freedom of Information

October 17/18

Total Quarter 1 (April – June)


Running total 17/18

Total 16/17

Number of FoIs received 54 153 169 376 662

Compliance within 20 day deadline

78% 95.0% 88.6 86% 94.3%

No of FoIs received from media outlets

2 24 24 50 100

Social Media

Twitter

Followers Posts Likes Retweets

October 2017 5,905 73 199 63

Our most popular Tweet was “It’s #worldstrokeday today. Our stroke unit has maintained its

great performance – ‘AA’ rating – the highest possible,” with 17 likes and 13 retweets.

Facebook

Followers Posts Likes Comments

October 2017 1,271 10 331 29

Our most popular post was about a family who donated 50 care bears to Sarratt ward, showing

appreciation for the care their relative received. The post “50 Care Bears have joined the ward

thanks to the amazing fundraising efforts of one family. They were so appreciative of our care

for their relative and so impressed by our end of life care project that they wanted to give

something back,” received 179 likes, 11 comments and was shared two times. The post

reached 7,885 people.

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4. LEADERSHIP CHANGES 4.1. Patrick Hennessey has been appointed to the role of Director of Environment. He is

currently the Deputy Director of Environment and will take up his new post when Kevin Howell, the current director leaves at the end of December 2017.

4.2. Rachel Hoey has been appointed as Director of Emergency Medicine. 4.3. Esther Moors has been appointed as Programme Director for Acute Redevelopment. 4.4. Nyarayi Mukombe, Associate Director of Infection Prevention and Control left the Trust

in November 2017 to take up a promotion at North Middlesex Hospital. Interim arrangements are being considered and a recruitment campaign is underway.

5. RECOMMENDATION

5.1. The Board is asked to receive the report for information. Katie Fisher Chief Executive December 2017

8



Trust Board Meeting

07 December 2017 Title of the paper Integrated Performance Report

Agenda item 09/54

Lead Executive Sally Tucker, Chief Operating Officer

Author Jane Shentall, Director of Performance


The Integrated Performance Report covers the November reporting period (October data). For this reporting period, the Board is asked to particularly note the following performance changes since the last reporting period: Safe, Effective, Caring:

% of patient safety incidents that were harmful dropped by 0.8% to 12.5% (13.3% in September).

Combined (elective and non-elective) emergency readmissions within 30 days deteriorated at 7.7% (6.4% in September)

Mixed sex accommodation breaches improved significantly, showing 5 for the month (10 in September)

3 cases of Clostridium difficile were reported but there is no evidence of transmission between cases

Harm free care improved to 93.3% (89.4% September) with an associated improvement in the 5 of new harm free care to 98.1%.

Complaints performance demonstrates a continuing trend of improvement, at 60% (51.4% in September), with consistent performance for early contact (within 3 working days) with patients

Combined Caesarean rates (elective and non-elective) increased to 32% (September 27.2%)

Responsive:

RTT (incomplete) performance improved to 88.45% (88.1% September)

ED 4 hour wait performance improved to 83.4% (81.6% in September)

Ambulance turnaround delays between 30-60 minutes decreased (by 9.5%)

The cancer 62 day (84.9%*) and 62 day cancer screening (72.2%*) were

provisionally below the standard (*data is provisional at the time of this

report)

Formal delayed transfers of care decreased to 5.6% (6.9% in September)

The number of patients not treated within 28 days of last minute cancellation increased to 4 (2 in September)

Well Led:

Appraisal (88.27%) and mandatory training (89.1%) remain below target

Staff turnover (rolling 3 months) increased to 18.2% (17.7% September)

% agency pay rose is in line with target at 8%

Staff FFT response rate showed good improvement at 19.4%(11.87% in September) however % who would recommend fell to 53.8% (59% September)

Further detail is provided in the executive summary and relevant exception reports, including performance trends.

Where the report has been previously discussed

Trust Executive Committee (Performance) 29.11.2017

9

Tab 9 Integrated performance report - month 7


Action required:

The report is provided for information and discussion.


PR1 Failure to provide safe, effective, high quality care PR2 Failure to recruit to full establishments, retain and engage workforce PR3 Current estate and infrastructure compromises the ability to deliver

safe, responsive and efficient patient care PR4a Underdeveloped informatics infrastructure compromises ability to

deliver safe, responsive and efficient patient care – IM&T PR4b Underdeveloped informatics infrastructure compromises ability to

deliver safe, responsive and efficient patient care – Information and information governance

PR5a Inability to deliver and maintain performance standards for Emergency Care

PR5b Inability to delivery and maintain performance standards for Planned Care(including RTT, diagnostics and cancer)

PR7a Failure to achieve financial targets, maintain financial control and realise and sustain benefits from CIP and Efficiency programmes

PR7b Failure to secure sufficient capital, delaying needed improvements in the patient environment, securing a healthy and safe infrastructure



PR10 System pressures adversely impact on the delivery of the Trust's aims and objectives PR6 – business continuity has been closed (incorporated into PR1)

Trust objectives To deliver the best quality care for our patients To be a great place to work and learn To improve our finances To develop a strategy for the future

Benefits to patients/staff from this project/initiatives The Integrated Performance Report provides a view of performance across all key metrics in the areas of Safe, Effective, Caring, Responsive and Well Led

Risks attached to this project/initiatives and how these will be managed The Integrated Performance Report is reviewed monthly at the Trust Executive Committee prior to submission to the Board. Individual performance indicators are also reviewed at divisional level at monthly Performance meetings, where associated risks and issues are discussed and documented, and relevant actions tracked. Data quality is regularly reviewed both internally and by the Trust’s auditors.

9

Tab 9 Integrated performance report - month 7


Integrated Performance

Report

November 2017

(October data)

1

9

Tab 9 Integrated perform

ance report - month 7

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Well ledReporting sub committee – PSE

ResponsiveReporting sub committee – TEC

Safe Effective CaringReporting sub committees – COE and S&C

2

Areas requiring performance improvement• VTE risk assessment was below threshold (pages 4 & 18) • Admissions to stroke ward within 4 hours was below the performance standard and marginally worse than the national average (pages 4 & 14) • There were 5 mixed sex accommodation breaches (pages 3 & 24)• Harm free care (new and all harms), as measured through the Safety Thermometer was worse than the performance standard and the national average (pages 4 & 20) • Complaints responded to within agreed timescales was worse than the 85% external performance threshold but meeting the internal improvement trajectory (pages 3 & 15)• Maternity FFT % positive indicator was worse than the performance standard (pages 3 & 36)

New to category this month:• The percentage of patients receiving a caesarean section was worse than the performance threshold (pages 4 & 24)• Clostridium difficile was worse than the monthly threshold (3 cases recorded) but better than the year to date threshold (9 vs 18) (pages 3 & 16)

Areas requiring performance improvement• A&E 4 hour wait performance was below standard (pages 5 & 30) • Formal DToCs were below standard (pages 6 & 31) • Ambulance turnaround times' performance was worse than standard (pages 5 & 30)• The RTT incomplete indicator was worse than the standard (pages 5 & 25)• Patients not treated within 28 days of their last minute cancellation was below standard (pages 6 & 26)• The 62 day GP indicator was provisionally worse than the standard (pages 5 & 29)• The 62 day screening indicator was provisionally worse than the standard (pages 5 & 29)• Diagnostic wait times did not achieve the performance standard (pages 5 & 26)

New to category this month:None

Areas requiring performance improvement• The staff turnover rate (rolling 12 months) was below the performance standard (pages 7 & 32)• Staff turnover (rolling 3 months) was worse than target (pages 7 & 32)• The vacancy rate was worse than the performance standard (pages 7 & 32)• Appraisals was worse than target(pages 7 & 33) • Mandatory training was worse than target (pages 7 & 33)• Friends and Family response rate for A&E was below threshold (pages 7 & 35)• Inpatient FFT response rate was worse than the target (pages 7 & 35)

New to category this month:• Maternity Friends and Family response rate was worse than target (pages 7 & 35)

Areas of good performance • Mortality indicators show sustained excellent performance (pages 3 & 13)• There were no cases of MRSA bacteraemia (pages 3 & 16)• Patients spending 90% of their time on the stroke unit was better than the performance standard (pages 4 & 14)

New to category this month:• A&E FFT % positive indicator was better than the performance standard (pages 3 & 36)• There were no never events reported (pages 4 & 17)• There were no medication errors causing serious harm reported (pages 4 & 18)

Areas of good performance • The 2WW and breast symptomatic cancer indicators achieved the performance standard (provisional) (pages 5 & 27)• Cancer 31 day first , 31 subsequent drug and surgery indicators are delivering to the performance standard (provisional) (pages 5 & 28 - 29)• Hospital initiated outpatient cancellations under 6 weeks performed better than the performance standard(pages 6 & 26) • The Trust did not report any patients waiting 52 weeks on an incomplete pathway (page 5)


Areas of good performance •• The sickness rate was better than target (pages 7 & 32)• Temporary costs and overtime as % of total pay bill was better than target (pages 7 & 32), including and excluding unfunded beds (two indicators)• Bank pay was within the new target range of 8 %– 12% (pages 7 & 32)


Executive Summary

Oct-17 11

Sep-17 10

Aug-17 13

Achieving

Oct-17 10

Sep-17 11

Aug-17 8

Not achieving

Better than

national

average

Oct-17 8

Sep-17 11

Aug-17 11

Worse than

national

average

Oct-17 9

Sep-17 6

Aug-17 8

NB. Indicators achieving relate only to where targets have been set - as seen on the indicator summary. Ratings showing the number of indicators better or worse than the national average relate to only those indicators where the national average

was available. Indicators which are identified in the main pack as provisional may lead to changes to achieving/not achieving counts previous months in Executive Summary.

Oct-17 9

Sep-17 9

Aug-17 12

Achieving

Better than

national

average

Oct-17 9

Sep-17 9

Aug-17 9

Worse than

national

average

Oct-17 5

Sep-17 5

Aug-17 5

Oct-17 4

Sep-17 5

Aug-17 8

Achieving

Better than

national

average

Oct-17 5

Sep-17 5

Aug-17 6

Worse than

national

average

Oct-17 5

Sep-17 5

Aug-17 4

Oct-17 12

Sep-17 11

Aug-17 8

Not achieving

Oct-17 12

Sep-17 12

Aug-17 9

Not achieving

NB. The sum of indicators achieving and not achieving may not be equal between months due to some indicators being reported with a lower frequency than monthly

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Indicator Summary

3

Data Quality RAG keyRed – Data accuracy is not known, it is incomplete and inconsistent with relevant standardsAmber – Data is assumed to be complete and accurate, although there may be limitations or unresolved queriesGreen – Data is complete, accurate and consistent with the standards set for the specific indicator

Exception indicators keyRed for a minimum of two data points and amber for one, out of the latest three data pointsRed for the latest data point

l

u

Domain a Indicator Target a Aug-17 Sep-17 Oct-17 a YTD Actual YTD Target aExecutive

LeadMonth

Included

in

Detailed

Reports

National

/ Locala

National

avg.

National

avg.

Period

Trend

Data

Quality

RAG

SHMI (Rolling 12 months) 100 89.6 89.5 91.9 MD May-17 Y National 100 May-17G

HSMR - Total (Rolling three months) 100 77.7 84.7 85.0 MD Jul-17 Y National 100 Jul-17G

Crude Mortality Rate (Non elective

ordinary)**3.5% 2.9% 2.7% 2.6% 2.6% 3.5% MD Oct-17 Y National 2.75% (East

of Eng.)May-17

G

l 30 Day Emergency Readmissions - Combined * 4.0% 7.7% 6.4% 7.7% 7.3% 4.0% MD Oct-17 Y National 11.4% 2011-12G £

Marginal tariff reimbursement, possible

penalties

30 Day Emergency Readmissions - Elective * n/a 3.2% 2.6% 3.0% 3.1% n/a MD Oct-17 Y National n/aG £


penalties

30 Day Emergency Readmissions - Emerg * n/a 11.6% 9.7% 11.8% 11.0% n/a MD Oct-17 Y National n/aG £


penalties^

Number of patients with a length of stay > 14

days *tbc 319 326 354 2372 tbc MD Oct-17 Local n/a

G £Reduction in reimbursement vs largely

fixed costs. No penalty levied.

Staff FFT % recommended care tbd NHSI^ 61.5% 51.1% 64.5% 59.5% tbd NHSI^ DoW Sep-17 Y National n/aG

Inpatient Scores FFT % positive 95% 91.0% 94.0% 93.4% 92.9% 95% CN Oct-17 Y National 95.9% Sep-17G

A&E FFT % positive 95% 93.3% 94.4% 99.7% 92.9% 95% CN Oct-17 Y National 86.9% Sep-17G

Daycase FFT % positive 95% 98.2% 97.8% 99.6% 98.6% 95% CN Oct-17 Y National n/aG

Maternity FFT % positive 95% 96.5% 94.6% 94.0% 94.6% 95% CN Oct-17 N National 96.2% Sep-17G

l

% Complaints responded to within one month

or agreed timescales with complainant85% 45.9% 51.4% 60.0% 53.8% 85% CN Oct-17 N Local n/a

R

Complaints - rate per 10,000 bed days tbd NHSI^ 48.2 34.9 30.8 35.3 tbd NHSI^ CN Oct-17 N National n/aR

Reactivated complaints 9 8 9 54 n/a CN Oct-17 N Local n/aR

Proportion of complaints with verbal

communication at the beginning of the

process

58.5% 66.7% 65.0% 62.7% CN Oct-17 N LocalR

l Mixed sex accommodation breaches 0 12 10 5 56 0 CN Oct-17 N National52 Trusts

breachingOct-17

G £Penalties from CCG. £250 per day per

service user.

u Clostridium Difficile 2 0 0 3 9 18 CN Oct-17 Y National 2.7 average Sep-17G £

Penalties from CCG, fines from other

statutory authorities. £10,000 per case

above threshold.

MRSA bacteraemias 0 0 0 0 1 0 CN Oct-17 Y National n/aG £


statutory authorities. £10,000 in respect

of each incidence in the relevant month.

E. Coli Bacteraemia tbc 3 2 4 22 tbc CN Oct-17 Y National n/aG

Safe

, Eff

ecti

ve, C

arin

g

* Performance may change for the current month due to data entered after the production of this report

** Crude mortality threshold UCL upper control limit (2 standard deviations from mean)

tbd NHSI^ - threshold/target to be determined by Trust Development Agency guidance when available

NB. Where national avg. blank - information not currently available

Financial impact

^Calculation of emergency re-admissions penalty – Re-admission rate is applied to the value of all admitted activity. 25% of this is

then applied on the basis that this proportion is avoidable.

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Indicator Summary

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l

u

Domain Indicator Target Aug-17 Sep-17 Oct-17YTD

ActualYTD Target

Executive

LeadMonth

Included

in

Detailed

Reports

National

/ Local

National

avg.

National

avg.

Period

Trend

Data

Quality

RAG

Never events 0 0 1 0 2 0 MD Oct-17 Y National n/aG £


statutory authorities, prosecution^

Serious incidents - number* tbd NHSI^ 3 5 3 22 tbd NHSI^ MD Oct-17 Y National n/aG

% of patients safety incidents which are

harmful*n/a 9.9% 13.3% 12.5% 11.4% n/a MD Oct-17 Y National n/a

G

Medication errors causing serious harm * 0 0 1 0 1 0 MD Oct-17 Y National n/aG

l CAS Alerts: Number issued each month n/a 16 5 6 6 n/a CN Oct-17 Y National n/aG

CAS alerts not acknowledged within 48 hours 0 0 0 0 0 0 CN Oct-17 National n/aG

Number of falls* 114 96 121 724 CN Oct-17 Y LocalG

Number of falls with harm* 20 19 22 146 CN Oct-17 Y LocalG

Number of G3 pressure ulcers (Hospital

acquired)0 2 3 2 12 0 CN Oct-17 Y Local

G

Number of G4 pressure ulcers (Hospital

acquired)0 1 0 0 1 0 CN Oct-17 Y Local

G

l

Safety Thermometer Harm Free Care (acquired

within and outside of Trust)*/**95.0% 88.4% 89.4% 93.3% 91.3% 95.0% CN Oct-17 Y National 94.3% Oct-17

G

Safety Thermometer % New Harm Free Care

(acquired within Trust)*/**tbd NHSI^ 97.6% 97.4% 98.1% 98.2% tbd NHSI^ CN Oct-17 Y National 98.3% Oct-17

G

Safety Thermometer New Harm Free Care:

Catheter & UTI New Harms*/**tbd NHSI^ 4 3 0 15 tbd NHSI^ CN Oct-17 Y National

WHHT 0.0

vs 0.29Oct-17

G

l VTE risk assessment* 95.0% 90.9% 91.0% 91.7% 91.4% 95.0% MD Oct-17 Y National 95.2% Q1 2017A

u Caesarean Section rate - Combined* 28.0% 24.3% 27.2% 32.0% 27.8% 28.0% MD Oct-17 Y Local 26.7%Apr15-

Aug15 A

Caesarean Section rate - Emergency* 15.0% 13.0% 16.6% 18.2% 16.2% 15.0% MD Oct-17 Y Local 15.3%Apr15-

Aug15 A

Caesarean Section rate - Elective* 11.0% 11.3% 10.6% 13.7% 11.6% 11.0% MD Oct-17 Y Local 11.4%Apr15-

Aug15 A

Maternal deaths 0 0 0 0 0 0 MD Oct-17 N National n/aG

lPatients admitted directly to stroke unit

within 4 hours of hospital arrival *90.0% 72.1% 62.9% 60.0% 65.7% 90.0% COO Oct-17 Y National 60.2% Jul-17

G

Stroke patients spending 90% of their time on

stroke unit *80.0% 88.4% 85.7% 87.5% 84.0% 80.0% COO Oct-17 Y National 85.7% Jul-17

A

* Performance may change for the current month due to data entered after the production of this report


** Indicators reported from NHS Safety Thermometer

Safe

, Eff

ecti

ve, C

arin

g

NB Exception reports not provided for FFT scores


Financial impact

^Recovery of cost of procedure or episode plus any additional charge incurred for

corrective procedure or care in consequence to the event.

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Indicator Summary

5



l

u


ActualYTD Target

Executive

LeadMonth

Included

in

Detailed

Reports

National

/ Local

National

avg.

National

avg.

Period

Trend

Data

Quality

RAG

l Referral to Treatment - Admitted* 90.0% 72.7% 69.5% 67.4% 72.1% 90.0% COO Oct-17 Y Local 75.0% Sep-17G

l Referral to Treatment - Non Admitted* 95.0% 89.5% 86.2% 88.4% 89.1% 95.0% COO Oct-17 Y Local 89.5% Sep-17G

l Referral to Treatment - Incomplete* 92.0% 88.8% 88.1% 88.4% 89.5% 92.0% COO Oct-17 Y National 89.1% Sep-17G £

CCG penalty of £100 in respect of each

excess breach above the threshold

Referral to Treatment - 52 week waits -

Incompletes0 0 0 0 0 0 COO Oct-17 National

1778 (all

Trusts)Sep-17

G

l Diagnostic wait times 99.0% 99.0% 98.1% 98.6% 99.0% 99.0% COO Oct-17 Y National 98.0% Sep-17G £


excess breach above the threshold

l ED 4hr waits (Type 1, 2 & 3) 95.0% 82.5% 81.6% 83.4% 82.8% 95.0% COO Oct-17 Y National 90.1% Oct-17G £


excess breach above the threshold (cap

off 8% of attendances)

ED 12hr trolley waits 0 0 0 0 0 0 COO Oct-17 Y National 53 (all Trusts) Oct-17G £ CCG penalty £1,000 per incidence

l

Ambulance turnaround time between 30 and

60 mins0 466 443 401 2,742 0 COO Oct-17 Y Local n/a

R £CCG penalty £200 per service user

waiting over 30 mins

l Ambulance turnaround time > 60 mins 0 169 163 170 1,229 0 COO Oct-17 Y Local n/aR £

CCG penalty £1,000 per service user

waiting over 60 mins

Cancer - Two week wait * 93.0% 95.3% 95.2% 96.1% 95.1% 93.0% COO Oct-17 Y National 93.7% Q2 17/18G £

CCG penalty breaches per qtr in excess

of tolerance is £200 for each breach.

Cancer - Breast Symptomatic two week wait * 93.0% 97.4% 97.6% 96.7% 92.8% 93.0% COO Oct-17 Y National 93.3% Q2 17/18G £


of tolerance is £200 for each breach.

Cancer - 31 day * 96.0% 99.3% 96.5% 99.2% 98.7% 96.0% COO Oct-17 Y National 97.7% Q2 17/18G £


of tolerance is £1,000 for each breach.

Cancer - 31 day subsequent drug * 98.0% 100.0% 100.0% 100.0% 100.0% 98.0% COO Oct-17 Y National 99.4% Q2 17/18G £



Cancer - 31 day subsequent surgery * 94.0% 100.0% 100.0% 96.0% 98.1% 94.0% COO Oct-17 Y National 95.8% Q2 17/18G £



u Cancer - 62 day * 85.0% 86.6% 80.7% 84.6% 87.5% 85.0% COO Oct-17 Y National 82.2% Q2 17/18G £



u Cancer - 62 day screening * 90.0% 94.1% 86.4% 72.2% 91.2% 90.0% COO Oct-17 Y National 91.7% Q2 17/18G £



*RTT and cancer performance for latest month is provisional and subject to validation


Res

po

nsi

veFinancial impact

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Indicator Summary

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l

u


ActualYTD Target

Executive

LeadMonth

Included

in

Detailed

Reports

National

/ Local

National

avg.

National

avg.

Period

Trend

Data

Quality

RAG

Urgent operations cancelled for a second time 0 0 0 0 0 0 COO Oct-17 Y National n/aG

lNumber of patients not treated within 28 days

of last minute cancellation0 12 2 4 40 0 COO Oct-17 Y National

8 (avg. all

Trusts)Q2 17/18

G

l Delayed Transfers of Care (DToC)* 3.5% 3.7% 6.9% 5.6% 6.0% 3.5% COO Oct-17 Y National 6.0% Feb-16G

Delayed Tranfers of Care (DToC) beddays used

in month1,163 1,150 1,093 9,233 COO Oct-17 Y National n/a

G

l Outpatient cancellation rate 8.0% 11.3% 12.0% 10.4% 11.3% 8.0% COO Oct-17 Y Local n/aG

Outpatient cancellation rate within 6 weeks^ 5.0% 4.0% 4.9% 4.1% 4.1% 5.0% COO Oct-17 Y Local n/aG

l Patient initiated cancellations (all) 13.1% 12.8% 12.8% 12.8% COO Oct-17 Y LocalG

Hospital + Patient initiated cancellations (all) 24.4% 24.7% 23.2% 24.2% COO Oct-17 Y Local n/aG

^ Excluding valid cancellations (cancellations to provide earlier appointments or where appointment no longer required, cancellations due to where patients have died, cancellations to appointments made in

error and cancellations where there was a change to a clinic template without a change to a patient's appointment date, time or site)


*DToC benchmark estimated by total delayed patients nationaly as percentage of occupied general and accute beds

Res

po

nsi

ve

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Indicator Summary

7



l

u


ActualYTD Target

Executive

LeadMonth

Included

in

Detailed

Reports

National

/ Local

National

avg.

National

avg.

Period

Trend

Data

Quality

RAG

l Staff turnover rate (rolling 12 months) 12.0% 16.2% 16.0% 16.2% 16.2% 12.0% DoW Oct-17 Y National 13.5% (Beds

and Herts orgs)Dec-15

G

Staff turnover rate (rolling 3 months) 12.0% 16.0% 17.7% 18.2% 15.1% 12.0% DoW Oct-17 Y National 13.5% (Beds

and Herts orgs)Dec-15

G

Nurse Band 5 Turnover Rate 25.8% 26.5% 26.7% 26.4% DoW Oct-17 Y Local n/aG

% staffleaving within first year (excluding

medics and fixed term contracts)18.6% 17.7% 18.5% 18.8% DoW Oct-17 Y National n/a

G

Sickness rate 3.5% 3.0% 2.8% 3.0% 3.0% 3.5% DoW Oct-17 Y National 3.8% (EoE

orgs)Dec-15

A

l Vacancy rate 9.0% 12.7% 11.8% 11.1% 12.4% 9.0% DoW Oct-17 Y National 11% (local

survey)Dec-15

G

u Appraisal rate (non-medical staff only) 90.0% 91.2% 89.5% 88.27% 88.3% 90.0% DoW Oct-17 Y National 85% (local

survey)Dec-15

G

u Mandatory Training 90.0% 90.1% 89.1% 89.1% 89.9% 90.0% DoW Oct-17 Y Local 86% (local

survey)Dec-15

G

% Bank Pay** 8% - 12% 9.3% 9.5% 9.2% 9.5% 8% - 12% DoW Oct-17 Y Local n/aG

u % Agency Pay** 8.0% 7.4% 8.3% 8.03% 8.4% 8.0% DoW Oct-17 Y Local 11.4% (local

survey)Dec-15

G

Temporary costs and overtime as % of total

paybill** (Inc. unfunded beds)22.6% 17.3% 18.3% 17.7% 18.4% 22.6% DoW Oct-17 Y National n/a

G

Temporary costs and overtime as % of total

paybill** (Excl. unfunded beds)6.9% 7.7% 7.4% 7.7% DoW Oct-17 Y National n/a

G

l Inpatient FFT response rate 50.0% 30.9% 21.9% 24.2% 23.1% 50.0% CN Oct-17 Y National 25.3% Sep-17G

l A&E FFT response rate 15% 6.3% 5.3% 4.3% 4.7% 15.0% CN Oct-17 Y National 12.5% Sep-17G

Daycases FFT response rate tbd NHSI^ 25.4% 27.5% 33.0% 30.7% tbd NHSI^ CN Oct-17 Y National n/aG

l Staff FFT response rate 50% 15.7% 11.8% 19.4% 15.6% 50% DoW Sep-17 Y National n/aG

Staff FFT % recommended work 66% 58.5% 59.0% 53.8% 55.8% 66% DoW Sep-17 Y National n/aG

u Maternity FFT response rate 35% 42.8% 37.1% 30.0% 37.8% 35% CN Oct-17 N National 22.4% Sep-17G

*Perfomance for current month may change due to data entry post production of this report

W

ell L

ed


*Medication errors causing serious harm data for latest month is provisional and subject to validation. Temporary costs and overtime performance is provisional for the current month

NB. Exception reports not provided for FFT scores ** Trajectory set as target


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Detailed reports

8

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Finance (Overview)

9

Operational performanceCurrent deficit of £27.57m is £12.72m adverse to plan as at M7 YTD. All areas are adverse to plan to some degree, with £4.50m due to unachieved CIPs (see left) and £3.25m due to NHS revenue, although it is worth noting that the latter is currently £26.01m up on the same point in 2016/17

Recovery plans have been identified to ensure the Trust achieves its revised target of a £35.00m deficit, all of which will be planned and implemented as soon as is practical.

Savings and outlook for FY18Savings achieved at £5.64m up to M7, slightly ahead of plan by £0.31m, i.e. projects costed vs actual delivery), and behind target by £3.32m (where we wanted to be at this point in the year). 2017/18 Trust savings target is £21.9m, of which £13.7m has been assigned to divisions and £9.74m identified.

Achievement within the £13.7m is on target, albeit with significant up- and down-sides across divisions. Current gap mainly due to centrally-held £8.3m CIP target in additional to those held by divisions.

£m Plan Actual Var

Surplus / (Deficit) (0.4) (2.9) (2.5)

£m

Surplus / (Deficit) (14.8) (27.6) (12.7)

Breakeven

£m % Budget

Medicine 0.3 27

Unscheduled Care (2.5) (27)

Surgery (4.3) (59)

Women's (0.3) (3)

BPPC Clinical Support 0.2 6

Estates & Facilities (0.1) (1)

Corporate 0.2 1

Other (6.2)

Total (12.7)

Month 7 performance - 19% (95% target)

Financial Risk Rating FY18

EFL The Trust has managed spend within its

External Financing Limit.

10 Days' Cash

Cash at 31/10/17 equated to 8 days' spend

FY18 YTD Variance by Division

Financial Overview as at 31 October 2017

Statutory / Regulatory Duties

The Trust has a deficit plan of £15m for

FY18.

CRL The Trust has not exceeded its Capital

Resource Limit.

Month 7 Income & Expenditure

Year to Date

0

5

10

15

Oct Nov Dec Jan Apr Mar Apr May Jun Jul Aug Sep

Forecast Cash £m

F'cast cash

10 days' cash

0

500

1,000

1,500

2,000

2,500

3,000

3,500

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

Savings £'000

Actuals

Target

0

20

40

60

80

100

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

Rolling BPPC Payment Performance

Target

No.

Value

-45.00

-40.00

-35.00

-30.00

-25.00

-20.00

-15.00

-10.00

-5.00

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

Income & Expenditure FY18 £m

Actuals

Plan

Base Forecast

RecoveryForecast

3

GG

Operational performanceRevised forecast of £35m provisionally accepted by NHSI, compared to agreed 2017/18 control total of £15m. Change driven by challenges re CIP achievement, commissioner challenges, and consequent STF loss.

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Finance (I&E)

10

Statement of Comprehensive Income (I&E)

Engagement with Commissioners• Contractual HVCCG activity continues to form the bulk of all income (small areas of block contract). • CQUIN management involves formal monitoring and regular operational controls, assuming 90% achievement at this stage less PY adjustment.• Final FY17 income remains under discussion.

Operational performanceNHS income was £3.3m below plan YTD (£0.4m above in month), with a favourable variance in Non-Elective (£1.9m) offset by Elective (£2.1m, primarily Surgery), Outpatients (£1.5m) and Other (£1.5m).Other income was £2.2m adverse YTD (£1.1m in month) primarily due to STF income assumptions offset by favourable car parking income.

Outlook for FY18The current income forecast reflects all known and anticipated pressures, including the outcome of the recent MSK tender (subject to confirmation) and any STF income forgone as a result of missing the overall control total of a £15m full year deficit. [All areas of NHS income are up on the same point in 2016/17]

Budget Actual Var Budget Actual Var

Volumes

3,693 3,676 (17) Elective 42,806 21,605 21,517 (88) 3,444

4,227 4,103 (124) Non elective 49,525 24,723 24,975 252 4,369

39,855 36,172 (3,683) Outpatient 433,803 230,358 219,416 (10,942) 36,512

10,054 9,639 (415) A&E 117,791 58,803 58,850 47 9,823

4,718 4,940 221 Elective 55,461 32,204 30,147 (2,058) 27,106

8,532 8,901 369 Non elective 100,978 58,942 60,816 1,874 47,917

5,956 5,869 (86) Outpatient 70,191 40,840 39,385 (1,454) 35,341

1,355 1,375 20 A&E 16,032 9,358 9,429 71 7,392

1,164 1,140 (24) Critical care 13,781 8,044 7,836 (208) 7,014

3,632 3,550 (82) Other NHS revenue 42,978 25,087 23,609 (1,477) 20,446

25,357 25,775 418 TOTAL NHS REVENUES 299,421 174,475 171,222 (3,253) 145,216

22 25 4 Private Patients 259 151 119 (32) 136

1,136 158 (978) Other non-NHS clinical income 11,306 5,092 2,435 (2,657) 6,789

1,157 183 (974) TOTAL Non NHS Clinical 11,565 5,243 2,553 (2,689) 6,925

1,116 1,039 (77) Education & Training 9,644 5,625 5,601 (25) 4,195

1,224 1,208 (16) Other Revenue 15,367 9,008 9,499 491 8,194

2,340 2,247 (93) TOTAL OTHER REVENUE 25,011 14,633 15,099 466 12,389

28,854 28,204 (649) NET HOSPITAL REVENUE 335,996 194,351 188,875 (5,476) 164,530

£000's

Month 7 (Oct)Prior Year

Actual

YTD FY18

Budget

£000's£000's £000's £000's £000'sNHS REVENUE£000's £000's

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Finance (I&E)

11

Statement of Comprehensive Income (I&E)

CIP schemesCIP schemes are a combination of expenditure, income, and transformational schemes.All cross-cutting CIP themes are closely monitored through formal meetings and operational actions. Targeted assistance from SD & PMO colleagues for a period of 6-8 weeks from October is helping to generate a greater range of CIP ideas alongside the means and expertise to implement them in the best possible way.

Operational performance Pay costs were £4.3m adverse YTD (Medical £1.6m adv, Other Clinical £0.9m adv, Sci / Tech / Prof £0.5m adv & Unidentified CIP £3.0m, offset by Non-Clinical £1.8m fav). Focus on agency management continues agency cost trend established in FY17, £0.6m behind plan YTD (see following slide).

Non-pay costs were £3.5m adverse YTD – Increased outsourcing and drugs overspends were offset by favourable depreciation and clinical services.[Further detail is given in the main Finance Report.]

Outlook for FY18Current costs and recovery actions are continually assessed as part of general good practice alongside a formal process with NHSI.

Mitigating actions, including use of the Model Hospital and the internal SDO are at various stages of progress.

Budget Actual Var Budget Actual Var

18,882 18,222 660 Permanent / Bank Staff 223,226 130,674 124,293 6,382 97,179

540 1,583 (1,043) Agency 6,348 3,680 11,354 (7,674) 14,038

(869) (869) Unidentified pay savings (8,887) (3,000) (3,000)

18,553 19,805 (1,252) TOTAL PAY 220,686 131,354 135,647 (4,293) 111,217

1,755 1,797 (42) Drugs 21,258 12,205 13,011 (806) 10,754

2,738 2,526 212 Clinical services 32,372 18,764 17,563 1,200 15,794

5,841 6,137 (296) Non-clinical services 71,081 41,992 44,392 (2,401) 34,911

(583) (583) Unidentified non-pay savings (5,278) (1,496) (1,496)

9,752 10,461 (709) TOTAL NON-PAY 119,433 71,464 74,966 (3,502) 61,459

549 (2,061) (2,610) EBITDA (4,123) (8,467) (21,738) (13,271) (8,146)

708 610 98 Depreciation & Amortisation 8,500 4,962 4,268 694 3,810

128 156 (28) Interest 1,545 904 1,051 (146) 824

73 73 - Dividends Payable 872 511 511 - 1,384

(360) (2,899) (2,539) Surplus / (Deficit) (15,040) (14,844) (27,568) (12,724) (14,164)

Month 7 (Oct)Prior Year

Actual

YTD FY18

Budget

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12

Finance (Agency)Agency spend trajectory

Green – 2015/16 £36.8m, large

proportion of pay costs on

agency spend; agency caps

and other measures

implemented in-year

Red - This year, where we

needed to be in order to

achieve target expenditure of

£17.0m. YTD results M7 were

£0.6m behind plan with plans

being implemented to

maximise the chances of

achieving FY18 targets. The

Purple line shows what may

happen if M7 spend persists.

Blue – 2016/17 £26.5m, a

>£10m decrease on 2015/16

but still a high proportion of pay

spend compared to peers.

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

Required trajectory 17/18 1,860 3,438 4,996 6,741 8,163 9,772 11,354 12,586 13,817 14,877 15,938 16,998

Trajectory based M7 1,860 3,438 4,996 6,741 8,163 9,772 11,355 12,938 14,521 16,104 17,687 19,270

Cumulative plan 17/18 1,701 3,571 5,102 6,462 7,823 9,183 10,713 12,074 13,434 14,625 15,815 17,006

Cumulative actual 16/17 2,605 5,416 7,655 9,846 11,932 14,004 16,635 18,938 21,560 23,847 24,973 26,501

Cumulative actual 15/16 2,772 5,712 8,744 11,930 15,236 18,418 21,978 25,157 28,255 31,149 34,046 36,827

Required trajectory 17/18 1,860 1,578 1,558 1,745 1,422 1,609 1,583 1,232 1,230 1,060 1,060 1,060

Trajectory based M7 1,860 1,578 1,558 1,745 1,422 1,609 1,583 1,583 1,583 1,583 1,583 1,583

Months plan 17/18 1,701 1,871 1,530 1,360 1,360 1,360 1,530 1,360 1,360 1,190 1,190 1,190

Months actual 16/17 2,605 2,811 2,239 2,191 2,086 2,072 2,631 2,303 2,621 2,288 1,126 1,528

Months actual 15/16 2,772 2,940 3,032 3,186 3,306 3,182 3,561 3,179 3,098 2,894 2,898 2,780

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Performance relative to targets/ thresholds

Executive lead Clinical lead Operational lead

Oct-17 4 4

Sep-17 3 5

Aug-17 4 4

Hospital

Standardised

Mortality

Ratio

(HSMR)*

Summary

Hospital

Mortality

Indicator*

Not achieving

Reporting sub committee - S&C &

COEC

Safe,

effective,

caring

Crude

mortality rate

(non-

elective)*

*Dr Mike Van der Watt

Tracey Carter

Achieving

0

30

60

90

120

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

HSMR (overall) HSMR (weekend) Threshold (HSMR overall)

0

30

60

90

120

Apr 2012 toMar 2013

Jul 2012 toJun 2013

Oct 2012 toSep 2013

Jan 2013 toDec 2013

April 2013 toMar 2014

July 2013 toJune 2014

Oct 2013 toSept 2014

Jan 2014 toDec 2014

Apr 2014 toMar 2015

Jul 2014 toJun 2015

Oct 2014 toSep 2016

Jan 2015 toDec 2015

Apr 2015 toMar 2016

Jul 2015 toJun 2016

Oct 2015 toSep 2016

Jan 2016 toDec 2016

Apr 2016 toMar 2017

SHMI (Rolling 12 months) Actual SHMI (Rolling 12 months) 100

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

Apr

May Jun Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Crude Mortality Non-Elective Actual Mean UPL 2 standard devs LPL 2 standard devs

13

Hospital mortality indices continue to demonstrate sustainedimprovement. Recent intelligence from Dr Foster benchmarks theTrust against the Shelford group, and places WHHT as one of six trustsin that peer group that sit within the ‘lower than expected’ range.

For the 12 month period (September 2016 to August 2017), the Trust’sHSMR of 91.92 was in the ‘lower than expected’ range. Nationally,WHHT had the 33rd lowest HSMR out of 136 non specialist trusts,placing the organisation in the top 25% when compared acrossEngland. The Trust has the 4th lowest HSMR within the East of Englandregion.

There was a peak in crude mortality over the winter period which was mirrored nationally.

The Summary Hospital Mortality Indicator’s (SHMI) latestperformance (for April 2016 to March 2017) was 91.94 and ‘asexpected’ (band 2), placing the Trust 20thnationally.

The Trust continues to hold monthly specialty/departmental MortalityReview meetings, cases from which are then discussed at a bi-monthlyTrust wide Mortality Review, chaired by the Medical Director. The casenote review process is currently being reviewed in order to align withthe recent publication, ‘National Guidance on Learning from Deaths’.

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Stroke 60 mins , s troke care and STeMI 150 mins* (to fol low)

% Emergency

re-admissions

within 30

days

following an

elective or

emergency

spell*

Patients

admitted

directly to

stroke unit

within 4

hours of

hospital

arrival*

Stroke

patients

spending 90%

of their time

on stroke

unit*

0%

2%

4%

6%

8%

10%

12%

14%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

30 Day Emergency Readmissions - Elective % 30 Day Emergency Readmissions - Emergency %

Combined Performance Combined Target

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

2015/16 2016/17 2017/18

Performance Target Mean Upper control limit (3 sd) Lower control limit (3 sd)

0%

20%

40%

60%

80%

100%

120%

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

2015/16 2016/17 2017/18

Performance Target Mean Upper control limit (3 sd) Lower control limit (3 sd)

14

Emergency ReadmissionsCombined emergency readmission rates, including both emergency andelective admissions, includes all patients with more than one admission tothe hospital within a period of 30 days, regardless of whether the secondadmission was related. Both elective and emergency re-admission rateshave risen but the combined rate remains lower than the nationalaverage

A pilot aftercare project was undertaken July – September. An analysis was undertaken and the paper shared. Consideration is underway as to how this can be taken forward .

StrokePerformance for October was 60% for 4 hour admission to the StrokeUnit, 0.2% the 90% target and below the national average. The latestreporting quarter results for SSNAP (April – July 17) shows the nationalaverage as 60.2%.

The target of 80% of patients staying 90% of their admission on thestroke unit was achieved at 87.5%.

Patients that arrive via a pre-alert ambulance are seen immediately onarrival by the stroke team. However, other potential stroke patientswho, during times of increased pressure, experience longer waits in A&Eare not always admitted to the stroke unit within 4 hours. When waitingtimes to be assessed in A&E are long there is a resultant delay in timelyreferral to the stroke team for specialist assessment.

Maintaining ring fenced capacity for stroke patients remains a focusoperationally.

The latest SSNAP results for April to July 2017, shows that Watford Strokeservices have continued to maintain an “A” rating.

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Number of

reactivated

complaints

% Complaints

responded to

within one

month or

agreed

timescales

with

complainant

Safe,

effective,

caring (continued)

Complaints -

rate per

10,000 bed

days

0

10

20

30

40

50

60

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Complaints - rate per 10,000 bed days Complaints - rate per 10,000 bed days

Mean Upper control limit (3 sd)

Lower control limit (3 sd)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Compliants timely response Target Mean

Upper control limit (3 sd) Lower control limit (3 sd) Trajectory

-30

-20

-10

0

10

20

30

40

50

60

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Reactivated complaints Threshold Mean

Upper control limit (3 sd) Lower control limit (3 sd)

15

Complaints rate per 10,000 bed days61 new complaints were received in October, of which 31% (19) relate to Surgery, Anaesthetics and Cancer (SAC), 26% (16) relate to Unscheduled Care (USC), 20% (12) relate to Women’s and Children’s (WACS), 16% (10) relate to Medicine, 3% (2) relate to environment, 3%(2) relate to corporate and there were no complaints received for Clinical Support. In 16% of complaints the patient was unhappy with their treatment and the majority of these were in unscheduled care. 16% of complaints related to appointments, two thirds of which were outpatient cancellations. There was only 1 complaint regarding a cancelled operation. There were a number of complaints relating to communication, particularly in Women’s and Children’s regarding insufficient written information about their care.

Complaints relating to transport have reduced from previous months’ numbers.

% Complaints responded to within one month or agreed timescales with complainant Progress continues against achieving the December 2017 target of responding to 65% of complaints within one month or to agreed timescales with the complainant, and then to sustain this until the end of the financial year. In October 60% (39) of complaints were responded to on time. 82 responses were sent in total, which is almost double the previous period. Complaints responded to on time, by division, is as follows:

Nine complaints were reactivated in October; in two cases complainants referred the Trust to the Ombudsman. Two of these have been long standing complaints where all the appropriate steps have been taken, including meetings with an executive.N/A denotes – no complaints valid for reply to this month.

Target Oct 17

% of complainants with verbal communication at the beginning of process (called within 3 working days of receipt of complaint)

95% by Q4 97%

% of complaints acknowledged within 3 working days 100% 100%

% of complaints taken longer than 6 months to investigate (figure taken at the end of October)

>5% 5%

Jul - 17 Aug - 17 Sep - 17 Oct - 17Trust wide 51% 46% 51% 60%

Medicine 67% 100% 100% 91%USC 33% 25% 29% 35%

SAC 57% 60% 46% 71%

WACS 31% 20% 14% 33%

Environment 33% 60% 78% 50%

CSS 100% 67% N/A 100%

Corporate N/A* 33% 33% 100%

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*Dr Mike Van der Watt

Tracey Carter

Safe,

effective,

caring

MRSA

bactaraemias

and E. Coli

Bacteraemia

Clostridium

Difficile

Never

events*

Reporting sub committee - S&C &

COEC

Apr

May

Jun

JulAug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

JulAug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

JulAug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

2015/16 2016/17 2017/18

MRSA bacteraemias Actual 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0

MRSA bacteraemias Target 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

E. Coli Bacteraemia 3 3 2 3 2 1 1 2 5 0 3 7 1 1 1 4 2 2 5 1 4 4 2 2 1 1 3 8 3 2 4

0

1

2

3

4

5

6

7

8

9

0

5

10

15

20

25

30

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

2015/16 2016/17 2017/18

Clostridium Difficile Actual Clostridium Difficile Target

Clostridium Difficile Actual YTD Clostridium Difficile Target YTD

Actual YTD (Excl. cases with no lapses in care)

0

1

2

3

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

2015/16 2016/17 2017/18

Never events Actual Never events Trajectory Never events Target

16


Sep-17 2 4

Aug-17 4 2

Jul-17 3 3

Achieving Not achieving

Clostridium difficile Infection (CDI)3 cases were reported in October. The full year target ceiling for WHHT apportioned CDIis 23. The year to date total the end of October was 9 cases.

RCAs for the 3 cases have been undertaken. All had different ribotypes and were ondifferent wards, and no evidence of transmission was identified between cases. TheIPCNs produce a trust wide Clostridium difficile newsletter, highlighting key learning andactions to prevent CDI.

The IPCT continues with antimicrobial rounds, weekly Clostridium difficile rounds, andtargeted training. There is also increased IPC support and power training to key clinicalareas.

To date there has been agreement with Herts Valleys CCG that there was no identifiedlapse of care in 1 case of CDI.

MRSA bacteraemia (MRSAb)The full year target ceiling for MRSAb is 0 avoidable cases. No MRSAb was reported inOctober.Key learning relating to the July MRSAb case: Failure to screen wounds on admission,phlebitis from cannula site; failure by staff to identify that a patient was a known MRSAcoloniser. Learning has been shared across all divisions and supported with targetededucation and training. The IPCT are focusing on education and training to improvemanagement of vascular (peripheral and central) devices and plan to undertake a trustwide point prevalence audit in November 2017.

E. Coli bacteraemia (E colib )4 cases of post 48hrs E colib were reported in October. The target set for the CCG thisyear is a 10% reduction equating to 36 cases. There is no target for WHHT. The IPCT isrepresented on the WHHT continence group. This group supports the review of post48hrs E colib RCAs, the outcome of which will influence WHHT’s focus to support thereduction of the Trust’s apportioned E colib cases. The IPCT will undertake a thematicreview of all the post 48hrs for Q1 and Q2 and share across all divisions.

Never eventNo never events were declared in October 2017.

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Medication

errors causing

serious harm*

% of reported

patient safety

incidents that

are harmful

Serious

incidents

0%

5%

10%

15%

20%

25%

30%

35%

40%

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

2015/16 2016/17 2017/18

Actual Target

Upper control and lower control limit to be added

-5

0

5

10

15

20

25

30

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

2014/15 2015/16 2016/17

Actual Target to follow UPL will be used Upper control limit (3 sd)

Lower control limit (3 sd) Mean

0

1

2

3

4

5

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

2015/16 2016/17 2017/18

Actual Target

17

Serious IncidentsThere were 3 SIs declared in October 2017 (5 in September). • 2 in Surgery, Cancer & Anaesthetics , relating to a treatment / procedure• 1 in Women’s and Children's, incident relating to surgical complications

At the end of October 2017 the Trust had 21 open SIs. Investigations are complete for 11 ofthese which are with the CCG pending formal closure on StEIS. In addition there were 10ongoing SI investigations, which were all within the deadline for completion.

Learning from SIsThe following actions and processes are in place to ensure learning from SIs and provideassurance that learning has taken place and changes have been implemented:• 45 day review meetings allow the SI draft report to be discussed and challenged by the

relevant clinical and management teams prior to the action plan being completed.• Each action plan is developed, signed off and monitored by the division leading the

investigation into the incident.• The SI review group (SIRG), chaired by the Medical Director, review all closed SI action

plans where senior divisional representation provides assurance and evidence thatactions have been implemented before the SI is formally closed internally.

Two 45 day meetings were held in October2017.

A SIRG meeting was held on 26 October 2017. 19 action plans were reviewed of which 14were closed. Outstanding evidence for those plans which were not closed will be followedup as part of the SIRG action log. A further 4 action plans were closed – these were actionplans which had been discussed at SIRG previously but not closed due to outstandingevidence.

% of patient safety incidents which are harmful12.5% of incidents reported in October 2017 were recorded as harmful, down from 13.30% the previous month.

There has been a small reduction in the number of reported incidents scored as moderate or above, from 26 in September to 23 in October, of which 17 still require harm validation and are therefore subject to change.

The number of reported incidents categorised as death/catastrophic continues to decrease, with none reported in October compared with 7 in April 2017.

Medication incidents causing serious harm No medication errors were reported as causing serious harm in October 2017 .

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Executive lead Clinical lead Operational lead*Dr Mike Van der Watt

Tracey Carter

Safe, effective,

caring

VTE risk

assessment*

Reporting sub committee - S&C & COEC

CAS alerts:a) number issued per month

(not target)

b) number where

acknowledgement overdue* (target = 0)

(Class 4: for information only and

class 2: Action within 48 hours) AprMayJun JulAugSepOctNovDecJanFebMarAprMayJun JulAugSepOctNovDecJanFebMarAprMayJun JulAugSepOctNovDecJanFebMar

2015/16 2016/17 2017/18

a) CAS alerts issued 7 4 4 8 19 8 12 8 12 6 5 4 1 22 24 14 11 11 10 7 5 7 4 1 6 11 16 5 16 5 6

b) CAS alerts target 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

b) CAS alerts overdue 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0

5

10

15

20

25

30

80%

85%

90%

95%

100%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

VTE risk assessment Actual VTE risk assessment Target Mean

Upper control limit (3 sd) Lower control limit (3 sd)

18


Oct-17 1 4

Sep-17 1 4

Aug-17 1 4


CAS alertsAll alerts issued by CAS in October 2017 were acknowledged within the 48hrdeadline. There were 6 alerts in total issued in October 2017, 2 of whichwere Medical Device alerts and 4 Estate & Facilities .

Neither of the Medical Device alerts was applicable to the Trust and havebeen closed.

3 of the Estate & Facilities alerts have been sent to the relevant divisions and actions are currently ongoing. The other Estates & Facilities alert was not applicable and has now been closed.

There were no breaches during October 2017 and all alerts with deadlines were closed on time

VTE There has been a small sustained percentage improvement in initial VTE riskassessment compliance but more work is required to target non-compliantareas.

Issued by CAS 6

Breached in month 0

Currently overdue 0

CAS alerts not acknowledged within

48hrs 0

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Hospital

acquired

pressure ulcers

Falls and falls

with harm

0

5

10

15

20

25

30

Ap

r

May Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Mar

2015/16 2016/17 2017/18

Hospital acquired pressure ulcers Hospital acquired pressure ulcers (G3) avoidable

Hospital acquired pressure ulcers (G4) avoidable

0

20

40

60

80

100

120

140

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Nu

mb

er

of

falls

Number of falls Number of falls with harm

19

Hospital acquired pressure ulcersIn October there were 27 new pressure ulcers, affecting twenty two patients : Nineteen grade 2 and Two grade 3, and six grade 1.

The Two grade 3 pressure ulcer s have been deemed avoidable.

The grade 2 pressure ulcers are validated by the Matrons for the clinical areas but not differentiated between avoidable and unavoidable.

A trust wide improvement plan is in place to continue the focus on reducing pressure damage as part of harm free care. Revised Best Shot care plan in trial . Some significant improvements have been made with a >58% reduction in grade 3 pressure ulcers developed during April –September 17.

Falls and falls with harmIn October there were 118 inpatient falls with 20 resulting in low harm and 2 moderate harm. In relation to the numbers of falls – falls with harms remains low.

The campaign to address falls continues with the Fall Champions, and with the multidisciplinary falls group.

There is joint working with the Community teams looking at falls and common themes.

Support is provided to specific clinical areas in relation to falls and devising resource packs for staff

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NB. Indicator reported at WHHT from April 2017

Children's

Safety

Thermometer:

Harm Free Care

Adult Safety

Thermometer:

Harm Free Care

and New Harms

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

Ap

r

Ma

y

Jun

Jul

Au

g

Se

p

Oct

No

v

De

c

Jan

Fe

b

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Se

p

Oct

No

v

De

c

Jan

Fe

b

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Se

p

Oct

No

v

De

c

Jan

Fe

b

Ma

r

2015/16 2016/17 2017/18

Harm Free Care (acquired within and outside of Trust)

Harm Free Care (acquired within and outside of Trust) Target

New Harm Free Care (acquired within Trust)

New Harm Free Care (acquired within Trust) national average

0%

20%

40%

60%

80%

100%

120%

Ap

r

Ma

y

Jun

Jul

Au

g

Se

p

Oct

No

v

De

c

Jan

Fe

b

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Se

p

Oct

No

v

De

c

Jan

Fe

b

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Se

p

Oct

No

v

De

c

Jan

Fe

b

Ma

r

2015/16 2016/17 2017/18

Harm Free Care Actual Harm Free Care national average

20

Adult Safety ThermometerThe Adult Safety Thermometer is a measurement tool for improvement that focuses on the four most commonly occurring harms in healthcare: pressure ulcers, falls, UTI (in patients with a catheter) and VTEs. Data is collected through a point of care survey on a single day each month on all patients. ‘Harm free’ care is defined by the absence of harm in these four areas. In October Harm Free Care was 93.4%, below the national target of 95%. This includes harms acquired both inside and outside of the Trust. New Harm Free care (harms acquired in the Trust) for October 2017 was 97.99%, slightly below the national average for October 98%.

Six Month Review of Harms.For September and October no patient has received more than 1 harm.There has been an increase in October safety thermometer numbers - New pressure ulcers increased from 5 to 8. A reduction has been seen with falls with harm ,catheters with new UTI and new VTE’S .

Children and Young People's Services Safety ThermometerHarm includes patients with a PEWS completed: triggered but not escalated,extravasation, patients in pain at point of survey and any pressure ulcer or anymoisture lesion. Harm free care was 100% in September for Acute Children’sServices compared to 82.1% nationally. An analysis of the October 2017 surveydemonstrated that all patients had a set of observations and had been assessed foran Early Warning Score in the last 12 hours. Of those patients with anintravenous (IV) device, extravasation (leakage of a fluid out of its container) wasnot observed in any patient . There were no reports of pressure ulcers or moisturelesions. No patient reported pain at the point of survey.

Harm Free Actions• Urology Steering group established to drive best practise with urinary catheters

and monitor E-coli in conjunction with Infection Prevention and control . Data will be monitored through the group.

• Focus on the Pressure Ulcer improvement plan with Divisions.• Collaborative working with community on harms.• Falls collaboration with community teams• Harm free Care focus on Fridays, prior to Safety Thermometer audits raising

awareness. • National Stop the Pressure awareness day 17th November • Harm free Care tweets on Thursdays and Tuesdays with key messaging• Targeted ward teaching• Implemented pain assessment recording on PEWs charts.

Indicator Apr17 May17 Jun17 Jul17 Aug17 Sep17 Oct17

Number of patients with two

harms - - 1 1 2 - -

New pressure ulcers 1 3 3 4 5 5 8

Old pressure ulcers 31 46 34 51 56 50 26

Number of falls 8 3 3 9 13 14 10

Number of falls with harm - 1 1 2 3 4 1

Catheters 98 103 74 117 86 99 111

Catheter & New UTI 1 1 1 5 4 3 -

New VTE 2 4 2 3 3 4 2

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21

Ward scorecard – key themesWhat is causing the variance in Trust performance

Safety Alerts – There has been an increase in October (46) from September (38). This is mainly due to numbers of falls, and falls with harm in clinical areas thatreported none in September. The areas with high numbers of falls are CCU PG3, Bluebell and Stroke . These are being reviewed by the Falls Specialist Nurse inconjunction with the clinical areas. Three clinical areas have had hospital acquired C – diff in October – Red Suite, AAUY1 and Letchmore.Process Alerts – slight increase in October (108) from September (103) . The increase is due to the overall Test Your Care results in Heronsgate/ Gade(medical), Sarratt (medical), Frailty (unscheduled care), Winyard (medical) and Flaunden (surgical) and the Tissue viability section completion scores. Thereappears to be a direct link between process – risk assessment and care planning with safety outcomes in relation to pressure ulcers demonstrated by theSafety thermometer data.Summary:• Paediatrics have no safety alerts• Maternity have no safety alerts.• Fourteen clinical areas are demonstrating a higher trend of alerts for October compared to September.• The wards that have improvement plans in place have either stayed the same or reduced their alerts.

What actions have been taken to improve performance

• After care project in Unscheduled care and ED focus groups to improve the level of feedback for FFT• Recruitment and Retention meeting. Targeted project focused on the band 5 RN’s. Rotational programmes. Overseas recruitment• Reviewing support mechanisms for staff such as care certificates, Band 6 and Band 7 development courses.• Education around suitable footwear and incidents with falls being monitored• Targeted ward teaching on Falls prevention and management• Falls Resource Folders for clinical areas• Bed rail audit to be shared for learning• Reviewing falls in the clinical areas• Targeted training in relation to Pressure ulcers with wards – purchased a body map that highlights pressure points• Harm Free Care promotion such as Newsletters, Mr B Harmfree – key messages, and Trolley dashes and use of simulation.• Targeted monitoring on practice and cleaning by infection control around C- Diff• Ward Accreditation being undertaken by all ward areas• Champion Roles in clinical areas

Changes in outcomes

• Improvements have been made with a >58% reduction in grade 3 pressure ulcers developed during April – September 17.• Falls with harm has remained low• No increase in incidents around patient deterioration• Test Your Care has increased across the Trust• Reductions in Thromboembolisms with preventable cases and deaths in the Trust

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22

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C-section rate

Mixed sex

accommodation

13%

9% 11%

11%

9% 11%

11%

11% 15

%11

%11

%11

%8% 11

%11

%10

%9%

16%

11%

8%13

%10

% 14%

15%

13%

12%

11%

10%

11%

11% 14

%

18%

21%

17%

19%

19%

16% 21

%20

%22

%20

%20

%20

%21

% 21%

19%

18%

20%

18%

22%

24% 16

%18

% 16%

14%

17%

18%

13%

17%

13% 17%

18%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Ma

r

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Ma

r

2015/16 2016/17 2017/18

Caesarean Section rate - Elective Actual Caesarean Section rate - Emergency Actual

Caesarean Section rate - Combined Target

0

2

4

6

8

10

12

14

16

18

20

Ap

r

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

MSA breaches Actual MSA breaches Target

24

C-section rate

Caesarean section rates are tracked on a weekly basis. There were 444 deliveries in October, 5% above the upper limit of expected activity, some with high acuity and complexity. There is no indication that this surge has continued in to the following month, where there are early indications that rates have reduced.

All caesareans sections undertaken in October are being reviewed to identify the specific cohort responsible for the variance to the last 4 month’s trend which has been between 24.25% and 27.15%. Any opportunities for learning will be actioned.

Mixed sex accommodation (MSA)The number of breaches reported has improved, down from 10 in September to 5 in October.

All breaches occurred in ITU and were due to pressures on the emergencycare pathway.

The monitoring and management of patients requiring step down fromITU is reviewed daily as part of the regular operational managementmeetings, with the intention of reducing where possible, the number ofmixed sex accommodation breaches that occur. Advance planning forcomplex patients requiring side-room capacity is reviewed as part ofthese meetings.

The Trust policy on mixed sex accommodation has been reviewed andratified.

The completion of the RCA template provided by HVCCG is being trialledin ITU.

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Responsive

Reporting sub committee - TEC


Sally Tucker Jeremy Livingstone Divisional Managers

Access indicators - RTT, diagnostics, cancelled operations

and outpatient appointments

Incomplete

pathways

within 18

weeks

Completed

pathways

within 18

weeks

Incomplete

pathways WL

profile

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

Ap

r

Ma

y

Jun

Jul

Aug Se

p

Oct

Nov

Dec Jan

Feb

Mar

Ap

r

Ma

y

Jun

Jul

Aug Se

p

Oct

Nov

Dec Jan

Feb

Mar

Ap

r

Ma

y

Jun

Jul

Aug Se

p

Oct

Nov

Dec Jan

Feb

Mar

2015/16 2016/17 2017/18

Admitted performance Non admitted performance

Non admitted target Admitted target

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

2015/16 2016/17 2017/18

52+ 3 1 - - - - - - - - - - 2 1 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0

26 < 52 701 657 528 358 349 358 347 347 455 550 492 636 649 761 892 984 1,03 987 990 892 964 884 782 659 661 647 625 748 892 993 921

18 - <26 1,62 1,35 1,48 1,29 1,23 1,15 1,10 1,10 1,38 1,34 1,24 1,62 1,83 1,68 2,07 2,21 2,17 2,26 1,96 1,83 1,96 1,65 1,53 1,43 1570 1522 1638 1757 1971 2082 2026

<18 20,7 21,1 21,4 19,6 18,9 17,8 17,4 17,4 17,3 17,2 18,8 19,6 19,2 20,0 22,9 21,7 21,8 21,0 20,5 19,9 19,3 19,1 19,2 20,7 20780212182217822550226292274922580

% of PTL within 18 weeks 89.9% 91.3% 91.4% 92.2% 92.3% 92.2% 92.3% 92.3% 90.4% 90.1% 91.6% 89.7% 88.6% 89.1% 88.5% 87.2% 87.2% 86.6% 87.4% 88.0% 86.9% 88.3% 89.2% 90.9% 90.3% 90.7% 90.7% 90.0% 88.8% 88.1% 88.5%

83%

84%

85%

86%

87%

88%

89%

90%

91%

92%

93%

0

5,000

10,000

15,000

20,000

25,000

30,000

% p

atie

nts

wit

hin

18

we

eks

Nu

mb

er

of

pat

ien

ts

80%

82%

84%

86%

88%

90%

92%

94%

Ap

r

May Ju

n

Jul

Aug Se

p

Oct

Nov

Dec Jan

Feb

Mar

Apr

Ma

y

Jun

Jul

Aug Se

p

Oct

Nov

Dec Jan

Feb

Mar

Ap

r

Ma

y

Jun

Jul

Aug Se

p

Oct

Nov

Dec Jan

Feb

Mar

2015/16 2016/17 2017/18

Performance Mean Upper control limit (3 sd)

Lower control limit (3 sd) Target Trajectory

25


Oct-17 5 2

Sep-17 5 2

Aug-17 5 2


RTTPerformance for October was 88.45%, better than the previous month (88.1%). Themost recent national data available (September) shows that the Trust’s performancethat month was below the national average (89.1%) with 92% achieved at L&D butnot at the RFH (87.4%). Comparative figures for E&NH were not available forSeptember. The median waiting time at WHHT (ie the weeks half the patients on anRTT pathway were waiting) was worse than the national position (7.6 vs 7.2 weeks)and marginally worse than the 92nd percentile wait time (20.3 vs 20.7 weeks).

Elective Medicine remains compliant at 95.3%, as does WACS at 97.2%, and in Surgery83.1% was achieved.

There has been a reduction in the number of services that are non-compliant(October 11 vs September 13).

Service18 Weeks

Plus

% Under 18

WeeksService

18

Weeks

Plus

% Under 18

Weeks

ANAESTHETICS 1 0.00% PAED GASTROENTEROLOGY 3 96.59%

PAIN MANAGEMENT 186 74.17% CLINICAL HAEMATOLOGY 9 96.60%

OPHTHALMOLOGY 619 76.03% ORTHOTICS 5 97.40%

ORTHODONTICS 17 77.33% GYNAECOLOGY 20 97.65%

VASCULAR SURGERY 34 78.62% DIABETIC MEDICINE 2 97.70%

TRAUMA & ORTHOPAEDICS 705 81.96% RHEUMATOLOGY 10 97.76%

ENT 377 82.21% NEPHROLOGY 2 97.80%

GENERAL SURGERY 267 85.85% PAED DERMATOLOGY 1 97.96%

UROLOGY 145 88.14% ENDOCRINOLOGY 6 98.13%

NEUROLOGY 119 88.87% GASTROENTEROLOGY 16 98.59%

ORAL SURGERY 96 90.44% GERIATRIC MEDICINE 1 98.86%

UPPER GI SURGERY 3 92.31% BREAST SURGERY 1 99.69%

PAED ENDOCRINOLOGY 3 93.18% GENERAL MEDICINE 0 100.00%

COLORECTAL SURGERY 35 93.22% OTHER 0 100.00%

RESPIRATORY MEDICINE 31 94.30% PAED EPILEPSY 0 100.00%

CLINICAL ONCOLOGY 3 94.34% HEPATOLOGY 0 100.00%

DERMATOLOGY 129 94.75% PAED CARDIOLOGY 0 100.00%

PAED UROLOGY 7 94.78% STROKE MEDICINE 0 100.00%

MEDICAL ONCOLOGY 1 95.00% RESPIRATORY PHYSIOLOGY 0 100.00%

PAED CLINICAL HAEMATOLOGY 1 95.24% CLINICAL NEUROPHYSIOLOGY 0 100.00%

PAED OPHTHALMOLOGY 5 95.45% NEONATOLOGY 0 100.00%

PAEDS 30 96.43% GYNAECOLOGICAL ONCOLOGY 0 100.00%

CARDIOLOGY 59 96.46% Total 2949 88.45%

9



27 of 125T

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Diagnostics

Patients not

treated within

28 days of last

minute

cancellation

and urgent

operations

cancelled for

2nd time

Hospital

outpatient

cancellations

all and %

cancelled*

within 6 weeks * Ex c l udi ng v a l i d c a nc e l l a t i ons

( c a nc e l l a t i ons t o pr ov i de e a r l i e r

a ppoi nt me nt s or whe r e a ppoi nt me nt no

l onge r r e qui r e d, c a nc e l l a t i ons due t o

whe r e pa t i e nt s ha v e di e d, c a nc e l l a t i ons

t o a ppoi nt me nt s ma de i n e r r or a nd

c a nc e l l a t i ons whe r e t he r e wa s a c ha nge

t o a c l i ni c t e mpl a t e wi t hout a c ha nge t o

a pa t i e nt ' s a ppoi nt me nt da t e , t i me or

si t e )

0

2

4

6

8

10

12

14

16

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Patients not treated within 28 days of last minute cancellation

Trajectory (28 day standard)

Target (28 day standard)

Mean

0%

2%

4%

6%

8%

10%

12%

14%

16%

Apr

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Outpatient cancellation rate Actual Outpatient cancellation rateTarget

Mean Upper control limit (3 sd)

Lower control limit (3 sd) Outpatient cancellation rate within 6 weeks

96.0%

96.5%

97.0%

97.5%

98.0%

98.5%

99.0%

99.5%

100.0%

100.5%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2014/15 2015/16 2016/17

Performance Trajectory Target

Mean Upper control limit (3 sd) Lower control limit (3 sd)

26

Hospital cancellations – patients not treated within 28 days of last minute cancellation

There were 4 breaches of the 28 day rebooking requirement (2 in previous month).There were in Cardiology (1), Oral Surgery (2) and General Surgery (1). One wascancelled due to staff sickness, two breaches were the result of capacity pressures,and one was deferred by the patient.

Hospital cancellations – patients cancelled within 6 weeks and overall

Short notice, hospital initiated cancellation remains below the Trust tolerance (5%) at4.1% (excluding valid cancellations and patient initiated cancellations).

NB: Total cancellation rate does not equate to unfilled capacity.

Diagnostic wait times

Diagnostics recovery is on track with the trajectory plan.

Non-compliance as a result of the significant increases in demand within Cardiology, the impact of changes in a community model.

Additional diagnostic sessions are in place to facilitate a return to compliance and progress against the plan/trajectory is monitored on a weekly basis to provide assurance of this.

All cancellations Under 6 weeks All cancellations Under 6 weeks

10.4% 4.1% 12.8% 10.4%

Total cancellations: 23.2%

Hospital initiated Patient initiated

9



28 of 125T

rust Board M


Responsive



Sally Tucker Jeremy Livingstone Divisional managers

Recovery plan/ existing actions and update

Breast

symptom two

week

standard

CWTs

Two week

standard

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Two week wait performance Two week wait target

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Breast Symptomatic performance Breast Symptomatic target

27

2wwThe provisional position for October is compliant at 96.1%.

Breast symptomaticThe provisional position for October is compliant at 96.7 %.


Sep-17 6 1

Aug-17 6 1

Jul-17 6 1


9



29 of 125T

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31 day

subsequent

surgery

standard

31 day

subsequent

drug standard

31 day

standard

93%

94%

95%

96%

97%

98%

99%

100%

Ap

r

May Jun

Jul

Aug Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

May Jun

Jul

Aug Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

May Jun

Jul

Aug Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

2015/16 2016/17 2017/18

Cancer - 31 day Performance Cancer - 31 day Target

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

102%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Cancer - 31 day subsequent surgery Performance Cancer - 31 day subsequent surgery Target

80%

85%

90%

95%

100%

Apr

Ma

y

Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

Ma

y

Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Cancer - 31 day subsequent drug Performance Cancer - 31 day subsequent drug Target

28

31 day first

Performance is compliant at 99.2% 130 treatments with 1 breach in Urology

31 Day subsequent – Drug

The position is provisionally compliant at 100%

31 day subsequent –Surgery

The position is provisionally compliant at 96.0%

9



30 of 125T

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62 day

screening

standard

62 day

standard

number of

104+ day

waiters

62 day

standard

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr

May Ju

n

Jul

Aug Se

p

Oct

No

v

Dec Jan

Feb

Mar

Apr

May Ju

n

Jul

Aug Se

p

Oct

No

v

Dec Jan

Feb

Mar

Apr

May Ju

n

Jul

Aug Se

p

Oct

No

v

Dec Jan

Feb

Mar

2015/16 2016/17 2017/18

Cancer - 62 day Performance Cancer - 62 day Trajectory Cancer - 62 day Target

0%

20%

40%

60%

80%

100%

120%

Apr

May Ju

n

Jul

Aug Se

p

Oct

Nov

Dec Jan

Feb

Mar

Apr

May Ju

n

Jul

Aug Se

p

Oct

Nov

Dec Jan

Feb

Mar

Apr

May Ju

n

Jul

Aug Se

p

Oct

Nov

Dec Jan

Feb

Mar

2015/16 2016/17 2017/18

Cancer - 62 day screening Performance Cancer - 62 day screening Target

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

Cancer 62 day patients waiting 104 days+ 24 3 3 4 4 2 3 3 2 0

Cancer 62 day PTL (total) 1466 1338 1284 1331 1312 1456 1521 1720 1392 1251

0

5

10

15

20

25

30

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

Nu

mb

er

of

pat

ien

ts w

aiti

ng

10

4+

day

s

Nu

mb

er

of

pat

ien

ts o

n P

TL

29

62 day GP – urgentThe provisional position for Oct is non-compliant at 84.5% There are currently 70.5 treatments and 11 breaches.

104 day waitsIn the October submission to NHSI (15/10) there were no patients reported to be waiting over 104 days on a 62 day GP pathway.

62 day screening Performance is provisionally non compliant at 72.2%. There were 9 cases with 2.5 breaches – validation is ongoing.

Tumour site Oct (prov.)

Breast 100

Gynaecological 85.7

Haematological 100

Head and Neck 0

Lower Gastrointestinal 100

Lung 0

Other 100

Sarcoma -

Skin 91.2

Upper Gastrointestinal 60

Urological 80

Total 84.6

9



31 of 125T

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30

Responsive


Executive lead Clinical lead Operational lead Performance relative to targets/ thresholds

Sally Tucker Dr David Gaunt Divisional managers

Oct-17 1 4

Sep-17 1 4

Aug-17 1 4

A&E

* Please note that the A&E trajectory is a working trajectory and awaiting final approval

Unscheduled care

indicators - A&E,

ambulance turnaround

and DToCAchieving Not achieving

Ambulance

turnaround

time

70%

75%

80%

85%

90%

95%

100%A

pr

May Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Mar

2015/16 2016/17 2017/18

Performance Trajectory Target


0

100

200

300

400

500

600

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Jan

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Jan

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Jan

Feb

Mar

2015/16 2016/17 2017/18

Ambulance turnaround 60 mins+ Ambulance turnaround between 30 and 60 mins Target

A&E performance improved further in October to 83.4% from 81.6% in September(July 82.9% and August 82.5%). Minors performance continues to improve to 96.5%from 94.9% in September, 93.4% in August and 90.6% in July. CED improved to97.8% following the previous months drop in performance that was related to a highvolume of attendances linked to respiratory illness.

Work with the external turnaround team supporting improving performanceconcludes in early November 2017. Work has taken place to clarify pathways andcompliance with the 30 minute response time target for Internal ProfessionalStandards (review of A&E patients by specialty teams). Streaming of patients is takingplace much earlier in the patient pathway. An A&E Performance Manager started inSeptember, working with clinicians to provide a more consistent and responsiveapproach to waiting times for assessment and treatment. The number of breachesdue to delays in assessment and treatment in A&E is reducing.

Focus on ensuring full use of assessment areas continues - Emergency SurgicalAssessment Unit (ESAU), Medical Assessment Area (MAU), Ambulatory Care (ACU)and Frailty. Frailty has relocated to a new dedicated area to protect capacity in ACU.

The number of ambulances waiting between 30 and 60 minutes continues toimprove. The number of ambulances waiting over 60 minutes remains at a similarlevel. The Trust has increased the resource available to care for patients in thecorridor during periods of significant demand, so it can respond flexibly to any queueof ambulances, enabling earlier release of crews. A new Ambulance ResponseProgramme (ARP) went live on 16 October 2017 providing more information aboutpatient conditions, tracking of arrival time and providing a more accurate recordingof handover times.

An activity comparison of the current financial period with the same period last year has shown:• Type 1 attendances are down marginally by 0.2%.• Ambulance arrivals are down by 4.6%.• Admission rate from A&E (excluding ambulatory and frailty) is up by 10.6%.• Discharges (Trust wide) are up by 10.7%

9



32 of 125T

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31

Delayed Transfers of CareDToC patients represented 5.6% of occupied beds in October, measuredusing the nationally reported method. This is based on a snapshot of thenumber of patients waiting at a point in time in the month, expressed as apercentage of beds.

The total beds occupied by DToC patients is a helpful measure to illustratethe impact of DToC because it includes all patients waiting in the month. InSeptember DToC patients consumed 1093bed days, the equivalent of 35.3beds.

There are regular audits of both DToC and other stranded patients (over 7day length of stay) to identify issues and remove avoidable causes of delay.

Ongoing escalation to system partners via the A&E Delivery Board continues,with significant resource directed to generating additional capacity andimproving discharge processes.

An IDT improvement plan is underway. However its impact will be marginaluntil capacity matches demand for onward health and social care services.

Streamlined processes for data monitoring and reporting have beenintroduced, as well as daily “live” patient monitoring with board briefingswith the discharge planning nurses. Lead roles have been introduced inrelation to self-funded patients, and continuing healthcare (CHC)assessments, and a number of staff have been re-allocated to different areasto tackle issues relating to a build up of referrals.

12 hour

trolley waits

Delayed

Transfers of

Care (DToC)

0

10

20

30

40

50

60

0%

2%

4%

6%

8%

10%

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

2015/16 2016/17 2017/18

Beds used by DToC patients in month DToCs DToC target

Apr

May

Jun

JulAug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

JulAug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

JulAug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

2015/16 2016/17 2017/18

Performance 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Target 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0

1

2

Performance Target

0

10

20

30

40

50

60

Nu

mb

er

of

be

ds

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Apr-16

May-16

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

Apr-17

May-17

Jun-17

Jul-17

Aug-17

Sep-17

Oct-17

Total number of beds used by DToC patients 27.1 35.1 32.5 40.535.7 38.7 38.6 41.2 32.7 31.8 43.2 45.0 41.335.135.2 42.7 47.3 52.8 51.6 47.9 47.6 44.0 37.538.335.3

NHS Days 12 21 25 31 24 29 23 23 17 20 25 26 25 21 19 21 24 25 24 19 20 26 18 17 15

DHSS Days 15 14 7 9 11 9 16 18 15 11 18 19 16 12 16 21 23 28 27 28 27 18 20 21 19

Days (BOTH) - - - - - 0 - - - - - - 0 2 0 1 - 0 0 1 0 - 0 0 0

Beds used by DTOC patients: DHSS vs NHS

9



33 of 125T

rust Board M


Well led

Reporting sub committee - PSE


Paul da Gama

Sickness rate

Staff turnover

and vacancy

rate

% bank,

agency and

temporary

pay

Workforce indicators - staff turnover, sickness, bank & agency,

vacancy, appraisal, and mandatory training

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Staff turnover Performance Staff turnover Trajectory Staff turnover target

Vacancy rate Performance Vacancy rate Trajectory Vacancy rate Target

0%

5%

10%

15%

20%

25%

30%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

% Bank Pay performance % Bank Pay Trajectory % Agency Pay performance

% Agency Pay Trajectory Temporary costs performance Temporary costs Trajectory

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Sickness rate performance Sickness rate target Sickness rate Trajectory


Jan sickness hard

32

Turnover and VacanciesThe overall Trust vacancy rate decreased from 11.8% in September to 11.1%. Thetrend is of a falling vacancy rate over the last 12 months, from a peak of 15.9% inAugust 2016, and with the rate falling 12 months out of 15. The current rate is thelowest since April 2016. Whole time equivalent (wte) staff-in-post increased by55wte over the last 2 months, while the establishment decreased by 10wte. Octobersaw the highest ever number of staff in post for the Trust, at 4278 wte’s. The vacancyrate for qualified Nursing & Midwifery posts remained constant at15.4%. Recruitment activity has built up a large pipeline of new N&M recruits and arecent recruitment drive in the Philippines in October has resulted in another 75 joboffers. Many staff in the pipeline are from overseas with long lead-in times, and overthe next few months, the vacancy rate for Nursing and Midwives is expected to rise ,largely due to the transitional time needed for nurses to register with the NMC. TheTrust currently has 54 (98 last month) such nurses awaiting registration. In addition,WHHT is particularly challenged with the turnover rate within Band 5 nursing (around27%), where it is significantly higher than the overall Trust average. The Trust isparticipating in a national initiative looking at ways to address this issue, presenting aproject plan to NHSI which was well received. The 12-month rolling turnover rateincreased to 16.2%. WHHT has the eighth highest turnover (out of 12 organisations)compared to Herts & Beds peers and is above the regional average of 15.4%. Overthe last 2 years, turnover has shown a modest downward trend, although Band 5nursing as noted above, is relatively high.

% Bank and Agency ExpenditureAgency spend in October reduced from £1.61m in Sept to £1.58. This spendrepresented 8% of the overall pay-bill (target 8%). Agency spend has reducedconsiderably over the last couple of years, with spend in 2016/17 being £10m lessthan 2015/16. Work continues on keeping agency spend as low as possible via theAgency Steering Group, and through partnership working across Herts & Beds, withthe latest initiative being the shared staff bank launch.

Sickness rateThe sickness absence rate remains low at 3% in October, and is comfortably below the Trust target of 3.5%. The Trust is currently well below the Herts & Beds average of 3.9% at the end of Quarter 2. Over the last 2 years, sickness absence has fluctuated between 3.8% and 2.8%. Average sickness absence in 2015/16 was 3.4%, whereas in 2016/17 it was fractionally lower at 3.2%. It has averaged around 3.0% in the current year to date.


Sep-17 3 4

Aug-17 3 4

Jul-17 2 5


9



34 of 125T

rust Board M


Number of

staff leaving

within first

year (excluding

medics and fixed term

contracts)

Mandatory

training

Appraisal rate (non medical staff only)

60%

65%

70%

75%

80%

85%

90%

95%

100%

Apr

May Ju

n

Jul

Aug Se

p

Oct

Nov

Dec Jan

Feb

Mar

Apr

May Ju

n

Jul

Au

g

Sep

Oct

Nov

Dec Jan

Feb

Mar

Ap

r

May Ju

n

Jul

Aug Se

p

Oct

Nov

Dec Jan

Feb

Mar

2015/16 2016/17 2017/18

Mandatory Training Performance Mandatory Training Target Mandatory Training Trajectory


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr

May Jun

Jul

Aug

Sep

Oct

Nov

Dec Jan

Feb

Mar

Apr

May Jun

Jul

Aug

Sep

Oct

Nov

Dec Jan

Feb

Mar

Apr

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Jan

Feb

Mar

2015/16 2016/17 2017/18

Appraisal rate Performance Appraisal rate Target Appraisal rate Trajectory


0%

5%

10%

15%

20%

25%

0

50

100

150

200

250

Apr

May Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Mar

Apr

May Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Mar

Apr

May Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Mar

2015/16 2016/17 2017/18

Number of staff % of new staff

33

Appraisal – non medical staffAppraisal rates are currently 88%, with an underlying general improvement trendsince April 2017. There is a significant challenge to maintain focus and ensureappraisal dates are aligned to staff increments to further improve organisationalperformance. For October, the rate dropped slightly below the 90% compliance rateand HRBPs will continue their work with Divisions to develop trajectories andmonitor and ensure performance is consistently above the 90% target. HR BusinessPartners are also working with managers producing bi-weekly reports to support thetransition to effective alignment of appraisals to increments and to plan thecompletion of all outstanding appraisals.

Mandatory training Mandatory training compliance is currently at 89%. This figure has been rolled overfrom the previous month as the database required some validation for competencyrequirements. All substantive current Trust staff and new starters are able to accesse-learning and book core & essential classroom training through a web-based portalthat is accessible outside of the Trust.

Acorn, the new self-service Learning Management System, has now beenimplemented across the trust and is available to all staff. Every current member ofstaff employed by the Trust has received an introductory letter and user guide,providing step by step instruction to enable them to access and use this new system.Substantive and non-substantive new starters can access Acorn to complete their

eLearning, even before they commence employment. The next stage of the Acornrollout involves sending out guidance to 1,000 line managers to enable them to see ata glance, which of the staff in their team(s) are compliant

Number of staff leaving within first yearThe overall rate is 18.5% in October, an increase compared to last month.

The Trust is closely monitoring staff leaver information, particularly data regardingreasons for leaving, via the web-based exit leaver system. The reconnectsessions following corporate induction continue, which bring new starters backtogether and offer an opportunity to resolve any issues and gather information tofurther improve staff experience in the first year in post. Key work is also under wayto support retention of Band 5 nurses, the group with the highest turnover. This alsoforms a part of the Nursing retention project with NHSI, where Band 5 nursing leavershave been identified as a key workforce to reduce leavers overall.

9



35 of 125T

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34

The Board Assurance Framework shows key workforce indicators in the context ofcurrent performance, performance 12 months and 3 months ago, Trust workforcetargets, the distance to these targets and a RAG rating based on 5 scales. It also hasbenchmarking data taken from NHS healthcare providers in the Hertfordshire andWest Essex and Bedford, Luton and Milton Keynes STPs.

The RAG rating is based on distance to targets – if current performance is within 0% to20% (or exceeds) its target then the RAG rating is green. If performance is within 60%– 80% of target then the rating is yellow. This is repeated at 20% intervals for amberand brown until performance is over 80% from the target when the RAG rating is red.If 2 indicators are rated red, then the overall rating is red. If all indicators are ratedgreen, or one is amber then the overall rating is green. Any other combination isamber.

There are 8 (8 last month) indicators rated Green, with performance of 80% or overtowards targets. There are 2 indicators within 60% to 80% of the target. (Turnoverand Vacancies). Vacancy rates have improved from 15.6% a year ago to 11.1%currently.

Trust targets reflect benchmarking of targets of other comparable acute Trusts,including those rated as ‘outstanding’ by the CQC. Appraisal and Core Trainingcompliance targets are now 90% rather than 95% previously. Agency costs as a % ofpay bill has changed from 10% to 8% as this reflects the Trust’s NHSI agency target..

Appraisals were just below target at 88% and mandatory training compliance is89%.Please note that the training compliance figure has been rolled over from Septdue to some validation of the training database.

For sickness the Trust has achieved its target of a rate less than 3.5%

For agency, costs, the current agency pay bill percentage is 8%, in line with the target.

12 month turnover rates are 16.2%, very slightly higher than the figures of 3 monthsago, but less than one year ago.

The latest Q2 FFT score shows a slight increase compared to Q1, and the currentscore is within 20% of the target.

Benchmark averages are taken from Q2 17/18 data and are from 12 nearby NHSorganisations.

Workforce BAF scorecard

9



36 of 125T

rust Board M



Well ledTracey Carter and Paul

Da Gama

Reporting sub committees - PSQ and PSE

Staff scores (%

reccommended

and not

recommended)

and response

rate

A&E scores (%

positive and

negative) and

response rate

Safe, effective,

caring

Friends and family

Inpatient scores

(% positive and

negative) and

response rate 0%

20%

40%

60%

80%

100%

120%

Ap

r

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Inpatient Scores FFT % positive performance Inpatient FFT response rate Inpatient FFT response rate Target

0%

20%

40%

60%

80%

100%

120%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

Ma

y

Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

A&E FFT response rate performance A&E FFT % positive Performance A&E FFT response rate Target

0%

10%

20%

30%

40%

50%

60%

70%

Mar

Apr

Ma

y

Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

Ma

y

Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Staff FFT % recommended work Performance Staff FFT response rate Performance

Staff FFT response rate target

Positive performance targets to follow

35

InpatientsThere has been an improvement in response rate and a slight reduction in recommended rate.

The comments made by patients are overwhelmingly very positive with ‘kind, caring and helpful’ most commonly used phrases.

A&EThere was a reduction in response rates but an increase in recommendation rates.

Staff The Trust is in the process of conducting the staff attitude survey for quarter 3, which isrunning until 1st December 2017. Staff have the opportunity to participate in the survey bycompleting either the online or paper survey. The survey has been promoted widely acrossthe Trust with several “You said, we did” campaigns, a dedicated intranet page, a weeklycommunication campaign, prize draws and managers walking around the Trust wearing“pink “ staff survey t shirts. Results will be analysed in February and key themes reportedback by following this. Currently the Trust has a 36% completion rate

Well led

Oct-17 0 3

Sep-17 0 3

Aug-17 0 3


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36

dupe

Daycases scores

(% positive and

negative) and

response rate

Maternity (Q2)

scores (%

positive and

negative) and

response rate

Outpatient

scores (%

positive and

negative) and

response rate

0%

20%

40%

60%

80%

100%

120%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Daycase FFT % positive Performance Daycases FFT response rate Performance

0%

20%

40%

60%

80%

100%

120%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

Ma

y

Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

Ma

y

Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Outpatient FFT % positive Performance Outpatient FFT response rate Performance

0%

20%

40%

60%

80%

100%

120%

Apr

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Maternity FFT % positive Performance Maternity FFT response rate Performance

The Trust is now measuring both the main DSU at SACH and also the Surgicaladmission lounge at WGH.

Analysis of the feedback deemed to be negative focused on:• lack of staff and staff (especially nurses) being ‘rushed off their feet/so busy’• noise at night from other patients and alarms going off outside of the hospital

but also some comments about night staff in specific wards• delays – waiting to be seen in out-patients and ED, for medications to go

home and also tests and procedures as inpatients• the cost and availability of parking• location/signage for the pre op assessment clinic at WGH, particularly for

elderly patients and/or those with mobility issues

OutpatientsThere was a significant increase in responses (circa 500) and slight increase inrecommended rates (0.4%) and not recommended (0.2%).

Maternity Question 2A reduction in response rate this month but marginal (0.6%) reduction in recommended and significant reduction (2.2%) not recommended.

The comments were overwhelmingly positive with many naming individual staff as outstanding.

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37

Safer staffingIndicator Performance (September) Threshold Trend Forecast next month

% Nursing hours versus planned 95.0% >95% Up >99%

Care hours per patient day 7.4 n/a Stable 7.2

Indicator by shift and skill mix Shift RN Care staff

% Nursing hours versus planned Day 83.1% 91.8%

Night 94.7% 100.2%

Care hours per patient day All 4.7 2.8

What actions have been taken to improve performance

Enhanced care needs team commenced 13 May 2017 – recruiting to theteam continues, continued use of temporary staff at night to support the team.

Local and international recruitment initiatives continue. Trust Recruitment Group formed chaired by Director of HR and Chief Nurse

Shared bank approach across four Trusts commenced 31st July. Project plan to address the retention rate of band 5s is in place chaired by

Executive Director. External Visit requested by Chief Nurse looking at Safe Staffing scheduled

for 11 December

What is causing the variance

Overall the Trust % fill rate for October was 90.0%, a decrease of 2.7% from last month and below the national threshold. The fill rate within the medicine/USC division was92.9 % , a decrease of 2.1%. Within Surgery, the fill rate was 87.6%, down 2%. Overall the fill rate in WACS was 89.4% , down 2.4%. This can be broken down further toshow maternity fill rates at 95% and paediatrics at 79.8%. Paediatric fill rate has decreased by 6.6% from last month and while RN fill rates for NNU day and night are at 80%.the fill rates for care staff (a combination of CSWs & Nursery Nurses )is 51% day and 64.8% night. 71.8% of Trust shifts (days and night) were RAG rated green, up 1.3% fromlast month. 27.7% of shifts (day and night) were RAG rated amber, down 1.4%. 12 shifts (day and night) were RAG rated red (0.5%), in AAU Level 1 Blue, AAU Level 3 Blueand Yellow, ESAU, Del La Mere, Letchmore, ITU and Neonatal Unit. All were logged on Datix and no harm was reported. Mitigations were put in place, eg moving staff to theareas, supervisory band 7s working, specialist and corporate nursing supporting in the numbers to maintain patient care and safety. There was 1 red flagged shift of less than2 registered nurses in October on Del La Mare, mitigated by amalgamating the two wards at SACH, possible as occupancy was low. There were 655 (27.7%) shifts red flaggedfor registered nurses more than 8 hours less than planned, down by 15 (1.7%) from last month. A number of areas have fill rates below 80% - AAU Level 1 Blue, Level 1 Yellow,AAU Level 3 Blue and Yellow, Winyard, Letchmore and Ridge. Sarratt, Tudor, Del La Mare, Flaunden and AAU Triage have fill rates of less than 70% . 8289 shifts wererequested via NHSP for bank and agency fill, 522 shifts more than September. This was due to vacancies, enhanced care requests and surge areas being opened. Howeverthe fill rate was only 76.5%, with 1948 shifts not filled (22.4 %), up 1.1% from last month. The following surge areas were open - MAU (3 days), CDU (6 days), ESAU (15 days),Ambulatory Care (23 days), Elizabeth (23 days) and Oxhey had an additional patient bed open for (31 days). Patients were cared for in these areas by redeployment ofsubstantive staff and bank and agency. Over 228 patients had enhanced care needs identified and were cared for by the enhanced care team by day and bank/agency atnight. The overall Trust Supervisory Hours Lost in October was 37.7%, an increase of 5.1% from last month.

96.8%

98.0%

97.1% 97.2%

96.2%

96.9%

97.6% 97.3%

94.3%

95.2% 95.0%

93.0%

90.9%

5.0

5.5

6.0

6.5

7.0

7.5

8.0

8.5

9.0

90%

91%

92%

93%

94%

95%

96%

97%

98%

99%

100%

Car

e H

ou

rs P

er

Pat

ien

t D

ay

Pe

rce

nta

ge o

vera

ll p

lan

ne

d v

s. a

ctu

al n

urs

ing

ho

urs

Percentage overall planned vs. actual nursing hours & CHPPD

Care Hours Per Patient Day (CHPPD) % Fill Rate Threshold - fill rate

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38

End of Life CareNumber of patients who are referred to the palliative care team and who have an identified preferred place of death

In 2008 the End of Life Care Strategy (Department of Health) was published and one ofthe insights from this was that people weren’t supported to die in their place of choice;and although progress has been made, this has been evidenced in many other reports.In July 2014 just over 50% of respondents to the National Survey of Bereaved People(VOICES-SF) felt that their relative had died in a place of their choice (Office of NationalStatistics, 2014).There is now a national focus on reducing the numbers of patientsdying in hospital and offering everyone who is approaching the end of their life theopportunity to express and share their preference for where they want to die as wellas any goals that are important to them (National Palliative and End of Life CarePartnership, 2015).

In October, 120 referrals were made to the Trust Specialist Palliative Care Team. Thenumber of patients seen by the Specialist Palliative Care Team with an identifiedpreferred place of death (PPD) was 43 out of the 49 patients who had capacity andwere appropriate to have this discussion, equating to 88%.

There were four patients who died in hospital although home was their preferredplace of death. This was due to their physical symptoms not permitting their statedpreference being met.

The measures of success in the Trust end of life strategy are being reviewed and willform part of the Trust Board committee dashboard from December.

Q1 2015/16 (avg per

month)

Q2 2015/16 (avg per

month)

Q3 2015/16 (avg per

month)

Q4 2015/16 (avg per

month)

Q1 2016/17 (avg per

month)

Q2 2016/17 (avg per

month)

Q3 2016/17 (avg per

month)

Jan-17

Feb-17

Mar-17

Apr-17

May-17

Jun-17

Jul-17

Aug-17

Sep-17

Oct-17

Nursing Home 0 3 5 6 5 6 2 3 11 9 6 6 5 4 5 2 5

Hospital 0 3 4 6 10 5 9 19 20 17 6 16 3 6 10 8 6

Hospice 0 11 15 12 10 13 1 15 7 8 12 10 10 9 8 6 16

Home 28 10 12 15 18 13 6 13 15 11 6 10 17 10 13 9 16

Impaired capacity to state a preference 12 14 13 22 17 12 23 35 28 27 23 29 29 23 21 20 26

% with identified preference 54.6% 58.8% 66.9% 82.0% 79.6% 73.0% 69.5% 94.3% 65.1% 51.1% 81.6% 100.0%79.5% 52% 71% 82% 88%

0

10

20

30

40

50

60

70

80

90

0%

20%

40%

60%

80%

100%

120%

Num

ber o

f ref

erra

ls b

y id

entif

ied

pref

eren

ce

Perc

enta

ge o

f ref

erra

ls

Number and percentage of referras with identified preference for preferred place of death, excluding patients unable to state preference, inappropriate referrals or deaths prior to being seen or transferred

back to other HCP’s

Q1

2015/1

6 (avg

per

month

)

Q2

2015/1

6 (avg

per

month

)

Q3

2015/1

6 (avg

per

month

)

Q4

2015/1

6 (avg

per

month

)

Q1

2016/1

7 (avg

per

month

)

Q2

2016/1

7 (avg

per

month

)

Q3

2016/1

7 (avg

per

month

)

Jan-17 Feb-17Mar-

17Apr-17

May-

17Jun-17 Jul-17 Aug-17 Sep-17 Oct-17

Total referrals 63 59 67 71 75 69 78 98 111 120 103 96 108 84 72 90 120

-

20

40

60

80

100

120

140

Nu

mb

er

of

refe

rral

s p

er

qu

arte

r

Referrals to Trust Specialist Palliative Care Team

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Trust data quality, by exceptionData Quality RAG keyRed – Data accuracy is not known, it is incomplete and inconsistent

Amber – Data is assumed to be complete and accurate, although there may be limitations or unresolved queries

Green – Data is complete, accurate and consistent with the standards set for the specific indicator

Domain a Indicator a

Data

Quality

RAG

a Description of issues Improvement action plan Target date for 'Green' rating

Safe, Effective, Caring% Complaints responded to within one month or agreed

timescales with complainant

R

Operational and clinical pressures has meant it has been

challenging to find the time for clinical and operational staff to

respond to concerns on time.

The Unscheduled Care Division are recruiting a 0.5 WTE

position to assist clearing the backlog.

The team are recruiting a new complaints manager and have

approach NHSP and agencies to fill the vacancy.

The Surgery Division has held a complaints workshop to

address backlog. The same will be done in Unscheduled Care.

The Women and Children’s Division are recruiting a post to

deal with complaints. The Environment and Medicines Division

have improved their response times considerably.

Recruitment expected to be completed by end of Summer.

Improvements are hoped to be seen by end of 2017.

Safe, Effective, Caring Complaints - rate per 10,000 bed days

R Capturing complaints across the Trust.

All complaints are captured and triaged daily. All complaints

are logged daily and there are systems in place to capture all

complaints received through the CEO, executive assistants,

through NHS net and on social media. Reminders are sent to all

staff about forwarding complaints received in clinical areas.

There is a system for auditing all new complaints taken through

triage on the following day. This risk is being minimised as much as possible.

Safe, Effective, Caring Reactivated complaints

R Increase in reactivated complaints

We telephone every reactivated complaint to talk through

concerns. We consider if someone independent needs to

investigate. We send reactivated complaints to external

investigators in complex cases. We invite complainants to

meetings to discuss their concerns.

We now record the reason for reactivated complaints and will

audit this. We have asked Healthwath Hertfordshire to review

a pool of complaints and provide feedback. We will ask that

they include a small pool of reactivated complaints also. This risk is being minimised as much as possible.

Safe, Effective, Caring VTE risk assessment*A

Paper based VTE forms used for assessing compliance by clinical

coding team. Evidence elsewhere within notes demonstrating

compliance not on form not previously identified.

Clinical Advisory Group has approved new process for coding

team to assess VTE compliance. Electronic system required to

improve compliance to green.

July 2017 (Amber). Electronic system date of implementation TBC

(for Green)

Safe, Effective, Caring Caesarean Section rate - Combined*A

Perception that there is a difference between caesarean section

rate on CMiS compared to what has been clinically coded

Review of clinically coded notes and comparison to CMiS to

review discrepancies July 2017

Safe, Effective, Caring Caesarean Section rate - Emergency*A As above As above As above

Safe, Effective, Caring Caesarean Section rate - Elective*A As above As above As above

Safe, Effective, Caring Stroke patients spending 90% of their time on stroke unit *A

Responsive Ambulance turnaround time between 30 and 60 minsR Identified inaccuracies in timing of Ambulance Service data Ongoing work with ambulance service TBA

Responsive Ambulance turnaround time > 60 minsR As above Ongoing work with ambulance service TBA

Well Led Sickness rate

A

1. Potential for under reporting

2. There can be issues with data recorded on ESR but this will be

fixed with the implementation of the new ESR 2 system.

1. HR undertook a number of audits to look into areas who were

reporting 0% sickness throughout 2016 and have implemented

learning from those audits, including a new process for

capturing absences if medical staff.

2. implementation of the new ESR 2 system.

September 2017 (linked to the ESR implementation). There will

also be ongoing audits to ensure that absence data is still being

accurately recorded

39

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Trust Board Meeting

07 December 2017

Title of the paper Winter Readiness briefing

Agenda item 10/54

Lead Executive Sally Tucker, Chief Operating Officer

Author Jane Shentall, Director of Performance


This briefing paper provides an overview of the Trust’s winter readiness, in line with the actions included in a letter (Gateway ref 07331) dated 12 October 2017 from Pauline Philip, National Urgent & Emergency Care Director at NHSI. This letter can be found via the following link: http://i.emlfiles4.com/cmpdoc/9/7/2/8/1/1/files/38266_winter-readiness-in-the-nhs-and-care-sectors---pauline-philip-letter.pdf?utm_campaign=1932400_Pauline%20Philip%20letter%20with%20Flu%20and%20other%20attachments%2012%20Oct&utm_medium=email&utm_source=Monitor&utm_orgtype=NHS%20Trust&dm_i=2J9J,15F1S,6YCJP4,3K0KH,1 There are a number of actions that sit with the system:

Upgraded NHS 111 advice

Extended GP access

Ambulance Response Protocols

Front door GP streaming

Capital works/upgrades

In addition, four further actions were described in the 12 October 2017 letter:

Expanding the flu vaccination programme

Reducing delayed transfers of care to provide additional hospital bed

capacity

Increasing the emergency care workforce

Clinical oversight and risk

High level scrutiny of winter planning is evident from the significant number of template returns, papers and plans that have been requested of the system and the Trust in recent weeks. This briefing is set out in table form in order to provide clear evidence against each of the actions noted above that are relevant for the organisation and give assurance that the Trust has robust plans for the coming winter months.


Trust Executive Committee – 29 November 2017

10

Tab 10 Winter readiness briefing


http://i.emlfiles4.com/cmpdoc/9/7/2/8/1/1/files/38266_winter-readiness-in-the-nhs-and-care-sectors---pauline-philip-letter.pdf?utm_campaign=1932400_Pauline%20Philip%20letter%20with%20Flu%20and%20other%20attachments%2012%20Oct&utm_medium=email&utm_source=Monitor&utm_orgtype=NHS%20Trust&dm_i=2J9J,15F1S,6YCJP4,3K0KH,1





Action required:

The Board is asked to note the report for information.






PR4a Underdeveloped informatics infrastructure compromises ability to deliver safe, responsive and efficient patient care – IM&T

PR4b Underdeveloped informatics infrastructure compromises ability to deliver safe, responsive and efficient patient care – Information and information governance













10



Benefits to patients/staff from this project/initiatives Patients and staff will benefit from the increased resilience that will be facilitated through robust winter readiness planning.


Deteriorating CCG financial position which is leading to services, such as community beds being

decommissioned – should be discussed at LDB prior to withdrawal (ED)

Gaps within the clinical workforce in ED with an inability to secure high quality locums consistently,

leading to delays in patient flow through ED – review by Emergency Care Transformation Group and

actions identified to mitigate.

Unpredictable fluctuations in demand – demand will be reviewed through HVCCG Quality Contract

Review meeting, LDB, system calls and escalation.

10



Trust Board – 07 December 2017

ACTION & LEAD ORGANISATION EVIDENCE COMMENT

Upgrades to A&Es across England

WHHT

Work to increase capacity in CDU, in the old

physiotherapy footprint, is underway with an

expected “go live” date of 18/12/2017

When complete, there will be an additional

10 assessment spaces in ED, which will

support an increase in streaming from the

front door.

Expanding the flu vaccination programme

WHHT

Flu vaccination programme underway. A weekly update is provided at TEC and included in the ED performance pack.

Only front line staff vaccination rates are included in the submission.

Staff who have not had the vaccination will be written to at the end of the programme and asked to confirm their choice.

Creation of extra hospital bed capacity by reducing delayed transfers of care

HVCCG / HCT

HVCCG’s original plan was to reduce DToCs to 3.5% by the end of August. This objective was not met.

A revised trajectory is in place to achieve 3.5% by the end of November.

The latest IDT sit-rep (27/11/17) shows 48 DToC patients which represents approximately 8%.

Onward patient flow from community beds is a challenge for the system. HVCCG has the lead on agreeing steps to improve flow/increase capacity with the relevant organisation.

10

Tab 10 W

inter readiness briefing

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ACTION & LEAD ORGANISATION EVIDENCE COMMENT

Increasing our emergency care workforce

WHHT

A range of actions have been taken in relation to the emergency care workforce including:

Increase in the AP establishment

Recruitment of 2 additional consultants

Recruitment to the Nurse Consultant post

Recruitment of middle grades

Review of alternative roles, eg ENP, ANP

Business case relating to ED workforce underway

Development of the Hospital at Night team to include alignment with Outreach team

Recruitment of HCA with phlebotomy skills for STARRing

Embedding the B7 nurse in charge role

Business case approved for increase in Operations team out of hours

Difficulty recruiting middle grades. Now advertising with opportunities for specialism alongside ED role.

Clinical Oversight and risk management

WHHT

Clinical TEC – chaired by CEO EDT – chaired by MD Discharge Planning Working Group – MDT membership Initiatives supported by Clinical TEC include:

Roll out of the 30 minute target for Internal professional standards

Re-structure of the divisions to better support patient flow

Both groups are well attended and there is good clinical engagement.

These groups provide clinical leadership and ownership of improving patient flow from ED through the hospital, and including discharge.

Jane Shentall Director of Performance 26 November 2017

10

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Page 1 of 10


Title of the paper Quality Improvement Plan Progress Update (October 2017 data)

Agenda item 11/54

Lead Executive Tracey Carter, Chief Nurse and Director of Infection Prevention and Control

Author Rita Oye, Head of Programme Management Office

Executive summary

This paper has been discussed at Service Delivery Board Trust Executive Committee (SDB TEC) and assurance was sought for the two ICT projects rated red, with nine red actions (largely relating to the ICT projects). It was agreed that the ongoing ICT & Information and ICT & Transformation projects currently reported within the QIP should be removed from report as the remaining ICT & Transformation actions are all part of the Trust-wide Make IT Happen programme. This programme is managed within the ICT department’s governance structure. The CIO formally reports monthly on progress to the Finance and Investment Committee, which in turn provides assurance to the Board.

Two change requests were approved. Any further actions from the most recent CQC inspection will be added to the QIP which will continue through until the end of March 18. There are 10 projects reported through the QIP reporting cycle this month. The overall status for the QIP at the end of October is green; the forecast status for November is also green. For the month of October 2 actions were closed, resulting in a total of 26 open actions for this reporting period. There are 26 open Risks and 24 open Issues currently associated with the QIP programme.


Strategy Delivery Board (TEC) - 15 November 2016

Action required: The Trust Board are asked to note the review by SDB TEC and accept this paper for information and assurance.

11

Tab 11 Quality improvement plan update


Page 2 of 10





PR4a


PR4b


PR5

a

Inability to deliver and maintain performance standards for Emergency

Care

PR5

b

Inability to delivery and maintain performance standards for Planned

Care(including RTT, diagnostics and cancer)

PR7

b

Failure to secure sufficient capital, delaying needed improvements in

the patient environment, securing a healthy and safe infrastructure

PR8 Failure to engage effectively with our patients, their families, local

residents and partner organisations compromises the organisation’s

strategic position and reputation.

Trust objectives X To deliver the best quality care for our patients X To be a great place to work and learn To improve our finances X To develop a strategy for the future

Benefits to patients/staff from this project/initiatives The QIP will deliver significant quality and safety improvements across the Trust in response to the CQC recommendations which will result in improved outcomes and patient experience.

11



Page 3 of 10

Agenda item: 11/54

Trust Board – 07 December 2017

Quality Improvement Plan Progress Update (October 2017 data) Presented by: Tracey Carter, Chief Nurse and Director of Infection Prevention and Control

1. Purpose

1.1 The Strategy Delivery Board reviews the quality improvement plan (QIP) and seeks assurance of progress and approves changes to the plan.

1.2 The QIP was formally submitted to the CQC and the Trust Development Authority (TDA), now NHS Improvement, on 8th October 2015 and is published on the Trust’s website www.westhertshospitals.nhs.uk/CQC/. The QIP was refreshed following the full CQC re-inspection in September 2016 and a further full review has been completed in response to the publication of the CQC Quality Report in March 2017.

1.3 The QIP has been migrated onto the new project management software, PM3, which is now being used for all major projects.

2. Background

2.1 To date (including this reporting period), sixteen projects have been completed: Vision, Safe Staffing, Information Governance, Data, Recruitment, Caring for our most acutely unwell patients, Outpatients, Patient Flow, Capital Programme, Environment Estates and Facilities, Safety Equipment and Security, Clinical Training, Medicine Management, Urgent and Emergency Care, Environment 2016 CQC Review Action Plan projects and Harm Free Care.

2.2 The QIP is designed to deliver improvements in outcomes and key performance measures.

2.3 This report summarises the progress of the QIP projects at the end of October 2017 and is reported using the Red, Amber and Green (RAG) rating.

2.4 There are 10 projects reported through the QIP reporting cycle this month. The overall status for the QIP at the end of October is green; the forecast status for November is also green.

2.5 Two change requests forms have been submitted to the programme management office from end of life care and patient feedback for change to milestone dates.

11



http://www.westhertshospitals.nhs.uk/CQC/

Page 4 of 10

3.0 QIP Programme Analysis The Portfolio Performance Report below highlights the status of each project (Active plans), the status of each key milestone and the number, and status, of the risks and issues associated with each project. Information presented as Changes in the Active Plans and Key Milestones is a sample of the projects in the QIP and the full detail is presented in section 4 and 5 and 6 of this report.

11

Tab 11 Q

uality improvem

ent plan update

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Page 5 of 10

3.1 Activity Trends

3.2 In the current reporting period there are 10 QIP projects incorporated into the one

QIP Programme making a total of 11 active plans this reporting period.

3.3 One QIP project has been closed this month.

Harm Free Care

3.4 Of the 10 active QIP projects reported against in October 2017, there are eight projects rated as green and two projects reporting as red; the red projects are the IT Transformation and IT Information projects.

3.5 Both IT projects are currently red. The reason for the overall red rating for the two IT projects is due to the impact of the response to recent cyber-threats, resource conflicts due to a raised number of priority 1 service incidents requiring remediation, and issues with supplier performance.

3.6 It has been agreed at Statutory Delivery Board (TEC) that both ICT & Transformation and ICT & Information projects will be removed from the QIP report as they are both part of a Trust wide Transformation Programme and are managed and reported through their various governance structures.

3.7 There are currently 2 projects with completed action plans, Safeguarding and Surgery will both remain as active projects as futher actions are due to be added to the projects.

3.8 The PMO continues to work with the project managers to close or review the forecast delivery dates of the outstanding actions.

3.9 Key Milestones – Status Trends

3.10 There are 26 open actions within the QIP in this reporting period, this is a reduction from the 28 open actions last reporting period. 13 of the 26 actions are currently rated as green and are on track to deliver as agreed in the milestones, 2 milestones are rated amber, and 12 of the 26 open actions are rated as red; compared to 7 amber actions and 10 red actions in the previous reporting period. Projects with red milestones include:-

ICT Transformation

ICT Information

End of Life Care

Patient Feedback

2 actions have been completed in the month of October and closed.

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Page 6 of 10

4.0 Project Activity Detail – RAG Status and Expected Project Completion month by Project

4.1 The table above shows the current RAG status of each of the 10 live QIP projects and 1 QIP Programme. The table also details

expected completion month by Project. Projects with no completion month are either red project or projects that have actions with no

planned completion date detailed in their plan. Work continues to deliver the approved actions. The PMO will work closely with project

leads to agree planned completion dates.

Portfolio Name Plan TypeParent

Plan IDRag Summary Rationale Sponsor Plan Name

Nov

Dec

Jan

Feb

Mar

Apr

May

Jul

Aug

Sep

Oct

Nov

Dec

Programme QIP Programme running to

planned schedule

QIP

Project/

Scheme

213 Project Closed Kevin How ell Capital Programme

Project/

Scheme

213 Project Closed Tracey

Carter

Clinical Training

Project/

Scheme

213 No end date agreed, aw aiting

CR form

Tracey

Carter

End of Life Care

Project/

Scheme

213 Project Closed Enviroment 2016 CQC

review Action Plan

Project/

Scheme

213 Project Closed Kevin How ell Environment, Estates, and

Facilities

Project/

Scheme

213 Project Closed Tracey

Carter

Harm-free Care

Project/

Scheme

213 Project currently running

behind schdule

Lisa Emery ICT and Information

Project/

Scheme

213 Project currently running

behind schdule

Lisa Emery ICT Transformation

Project/

Scheme

213 Aw aiting CR to change detail

of last remaining milestone

Paul Da

Gama

Leadership

Project/

Scheme

213 On Track Tracey

Carter

Maternity

Project/

Scheme

213 Project Closed Mike van der

Watt

Medicine Management

Project/

Scheme

213 Project Closed Arla Ogilvie Outpatients

Project/

Scheme

213 On Track Tracey

Carter

Paediatrics

Project/

Scheme

213 On Track Tracey

Carter

Patient Feedback

Project/

Scheme

213 Project Closed Sally Tucker Patient Flow

Project/

Scheme

213 On Track Tracey

Carter

Quality & Risk

Project/

Scheme

213 Aw aiting additional milestones

to be added

Tracey

Carter

Safeguarding

Project/

Scheme

213 Project Closed Kevin How ell Safety, Equipment, and

Security

Project/

Scheme

213 Aw aiting additional milestones

to be added

Jeremy

Livingston

Surgery

Project/

Scheme

213 Project Closed Tammy

Angel

Urgent & Emergency Care237

286

231

233

225

235

277

215

1788

219

217

1168

221

223

266

1019

255

227

ID

JunQIP 213

252

229

Q4Q4 Q1 Q2 Q3

2017 2018

Project Activity Details

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5.0 Recommendation

5.1 The Trust Board are asked to note the review by SDB TEC and accept this paper for information and assurance.

Tracey Carter

Chief Nurse and Director of Infection Prevention and Control

November 2017

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Page 8 of 10

Appendix 1

Oversight Metrics Performance Challenges

A&E performance (WGH time to initial assessment % within 15 mins) No baseline however, A&E performance improved slightly this month from 85.5% in September to 85.9% in October. This continues to be below the target of 95%

Mandatory training compliance remained the same in October as September at 89.1%. HR continues to implement the new e-learning system although the 95% target has not been achieved.

Outpatients Appointments:

Cancelled appointments decreased in October to 4.1% from September’s figure of 4.9%. This is below the target of 5%

Vacancy rate:

The vacancy rate continued to improve this month from 12.7% in August, 11.8% in September to 11.1% in October. Vacancy rate continues to be behind the trajectory.

Harm Free care (Test Your Care):

Compliance with equipment checks (Test Your Care excluding Maternity, Oxhey and Gade) has fallen in October to 92.5% from 94% in August and 96.7% in September (Target is 90%). Accurate Record Keeping also declined slightly this month to 90.9% from 92.4% in August and 93.6% in September.

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Page 9 of 10

Appendix 1 – Oversight Metrics – October data

Theme Project Metric Target Trend

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17

Our PeopleLeadership and People

DevelopmentMandatory Training 90.00% 86.0% 86.4% 87.7% 87.4% 89.4% 87.9% 87.7% 86.6% 87.2% 88.1% 86.5% 89.1% 87.7% 89.2% 92.1% 91.7% 90.1% 89.1% 89.1%

Our People Recruitment and Induction Vacancy rate 9.0% 13.5% 14.2% 14.5% 15.2% 15.9% 15.7% 15.6% 15.2% 14.3% 13.5% 13.1% 12.5% 13.0% 12.7% 13.0% 12.3% 12.7% 11.8% 11.1%

Our PeopleLeadership and People

DevelopmentAppraisal rate (non-medical staff only) 90.0% 76.5% 85.7% 89.2% 94.0% 91.7% 87.9% 84.6% 80.9% 75.9% 74.6% 73.2% 73.3% 76.5% 90.0% 90.0% 91.2% 89.5% 88.3%

Our People Safe Staffing Red rated shifts (8 RN hours+ less then planned) < 20% 8.6% 6.4% 8.8% 15.8% 19.4% 16.4% 14.2% 10.8% 17.2% 20.1% 16.6% 20.8% 21.0% 18.1% 19.3% 24.3% 32.4% 29.4% 27.7%

Getting the Basics Right Information Governance IG breaches - Level 1 5 3 5 4 5 5 3 4 4 3 4 2 8 3 5 15 10 7 5 13

Getting the Basics Right Information Governance IG breaches - Level 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Getting the Basics Right Harm Free CareCompliance with equipment checks (Test Your

Care excluding Maternity, Oxhey and Gade)90% 88.6% 90.1% 93.2% 93.6% 93.4% 93.3% 91.4% 94.0% 94.4% 92.2% 94.6% 94.9% 94.8% 96.5% 94.0% 93.7% 94.0% 96.7% 92.5%

Getting the Basics Right Harm Free CareMedicines audits - (Drug omissions from

quarterly Pharmacy audit)5% 5.0% 5.4% 5.4% 7.1% 5.2%

Patient FocusCaring for our acutely ill

patients

A&E performance (WGH time to initial

assessment % within 15 mins)95% 75.4% 75.0% 73.9% 76.4% 78.8% 79.5% 74.9% 80.4% 75.0% 78% 76.9% 75.8% 75.9% 87.3% 91.4% 89.0% 88.9% 85.5% 85.9%

Patient FocusCaring for our acutely ill

patientsReturns to ITU within 48 hours 2 3 2 5 2 2 4 400.0% 7 1 5 7 3 4 2 5 3 3 6

Patient Focus OutpatientsCancelled appointments with less than 6 weeks'

notice by the hospital^5% 5.3% 4.1% 3.8% 4.2% 3.7% 3.8% 3.7% 3.2% 3.6% 3.1% 4.1% 4.8% 4.9% 4.0% 3.8% 3.8% 4.1% 4.9% 4.1%

InfrastructureEnvironment, Estates and

facilitiesCompleted Fire and H&S risk assessments 95% 98.9% 99.6% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

InfrastructureEnvironment, Estates and

facilitiesSecurity - completed checkpoints 95% 92.2% 92.0% 87.7% 96.1% 99.5% 99.8% 99.0% 1 98.0% 99.0% 98.0% 99.0% 99.0% 100.0% 98.0% 97.0% 98.0% 99.0% 97.0%

Governance, risk

management and informed

decisions

Quality GovernanceAccurate record keeping (Test Your Care

excluding Maternity, Oxhey and Gade)90% 84.7% 85.6% 89.3% 90.0% 89.7% 89.5% 89.6% 1 91.6% 89.5% 92.2% 91.9% 93.1% 94.2% 90.8% 92.0% 92.4% 93.6% 90.9%

Governance, risk


decisions

Quality Governance Number of SIs submitted to the CCG within time 95% 88.9% 66.7% 33.0% 83.0% 60.0% 50.0% 67.0% 29.0% 0.0% 100.0% 25.0% 100.0% 0.0% 100.0%

Governance, risk


decisions

Risk Processes

Risk - Completed SIs and complaints

investigations with documented actions on

Datix.

90% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

* Indicator measured using response sections: Infection Control, Privacy and Dignity and Resuscitation Trolley. Community Midwifery and Maternity Delivery Suite Care Indicators excluded along with new wards included on TYC in 16/17, Oxhey and Gade.

Performance

* Note that targets for mandatory training, appraisal and vacancy rate have been amended to reflect new Board-agreed levels

^ Excluding valid cancellations (cancellations to provide earlier appointments, cancellations due to where patients have died and cancellations to appointments made in error)


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Appendix 2

REFERRAL TO TREATMENT PERFORMANCE IMPROVEMENT

October 2017 (September performance)

Plans must be put in to place to ensure referral to treatment (RTT) times continue to improve so that

they are similar to or better than the England average

…to improve the percentage of patients to be seen within 18 weeks of referral from a GP for an

outpatient appointment

Submitted performance

Performance against the 92% RTT incomplete pathway standard in September was 88.1% (August

88.8%). The most recent data for August shows that the Trust’s position fell below the national

average (89.4%). Comparison with local peers shows that WHHT performance was however, better

than the Royal Free (87.4%) and East & North Herts (85.7%).

NHS Improvement acknowledged the ongoing challenge of reducing the admitted backlog in the face of

significant capacity constraints. Any additional capacity would come at high cost and would add further

risks the organisation’s financial position. Following discussion, renewed focus on reducing the non-

admitted backlog has been agreed and the divisions were asked to formulate plans to address this.

Recovery trajectory 2017/18

Performance and PTL 2017/18

Oct-17 Nov-17 Dec-17

Week commencing

24/0

4/2

017

29/0

5/2

017

26/0

6/2

017

30/0

7/2

017

27/0

8/2

017

24/0

9/2

017

29/1

0/2

017

26/1

1/2

017

24/1

2/2

017

Planned Performance (92%) 89.4% 90.0% 90.5% 91.1% 91.5% 92.0% 92.0% 92.0% 92.0%

Actual performance 89.5% 90.2% 89.9% 88.9% 88.4% 87.1%

Backlog to clear to achieve

92%643 473 559 831 1,016 1,392

Jul-17 Sep-17Apr-07 May-17 Jun-17 Aug-17

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Trust Board Meeting

07 December 2017

Title of the paper Strategy update

Agenda item 13/54

Lead Executive Helen Brown, Deputy Chief Executive

Author Helen Brown, Deputy Chief Executive


This report provides an update on the current position in relation to a range of longer-term service changes and strategic developments. It will briefly outline progress regarding the following:

1. Your Care Your Future ~ integrated care and pathway re-design.

2. Stroke

3. Vascular

4. Strategic Outline Case for the Redevelopment of Acute Hospital Services

5. Hemel Hempstead Strategic Outline Case

6. Car Parking Strategic Outline Case

7. Pathology

8. Sustainability and Transformation Partnership


Updates on specific issues have been provided to the trust executive committee and other relevant forums.

Action required:

The Board is asked to note the report for information.





PR4a Underdeveloped informatics infrastructure compromises ability to deliver safe, responsive and efficient patient care – IM&T

PR4b Underdeveloped informatics infrastructure compromises ability to deliver safe, responsive and efficient patient care – Information

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Tab 13 Strategy update - month 8


and information governance








Trust objectives To deliver the best quality care for our patients





Continuous improvement in care pathways.

Improved physical environment from which care is provided.


Financial risks relating to pathway redesign: detailed mapping is being undertaken and a standard methodology developed.

Limited funding availability to support the development costs of major capital business projects: progress will be limited until funding sources are confirmed and so, where possible, internal resource is being deployed to support these programmes.

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Agenda item: 13/54

Trust Board Meeting – 07 December 2017

Strategy Update

Presented by: Helen Brown, Deputy Chief Executive

1. Your Care Your Future ~ integrated care and pathway re-design.

The Trust continues to work with partners on the redesign of a range of planned and

unplanned care pathways. A brief summary for each pathway is attached as

appendix one for information.

Good progress is being made overall in developing the clinical models for pathway

redesign initiatives.

Detailed activity and finance assumptions are being worked through between

HVCCG and the Trust. The CCG is seeking to agree new contractual arrangements

for the pathways, generally including a ‘capitated’ or ‘mini-block’ arrangement. An

update on the current status of contract negotiations with the CCG for each pathway

redesign is included in separate Part 2 Board paper.

HVCCG has confirmed that it intends to competitively procure the following services in 2018. This is not necessarily an exhaustive list and additional procurements may be added as HVCCG continues to develop its commissioning work programme.

Community Vasectomy

Community Dietetics service

Community ENT

Community Ophthalmology

GP Direct Access Ultrasound Services

Potential Joint Procurement with HCC and ENHCCG for Obesity

Adult Community Services

The Trust Executive Committee will review the list of procurements in Q4 to inform bid / no bid decisions.

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2. Stroke

HVCCG has confirmed that it would like WHHT to take the overall co-ordinating lead

across a WHHT and HCT provider partnership for the delivery of an integrated stroke

pathway.

As previously reported it is recognised that additional investment would be required

for WHHT to make further progress towards the delivery of the full hyper-acute stroke

service specification. Detailed discussion with HVCCG and with HCT on mobilising

the lead provider model is continuing, including confirmation of service specification

recently issued by the CCG and a review of the financial envelope required to meet

the specification.

3. Vascular

Work continues with E&NHT to develop the operating model and implementation

plan for the vascular hub. A programme board has been established by E&NH.

Internally, a paper is being drafted for initial review by the Clinical Advisory Group

regarding potential care pathway implications and the clinical requirements from the

vascular hub to maintain a high quality local service for vascular patients in line with

hub and spoke model, as well as confirming the support required from the vascular

team to ensure patients admitted to Watford General Hospital under other specialities

are able to access appropriate specialist vascular expertise. A more detailed update

will be provided to the Trust Board following review by CAG and TEC.

4. Your Care, Your Future - strategic outline case (SOC) for the redevelopment of

acute hospital services.

The main acute transformation / redevelopment SOC is currently being reviewed by

NHS Improvement following the standard business case review process. Given the

scale of investment required Department of Health review and approval will also be

required.

A conference call was held with NHS Improvement (NHS I) and HVCCG in October

2017. A separate meeting was held with NHS England (NHS E) who were not able

to join the conference call. NHS I confirmed that the business case is currently

progressing through their review and approvals process, with a target timeline for a

decision on the SOC by December 2017.

Proposed governance arrangements for the next phase of the redevelopment

programme have been agreed in principle – this includes the establishment of a

redevelopment programme board with representation from WHHT, HVCCG, NHS I,

NHS E, Hertfordshire County Council and Hertfordshire Healthwatch.

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The WHHT redevelopment SOC has also been put forward for capital funding via the

STP capital bidding process. Additional capital funding was announced for the NHS

in the Chancellor’s autumn statement, together with an initial list of STP schemes.

This initial list did not include our redevelopment SOC. However, the Trust has been

advised that further tranches of schemes are expected to be announced over the

coming months and the non-inclusion of the WHHT scheme at this stage does not

necessarily mean that funding will not be made available in future. Any funding

made available at this stage would be subject to SOC approval and would effectively

support the development of the outline business case (OBC). As set out in the SOC

it is anticipated that the redevelopment itself is most likely to be taken forward

through a Private Finance 2 (PF2) route or similar and entail a combination of public

and private finance. The OBC will consider the funding options in more detail.

The strategy team continues to undertake preparatory work for the development of

the OBC and on the delivery of the interim estate strategy. Esther Moors has been

appointed Programme Director – acute redevelopment and a new service planning

role has been recruited to support this work. (Louise Halahamy, commenced in post

November 2017). Tim Duggleby continues to provide expert estates advice to the

programme. The team will need to be further expanded to support the development

of the OBC; decisions regarding funding for 2018/19 will be taken forward through

the Trust’s annual business planning process.

The Trust is working with Princess Alexander Hospital to develop a bid to the STP for

funding to progress a detailed STP activity and finance model to underpin both

WHHT and PAH outline business cases.

5. Hemel Hempstead strategic outline case (SOC)

As previously reported joint work is underway with HVCCG, WHHT clinical teams

and other partners to develop in more detail the proposed clinical model for Hemel

Hempstead & Dacorum. A separate paper has been provided for Part 2 discussion

that sets out the emerging proposed model for Board review and approval prior to

inclusion within the SOC.

The target timeline for the SOC completion is March 2018 (i.e. finance and

investment committee February 2017, Board review March 2018).

Stakeholders have been involved in the development of the proposed service model

via the Hemel SOC steering group and a stakeholder event held in September 2017.

Further engagement is planned following SOC approval to enable the detailed clinical

service model to be finalised prior to completion of the outline business case.

6. Car Parking Strategic Outline Case

The Car Parking strategic outline case has been submitted to NHS Improvement for

review and approval. The Trust has provided a comprehensive response to a series

of clarification questions. Our understanding is that the SOC is now with the national

NHS Improvement ‘cash and capital’ team for review prior to submission to the

relevant NHS Improvement Committee for formal approval.

[NB – no change to October reported position]

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The Trust is actively working on an ‘appointment business case’ for review by the

finance and investment committee in December 2017. There is an urgent need to

progress decision making for the car park in early 2018 due to the interdependencies

for the Watford Riverwell scheme and the expiry of our current lease on the Cardiff

Rd car park in 2019. This issue has been escalated to NHS Improvement.

7. Pathology

The pathology SOC approved by the Board in November has been submitted to NHS

I for review and approval. Work on the outline business case has commenced at

risk.

8. Royal Free London (RFL) partnership

The work programme was approved at the November Board.

Trust clinicians continue to actively engage in a number of the clinical pathway

groups that have been established by the RFL. An internal working group is being

established to scope implementation requirements for new pathways being

developed by CPGs.

The RFL is making good progress in defining future options for provision of ‘at scale’

clinical and non-clinical support services. A Board development session is proposed

for March 2018 to share this work with Board members and explore WHHT appetite

to engage in this element of the group model.

The Trust continues to explore opportunities to accelerate its digital transformation

strategy through working with the RFL Global Digital Exemplar programme.

9. Sustainability and Transformation Partnership (STP)

Highlights this month include:

Clinical engagement and support for transformation has been strengthened

by the appointment of the three CCG Chairs as clinical leads to the STP.

This shared appointment will bring additional clinical resources and oversight

to the workstreams to help resolve issues and speed up the process of

introducing new models of care.

A new workstream has been initiated to review future governance models for

the STP and the potential for the STP to transition to an accountable care

system (ACS).

ACS development will emphasise collaboration rather than competition

between STP member organisations and when completed will be comprised

of the ACS as a strategic commissioner of health and social care services,

contracting with Accountable Care Organisations (ACOs) to deliver services.

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ACOs will be made up of several providers and/or local commissioners and

their configuration has yet to be determined.

The STP is now planning the delivery of the ACS, to include the following:

Delivery of service transformation through priority workstreams;

Performance improvement across the STP system;

Strategic commissioning and detailed planning based on population health analytics;

System governance and assurance;

Establishment of Accountable Care Organisations;

Delivery of place based care and support;

System-wide agreement of a single financial control total and incentives for compliance, including risk-sharing;

Comprehensive workforce and Organisational Development strategies;

A singe estates, facilities and capital investment strategy based on the concept of one public estate and effective use of technology;

Robust communications and engagement processes and systems.

Recommendation

The Board is asked to receive the report for information.

Helen Brown


December 2017

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Agenda item 13/54

Board meeting 07 December 2017 Strategy update

Pathway Type of

pathway redesign

Key partners developing models

Development stage Expected date of service commencement

Next key milestone

Community Musculoskeletal Service

Open market competitive tender 3years +2 contract

A WHHT led service in partnership with Hertfordshire Community Trust, HertsOne GP Federation, Herts Valley Physio Group the current 17 AQP providers) & the Royal Free London NHS Foundation Trust (RFL).

Collectively we have called ourselves the Herts Musculoskeletal Collaborative (HMSKC)

Connect have approached WHHT to provide consultant Rheumatology and Pain sessions on a sub contracted basis. Proposal received and evaluated on a clinical, strategic and financial basis. In negotiation with Connect for contractual terms to be agreed

CCG contract with Connect expected to commence January 2018.

Service line plans being worked through to reduce capacity as activity reduces and to mitigate against stranded costs as income reduces.

Community Dermatology

Multi Provider Partnership Collaborative (MPPC) 3years +2 contract (tbc)

A WHHT led service in partnership with the two other incumbent providers, HertsOne GP Federation & Royal Free London NHS Foundation Trust (RFL).

Teledermatology commenced on 01/09/17 as planned as a 6month pilot.

MPPC launch now expected by CCG December 2017.

Analysis by diagnosis of potential community activity by WHHT in partnership with GP Federation lead

01/09/17 for Teledermatology

Dependant on MPPC timescales & based on service scope

Launch of MPPC (now expected by CCG December2017). Finalisation of specification, activity and financial envelope still required.

Community Gynaecology

Most Capable Provider 3 year contract

Lead provider is Hertfordshire Community Gynaecology Practice owned by the Drs Kedia. Subcontracting with WHHT, RFL & Luton & Dunstable University Hospital.

Finalisation of activity and finance and standard operating procedure as part of mobilisation.

Quality schedule and governance framework for the community service agreed on going work around specific assurance areas required from the lead provider

HVCCG timescales revised in Oct 2017 and are now:

01/03/18 for triage.

Full service delivery from 01/04/18

CCG refreshed the data with the lead provider. Impact for WHHT ultrasound being worked through. Development of the subcontract between the lead provider and WHHT

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Community Diabetes

Multi Provider Partnership Collaborative (MPPC) 5year contract

Now to be a WHHT led service in partnership with Hertfordshire Community Trust and HertsOne GP Federation

Assurance document returned to HVCCG 21/07/17.

CCG confirmed the proposal for a WHHT led integrated diabetes service. Significant comments received from CCG on the HCT submission which have been responded to by WHHT

Original plan was for Oct 2017, however delays in response to MPPC proposal by CCG will see start date pushed back.

New mobilisation plan completed with staged implementation already started.

Contract negotiations with HVCCG in progress

Awaiting CCG response to WHHT update on MPPC proposal (which includes the contract form to be a 1 year shadow to baseline data and the significant changes required in primary care elements of the pathway –not in the direct control of the MPPC partners and so presents a significant risk which is mitigated by a shadow year.

National Diabetes Treatment and care programme (foot health, structured patient education & recommended treatment targets) 2 years funding with only 1

st

year confirmed

As with the MPPC arrangement but a separate contract

MOU with national programme agreed. Working groups for service delivery in place

From October 2017 (staged delivery of programme)

Foot group to agree start date of service based on recruitment of team.

EDEN diabetes training programme commences Oct 2017

Integrated Community and Secondary Care Respiratory Service for Herts Valleys

Service led redesign ahead of Multi Provider Partnership Collaborative (MPPC) planned for Oct 2019

WHHT in collaboration with Central London Community Healthcare (CLCH)

Phase 1A - Development of Respiratory Hot Clinics to support prompt assessment of acutely unwell patients, minimise need for admission and facilitate safe early discharge, ensure appropriate follow up on the right clinical pathway

Pilot of Hot clinics November 2017

Finalisation of clinical model and development of contractual arrangement

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Phase 1B - Referral management including referrals filtered by disease specific pathways, advice and guidance and advice and guidance plus (includes virtual consultation and investigations)

April 2018 Finalisation of clinical model, agreement on preferred electronic system to support

Phase II -Develop and implement

the full integrated acute and

community model for Respiratory

Services

April 2019 Development of Integrated Respiratory Service Specification and Pathways by April 2018

Lower GI Telephone Assessment Clinic (TAC)

Service led redesign

WHHT Implementation of nurse led

telephone assessment clinic (TAC)

service enabling ‘straight to test’ for

2ww patients

HVCCG looking for contract variation by 31/12/17. However, consideration required for JAG inspection February 2018.

To be finalised in line with tariff agreement. Agreement to include scoping to manage straight to test & subsequent decontamination requirements (expected completion December 2017).

Integrated Heart Failure Service (to include Cardiac Rehabilitation)

Multi Provider Partnership Collaborative (MPPC)

HVCCG requesting a WHHT led model in partnership with HCT

Letter of intent issued to WHHT. Awaiting scope of service with finance and activity information from HVCCG

HVCCG have withdrawn the notice that they served HCT for Heart Failure and Cardiac Rehab Services as they have realised that the service re-provision and integrated pathways are going to be more complicated than they originally thought

Proposal being revised in light of inclusion of tertiary work (previously excluded)

To be agreed HVCCG to identify activity and assumptions for inclusion and update position with HCT service

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FIRST (Facilitating Integrated Re-enablement to Support Transition)

Service redesign with a block contract to test a care model before moving to a bundle based approach

WHHT commissioning HCT to provide the service

Service specification developed by WHHT in partnership with HCT & the Integrated Discharge team

WHHT gave notice October 2017 with all patients to transition to Specialist Care at Home in November 2017.

Pilot evaluated. Discharge to Assess capacity being increased through current enablement provider (Specialist Care at Home)

FIRST service in decommissioning phase from HCT, patients care provider being transferred

Pathway developments (including gall bladder & hernia)

Pathway developments to reduce unwarranted clinical variation

WHHT clinicians working with Royal Free London

Early stages of joint pathway work

HVCCG to share their benchmarking work from Deloittes

To be agreed To be agreed

Development of a Fracture Liaison service (FLS) & pathway for minor head injury

HVCCG looking to agree a local tariff for front end acute frailty unit at Watford

HVCCG with WHHT clinicians Still require FLS pathway and scope to inform CCG business case and service specification

Pathway for minor head injury management to be scoped and agreed

HVCCG anticipating business for FLS developed in Dec 2017 with implementation requested for early 2018

Service specification required for initial scoping

Urinary tract infections and urology

Pathway development between WHHT

HVCCG with WHHT clinicians Implementation of nurse led clinics with a local tariff

To be agreed Significant work required to develop protocol with primary and community teams

Stroke Multi Provider Partnership Collaborative (MPPC)

A WHHT led service in partnership with the two other incumbent providers, Hertfordshire Community Trust and Hertfordshire county council

HVCCG expecting to share activity, financial plan and contractual form in January 2018.

Launch of MPPC assurance framework expected January 2018

CCG looking for an April 2018 new service commencement

Agreement of activity and financial and contract form

End of life care and use of Electronic Palliative Care Co-ordination Systems (EPaCCS)

Implementation of EPaCCS at WHHT

HVCCG with WHHT Scoping of key areas for implementation and development of a mobilisation plan for EPaCCS

To be agreed Scoping of key areas for implementation

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1

Report to: Trust Board

Title of Report: Assurance Report from the Finance and Investment Committee

Date of meeting: 7 December 2017

Recommendation: For information and assurance

Chairperson: John Brougham, Non-Executive Director

Purpose

The report summarises the assurances received, approvals, recommendations and decisions made by the Finance and Investment Committee at its meeting on 30 November 2017

Background The Committee meets monthly and provides assurance on scheduled reports from all Trust operational committees with a finance and information technology brief according to an established work programme.

Financial Performance

i. I&E Deficit

The Committee reviewed the actual performance in the month and year to date, and focussed on the challenging action plans in place to deliver the budgeted deficit for the year.

The deficit in October of £2.9m was £2.5m worse than budget, but £0.4m better than forecast, due to higher revenues. The deficit to date is £27.6m, £12.7m worse than budget, and includes £3.4m of lost STF income and £1.5m of unbudgeted income reductions relating to last year, £0.8m of CQUINs, and £0.7m relating to CCG challenges. The balance of £7.0m comprises lower revenues of £0.6m, higher pay costs of £4.3m, and higher non pay costs of £2.9m. The Committee focussed on the plans and associated risks to achieve the forecast deficit for the year of £35.0m. The forecast recognises that a number of budgeted challenges for the year will not be realistically achieved, comprising the £8.2n extra CIP stretch target, a shortfall in STF income of £9.3m and post budget decisions that have increased the deficit by £2.5m, £2.1m of which relates to 2016/17. The Committee supported the detailed actions in place, and planned, to achieve the £35m forecast, and were assured by the Trusts commitment to deliver it, whilst recognising that it will be extremely challenging. 14

Tab 14 Assurance report from Finance and investment committee


2

Success demands, for the remaining months, a doubling of the monthly rate of CIPs achieved year to date, to increase the £5.6m delivered so far to reach the target of £13.7m for the year, plus delivering a further £3.3m of deficit reducing plans. At this point in the region of £5m of deficit reduction actions are still to be underpinned. The Committee also reviewed the risks to revenues from outstanding disputes with HVCCG, which amount to several millions of pounds including issues related to last year, non payment of invoices this year and other contractual disputes. The Committee supports the Trust’s view that these challenges are without foundation and if necessary should go to arbitration. The Committee recommends that the plans and risks in achieving the £35m forecast deficit are reviewed in Part 2 of the December Board.

ii. Update on Carter Report recommendations and Back Office Savings A review of the progress being made on achieving productivity improvements using Model Hospital data is now a standing item on the agenda. The data shows a productivity opportunity of £23m for the Trust and work is underway to validate opportunities and agree milestones for delivery. The Committee was assured by the plans already in place to evaluate and deliver potential savings in both payroll and finance.

iii. Capital Expenditure/Funding

Capital spend in October of £0.4m brings year to date spend to £2.5m. The Committee was assured that commitment and spend is being carefully prioritised and managed not to exceed the current NHSI authorisation limit of £7.7m.

Following review and recommendation by the Project Appraisal Unit (PAU) of NHSE, a revised ITFF application for £14.5m of funding has been made which, if approved, would authorise capital spend in the year of £22.2m, £0.8m lower than originally planned.

The Committee remain concerned that the timing of approval would not enable all the spend to be made in the year, and supported the Executive working with NHSI to secure early agreement to carry forward unspent approved funds into 2018/19.

iv. Revenue Funding Funding of revenue spend by NHS is subject to monthly approval and following review, the Committee recommends ratification by the Board of a loan of £8.0m which is to meet the forecast deficit to the end of November, in line with the revised forecast deficit of £35m for the year. 14



3

Financial Planning for 2018/19

The Committee reviewed the planned approach and timetable to produce the Trust’s operational and financial plan for 2018/19. The Committee agreed the approach to agreeing the assumptions and underlying plans for the financial plan, covering I&E, capex, funding and cash, and noted the challenges in the plan to achieve the target deficit, excluding STF income, of £21.6m, compared with the current year’s like-for-like forecast of £36.4m. There will be monthly reviews by the Committee and Board of draft plans from January to March 2018 prior to final approval by the Board in April/May.

SLR Pilots

The Committee reviewed and agreed the proposal for deep dive patient level costing pilots to take place in Respiratory Medicine (non invasive) and Maternity (induction of childbirth pathway). The deep dives will challenge the existing assumptions and methodology in deriving costs. This should result in increased confidence among clinicians and managers that the data is fit for purpose, presented meaningfully, and a valuable aid in improving decision making in the development of services and in their efficiency.

Corporate Risk Register

The Committee reviewed 11 risks under its remit, rated 15 or more and on the CRR, 5 relating to Finance and 6 to IM&T. The Committee noted that there were no changes to the risk ratings agreed at the November Board, and following review, was assured that all mitigating actions and review dates were up to date.

Finance and IM&T Policies Update

The Committee reviewed the status of Trust Policies under its remit relating to Finance and IM&T. The Committee was assured that all 5 Finance policies were up to date, as were 27 of the 29 IM&T policies. The Committee was further assured that all IM&T policies would be fully up to date by the end of a January 2018.

Information & Communications Technology The Committee reviewed progress of the infrastructure improvement plan, and noted progress in terms of rollout of end user devices to the three Trust sites, with delivery now at 95%. The Committee was also updated regarding completion of network remediation, noting however that residual risks require further work to mitigate. The Committee received a presentation on refreshing the Trust’s Digital IT Strategy: Framework for Delivery. The Committee agreed with its direction and the suggested delivery framework. The Committee recommends that the presentation is also made at Part 2 of the Trust Board in December.

Risks to refer to risk register

None.

14



4

Issues to escalate The Committee recommends the following:

To Part 1 of the December Board for ratification:

i. the NHS revenue support loan of £8.0m to cover funding requirements in November

To Part 2 of the December Board for review:

ii. the plans and risks in achieving the £35m deficit forecast

iii. a briefing on the Trust’s refreshed Digital IT Strategy: Framework for Delivery

Attendance record

Attended

John Brougham, Non-Executive Director (Chair)

Don Richards, Chief Financial Officer

Jeremy Livingstone, Divisional Director, Surgery, Anaesthetics & Cancer

Katie Fisher, Chief Executive

Lisa Emery, Chief Information Officer

Mike van der Watt, Medical Director

Phil Townsend, Non-Executive Director

Prof. Steve Barnett, WHHT Chair

Tom Drabble, Patients’ representative

Apologies

Helen Brown, Deputy Chief Executive

Kevin Howell, Director of Environment

Lesley Headland, Chair of Staffside

Sally Tucker, Chief Operating Officer

Stephen Dunham, Assistant Director of Finance & Commercial Development

Clerk

Clare Ransom, Executive Assistant

14



Report to: Trust Board

Title of report Patient and Staff Experience Committee Assurance Report to Trust Board

Date of Board meeting:

07 December 2017

Recommendation: For information and assurance

Chairperson: Ginny Edwards, Non-Executive Director Purpose

The report summarises the assurances received, approvals, recommendations and decisions made by the Patient and Staff Experience Committee at its meeting on Thursday 26 October 2017.

Background The Committee meets bi-monthly and provides assurance on:

Patient and staff experience measures, i.e. outcomes of surveys and audits

Staff engagement

Progress against the patient experience and workforce strategies

Organisational development

Workforce performance (IPR), including training, appraisals, revalidation, recruitment and retention

Equality and diversity

Health and wellbeing

Lessons learnt through comparison of best practice between services

Business undertaken

Workforce Report The Committee received October’s workforce report which covers key workforce metrics for September 2017. It noted that the Trust’s vacancy rate has fallen from 13% to 11.8%. Sickness absence reduced from 3.1% to 2.8%. This is well below the Herts and Beds average (4% at the end of Q1 June 2017). Agency spend had increased slightly from £1.6M in June to £1.7M in July. The Trust appraisal rate increased to 90%, whilst compliance with mandatory training requirements reduced slightly to 89%. The Committee also reviewed progress being made in relation to this year’s staff survey and flu vaccination campaign. Workforce and Staff Experience Risk and BAF The committee received an update on all current workforce related risks. It was noted that currently there are four risks scoring 15 or above. It was also noted that the risk in relation to staff engagement had been further reduced from 16 to 12. The Committee received confirmation that this reduction had received the endorsement of the Risk Review Group. It was also noted that the risk in relation to band 5 nurse recruitment and retention had increased to 20.

15

Tab 15 Assurance report from the Patient and staff experience committee


Board Assurance Framework The committee received a paper regarding the BAF to review the description assurances and controls for Principal Risks (PRs) 2 and 8. Given the high level of band 5 nurse vacancies the Committee asked that the current approach to assessing the PR2 be reassessed so that more focus is placed upon vacancy levels and turn over. The Committee also questioned whether the current RAG rating for PR 8, which looks at external stakeholder relationships, is accurately rated at ‘amber-green’. The point was made that given the issues connected to the new hospital project it might be prudent to review this rating. Patient Experience Performance Report The Committee reviewed the Patient Experience & Carer Strategy

dashboard which provides an update on progress being made against this

strategy.

Band 5 Nurse Retention Programme The committee received a paper regarding the Band 5 Nurse Retention Programme. The Trust’s turnover rate for Band 5 nurses is currently 27% compared to our overall turnover rate of 16%. It was noted that the impact of overseas nurses not yet able to work at a band 5 level, plus long term sickness and high maternity rates made the ‘real’ impact of the vacancy rate much greater. The committee were advised that a cross Trust steering group has been established to develop a programme of work, with an overarching aim to reduce band 5 turnover rates from 27% to 16% by December 2018. There is a retention action plan in place which focuses around 4 key areas:

Career pathways

Formal skills development

Recognising staff effort

Supporting health and well-being

The retention programme will be overseen by the Band 5 Nurse Steering Group to ensure that the retention target is met. This group will report progress and escalate appropriate risks, issues and decisions, via the Workforce Transformation Group into the Strategy Delivery Board (TEC). Progress updates will also be shared with this committee. The Committee welcomed this work and asked that progress continued to be shared. Midwifery Workforce Analysis The Committee received a paper regarding Midwifery workforce analysis intended to help determine whether the current establishment within the service was appropriate to the level of service being delivered. The key finding being a recommendation that the current establishment be increased by 3.4 midwives and 2.14 support roles. The Committee noted this recommendation. PLACE Results The committee received an update on the 2017 PLACE (Patient Led Assessment of the Care Environment) audit. This identified both areas of improvement and deterioration. Areas which demonstrated year on year

15



improvements included cleanliness, quality of food and privacy and dignity. Areas where the results had been poorer included condition and appearance of the Trust, dealing with dementia and disability provisions. It was noted that across virtually all areas the trust performed worse than the national average. Stakeholder Engagement Strategy The committee received a paper setting out the Trust’s strategic engagement strategy and approach. It was noted that the paper was deliberately intended to be a high level and overarching strategy from which more detailed engagement plans would follow and be developed for individual topics. The Committee welcomed this paper and felt that it should be revisited as part of a future Part II Board meeting, as the issue is of such significance to the Trust’s future plans. Medical Staff Engagement Update The committee received a short summary providing an overview of a Medical Staff Engagement Research Project. Overall the paper showed a significant improvement in general engagement levels within the Trust’s medical workforce and a real desire by our doctors to be involved in the running and management of the Trust. It was agreed that a work plan would be devised to meet some of the issues raised by the study and that this would be presented at a future Committee meeting. The Committee welcomed the apparent improvement made over the previous 12 months.

Overview of Key workforce issues with Clinical Support Services The committee received a paper providing an update on current workforce indicators and other related issues within Clinical Support Services. The paper outlined progress which had been made against three key workforce objectives; reduction in vacancies, reductions in agency spend and reducing turnover by staff. The Committee welcomed the progress which was being made.

The committee were also asked to note the following: Update on Medical Education Health Education East of England Foundation School Visit The Committee received a paper that provided an update on the Trust’s response to the most recent HEEE Foundation Programme Visit. It was noted that good progress was being made against the plans key actions. Patient Experience Group Minutes The committee were asked to note the minutes from the Patient Experience Group. Guardian of Safe Working Annual Report & Quarterly Update Annual Report The Committee received the first Annual Report on Rota Gaps and Vacancies for Doctors in Training. The committee were advised that there have not been any significant areas of concern around the hours being worked by the Trust’s junior

15



doctors, although there were known rota gaps within A&E and Anaesthetics. It was noted that the trust’s response to the exception reporting system has been on the whole positive and it had served as a useful tool to highlight areas where doctors are working under strain. Some changes to rota patterns have been made as a result with good effect. The Committee welcomed the overall finding set out by this report. Guardian of Safe Working Annual Report & Quarterly Update Quarterly Update The committee received the quarterly update which reviews safe working by Trust junior doctors. Overall there have been no significant exceptions resulting in a Guardian Fine and the Committee noted that it was the view of the Guardian of Safe Working that there are no significant issues in regard to the safe working of junior doctors working on the new Terms & Conditions. Review Patient Experience and Carer Strategy implementation plan The Committee received a paper on the Patient Experience and Carer Strategy Implementation Plan. The paper outlined the progress made with regards to improving patient and carer experience since the launch of the Patient Experience and Carer Strategy in November 2016 and the bi- annual update presented in April 2017. Workforce Wellbeing Charter – Update October 2017 The Committee received a paper on the Workforce Wellbeing Charter. This paper provided an update on progress towards meeting the requirements of the Workplace Wellbeing Charter which is a key ambition outlined in the Staff Health & Wellbeing Strategy, approved in April 2017. It was noted that strong progress had been made in meeting the requirements of the charter with 75 out of 95 commitments having now been met. The Committee noted and welcomed this progress. NHS Professional Banks Shift Pay Inaccuracies The Committee received a paper on pay inaccuracies which had been made by NHSP in relation to the payment of banks shift. The Committee noted that there had been issues with payments to staff by NHSP that had resulted in up to 180 substantive staff working bank not being paid the correct rate of pay for some banks shifts worked and the subsequent actions taken to resolve this matter. The Committee registered its concern that this error had occurred but were also pleased by the actions taken to resolve this matter. Library and Knowledge Services (LKS) Annual Report 2016/17 The Committee received a paper on the Library and Knowledge Services Annual Report 2016/17. This paper gave the committee background and context to the LKS Annual Report 2016-17 and provided a benchmark for future service development moving forward. Right to Work Data Check The Committee received a verbal update on an issue which had recently been identified in relation to right to work data checks. The Committee received assurances from the Director of Human Resources that this matter was being appropriately managed and further updates on progress would be provided to both the Trust Executive Committee and at future

15



PSEC meetings. Friends & Family Remedial Action Plan (RAP) October 2017 The Committee received a paper on the Friends & Family Remedial Action Plan. The Trust has a contractual requirement to achieve a minimum response rate to the Friends & Family Test. The RAP focuses on the Trust’s delivery of actions to improve on the current levels of performance. The paper contained the current position and agreed actions by the Divisions to improve both the response rates and positive recommendations from all patients. Independent Review of Patient Experience (Healthwatch Hertfordshire Enter & View visits and Patient Survey Report) The Committee received a paper on the reports from Healthwatch Hertfordshire (HwH) following the Enter and View visits and Patient Survey that took place during August 2017. A total of 14 recommendations have been made, with a number having already been completed. Future updates will be provided as part of the Patient Experience & Carer Strategy action plan which will come to future meetings.

Risks to refer to risk register

The Committee recommended the following:

That a new risk be created in relation to the management of key external stakeholders.

That the approach currently undertaken to provide assurance in relation to PR 2 is reviewed to ensure that greater weighting is given to vacancy and turn over levels.

That the current RAG rating in relation to PR 8 is reviewed.

Key decisions taken

None

Issues to escalate It was recommended by the Committee that a discussion around PR 8 be

undertaken at a future Part II of the Trust Board meeting.

Attendance record

Ginny Edwards, Non-Executive Director Tracey Carter, Chief Nurse & Director of Infection Prevention and Control Paul da Gama, Director of Human Resources Paul Cartwright, Non-Executive Director Jonathan Renison, Non-Executive Director Sally Tucker, Chief Operating Officer Maxine McVey, Deputy Director of Nursing Lesley Headland, Chair of Staffside Angela White, Head of Nursing, Unscheduled Care Paula King, Head of Nursing, Surgery, Anaesthetics and Cancer Phil Downing, Head of Nursing, Medicine Jo Fearn, Head of Nursing (Children’s Services) Gill Balen, Patient Representative Dr Emmanuel Quitst-Therson, Associate Medical Director for appraisal and revalidation

15



Page 1 of 2


Title of the paper Corporate governance meeting schedule 2018/19

Agenda item 17/54

Lead Executive Jean Hickman, Trust Secretary


Executive summary

This schedule provides an overview of the Board and Committee meetings which are required in 2018/19. Board and committee members will receive invitations via the governance@ account to the meetings that they are expected to attend.


Trust Executive Committee – 29 November 2017

Action required: The Trust Board is asked to receive this schedule for information.

17

Tab 17 Corporate governance meeting schedule


Page 2 of 2





PR4a


PR4b


PR5

a

Inability to deliver and maintain performance standards for Emergency

Care

PR5

b

Inability to delivery and maintain performance standards for Planned

Care(including RTT, diagnostics and cancer)

PR7

b

Failure to secure sufficient capital, delaying needed improvements in

the patient environment, securing a healthy and safe infrastructure

PR8 Failure to engage effectively with our patients, their families, local

residents and partner organisations compromises the organisation’s

strategic position and reputation.

Trust objectives X To deliver the best quality care for our patients X To be a great place to work and learn X To improve our finances X To develop a strategy for the future


17

Tab 17 Corporate governance meeting schedule


Monday

2 2 3 1 3

Tuesday

3 1 3 4 2 4 1

Wednesday

4 2 4 1 5 3 5 2

Thursday

5 3 5 2 6 4 1 6 3

Friday

6 4 1 6 3 7 5 2 7 4 1 1

Saturday 7 5 2 7 4 8 6 3 8 5 2 2

Sunday 8 6 3 8 5 9 7 4 9 6 3 3

Monday

9 7 4 9 6 10 8 5 10 7 4 4

Tuesday

10 8 5 10 7 11 9 6 11 8 5 5

Wednesday

11 9 6 11 8 12 10 7 12 9 6 6

Thursday

12 10 7 12 9 13 11 8 13

PSE SC CF

10 7 7

Friday

13 11 8 13 10 14 12 9 14 11 8 8

Saturday 14 12 9 14 11 15 13 10 15 12 9 9

Sunday 15 13 10 15 12 16 14 11 16 13 10 10

Monday

16 14 11 16 13 17 15 12 17 14 11 11

Tuesday

17 15 12 17 14 18 16 13 18 15 12 12

Wednesday

18 16 13 18 15 19 17 14 19 16 13 13

Thursday

19 17 14 19 16 20 18 15 20 17 14 14

Friday

20 18 15 20 17 21 19 16 21 18 15 15

Saturday 21 19 16 21 18 22 20 17 22 19 16 16

Sunday 22 20 17 22 19 23 21 18 23 20 17 17

Monday

23 21 18 23 20 24 22 19 24 21 18 18

Tuesday

24 22 19 24 21 25 23 20 25 22 19 19

Wednesday

25 23 20 25 22 26 24 21 26 23 20 20

Thursday

26

PSEInformal

Audit

24 21 26 23 27

COE CF

25

PSE

22 27 24 21 21

Friday

27 25 22 27 24 28 26 23 28 25 22 22

Saturday 28 26 23 28 25 29 27 24 29 26 23 23

Sunday 29 27 24 29 26 30 28 25 30 27 24 24

Monday

30 28 25 30 27 29 26 31 28 25 25

Tuesday

29 26 31 28 30 27 29 26 26

Wednesday

30 27 29 31 28 30 27 27

Thursday

31 28

FI CF

30

PSE

29 31 28

PSE

28

FI CF

Friday

29 31 30 29

Saturday 30 1 30

Sunday 1 2 31

KEY

10AM - 1PM

10AM - 1PM

10AM - 1PM

LAST UPDATED November 2017

SC

AUDIT

DIVISIONAL PERFORMANCE

SC

SC

TRUST EXECUTIVE STRATEGY DELIVERY BOARD

(TEC)

TRUST EXECUTIVE

BOARD DEVELOPMENT FI

STRATEGY DELIVERY

BOARD (TEC)

TRUST EXECUTIVE

STRATEGY DELIVERY

BOARD (TEC)

FI

BOARD BUSINESS

WORKSHOP

STRATEGY DELIVERY BOARD (TEC)EXECUTIVE PERFORMANCE

REVIEWS (TEC)

TRUST BOARD REM

TRUST BOARD

STRATEGY DELIVERY BOARD

(TEC)


EXECUTIVE PERFORMANCE

REVIEWS (TEC)

TRUST EXECUTIVE TRUST EXECUTIVE

STRATEGY DELIVERY

BOARD (TEC)


REVIEWS (TEC)

TRUST

BOARD

BOARD BUSINESS

WORKSHOP


SC

AUDIT

COE



(TEC)


REVIEWS (TEC)

FI

EXECUTIVE

PERFORMANCE REVIEWS

(TEC)


BANK HOLIDAY

TRUST EXECUTIVE

FI

BANK HOLIDAY

TRUST EXECUTIVE


COE

REM


COE

May-18Apr-18


Jul-18Jun-18


TRUST EXECUTIVE

TRUST BOARD


(TEC)


REVIEWS (TEC)

STRATEGY DELIVERY

BOARD (TEC)TRUST EXECUTIVE

TRUST EXECUTIVE



Aug-18 Jan-19Dec-18 Feb-19

TRUST BOARD TRUST BOARD

TRUST BOARD

TRUST EXECUTIVE

STRATEGY DELIVERY

BOARD (TEC)


(TEC)


TRUST EXECUTIVE

AUDIT

DIVISIONAL PERFORMANCEDIVISIONAL PERFORMANCE BANK HOLIDAY

TRUST EXECUTIVE

TRUST EXECUTIVE

TRUST EXECUTIVE


REVIEWS (TEC)


(TEC)

TRUST EXECUTIVE

BANK HOLIDAY

TRUST BOARD

STRATEGY DELIVERY BOARD (TEC)


BOARD AND COMMITTEE MEETING SCHEDULE 2018/19

TRUST EXECUTIVE


Mar-19Sep-18 Nov-18Oct-18


REVIEWS (TEC)

AUDIT

COE FI

BANK HOLIDAY

TRUST EXECUTIVE


REVIEWS (TEC)


REVIEWS (TEC)

TRUST EXECUTIVE

TRUST

BOARD

0900AM - 1130AM

9.15AM - 11.15AM

CHARITABLE FUNDSCLINICAL OUTCOMES AND

EFFECTIVENESS



TRUST EXECUTIVE


BANK HOLIDAY


FI

BANK HOLIDAY

EXECUTIVE

PERFORMANCE

REVIEWS (TEC)

11.30AM - 1.30PM 11.30AM - 1.30PM

PSE

TRUST EXECUTIVE EXECUTIVE PERFORMANCE

REVIEWS (TEC)

SAFETY & COMPLIANCE

FINANCIAL AND INVESTMENT


TRUST BOARD

PLEASE NOTE THE MEETING TIMES STATED BELOW MAY CHANGE ON OCCASION AND THE MEMBERSHIP WILL BE ADVISED VIA DIARY INVITATIONS, VENUES AND PAPER DEADLINES CAN BE

FOUND ON THE INDIVIDUAL TABS SUPPORTING THIS SPREADSHEET

BOARD

DEVELOPMEN

T

AGM

BOARD BUSINESS WORKSHOP

BOARD DEVELOPMENT SESSION 10AM - 4PM

9.30AM - 12.30PM TBC

FI FI COE


SC

2PM - 4PM

2.30PM - 4PM

9.30AM - 2PM

BOARD BUSINESS

WORKSHOP

PATIENT AND STAFF EXPERIENCE

REM

TRUST BOARD

TRUST BOARD REM

REMUNERATIONAUDIT


DIVISIONAL

PERFORMANCE

FI

DIVISIONAL

PERFORMANCE



BOARD DEVELOPMENT

TRUST EXECUTIVE

Extra-ordinary Audit

9.15AM - 11.15AM

FI

TRUST EXECUTIVE

17

Tab 17 C

orporate governance meeting schedule

3 of 125T

rust Board M


Page 1 of 2


AGENDA Agenda item: 22/54

11 January 2018 at 9.30am – 12.00noon

Terrace Executive Meeting Room, Spice of Life Restaurant, Watford Hospital

Apologies should be conveyed to the Trust Secretary, Jean Hickman on [email protected] or call 01923 436 283

Item ref

Title Objective Previously presented

Lead Paper or verbal



02/55 Patient experience presentation

To receive N/A Chief Nurse Presentation

OPENING

03/55 Apologies for absence


04/55 Conflict of interests To note N/A Chair Paper

05/55 Minutes of the meeting held on 07 December 2017

For approval

N/A Chair Paper

06/55 Board action log from 07 December 2017 and previous meetings and decision log




08/55 Chief Executive’s report To note N/A Chief Executive

Paper

PERFORMANCE

09/55 Integrated performance report – month 8

To note Trust Executive Committee


Paper


10/55 Quality improvement plan update

For information

and assurance


Chief Nurse

Paper

11/55 Annual establishment review - paediatrics

For information

and assurance

Safety and Compliance

Chief Nurse Paper

12/55 Patient experience and cares strategy update

For information

and assurance


Chief Nurse Paper

22

Tab 22 Draft agenda for the next board meeting


Page 2 of 2

13/55 Nursing and Midwifery and Allied Health care strategy update

For information

and assurance


Chief Nurse Paper


14/55 Strategy update – month 9 To note Trust Executive Committee


Paper

GOVERNANCE

15/55 Summary report on corporate risk register

For information/assurance



Paper

COMMITTEE REPORTS

16/55 Assurance report from Finance and Investment Committee

For information

and assurance

Finance and Investment Committee

Committee Chair/ Chief Financial

Officer

Paper


For information

and assurance



Human Resources

Paper

18/55 Assurance report from Safety and Compliance Committee

For information

and assurance

Safety and Compliance committee

Committee Chair/Chief Nurse

Paper

REPORT TO CORPORATE TRUSTEE

19/55 Assurance report from the Charitable Funds Committee

For information

and assurance

Patient & staff experience committee


Human Resources

Verbal

ANY OTHER BUSINESS


N/A N/A Chair Verbal

QUESTION TIME


To receive

N/A

Chair Verbal


To receive N/A Chair Verbal

ADMINISTRATION


To approve N/A Chair Paper

24/55 Date of the next board meeting in public: 01 February 2018, Terrace Executive Meeting Room, Watford Hospital


22

Tab 22 Draft agenda for the next board meeting


Documents

TRUST BOARD MEETING IN PUBLIC AGENDA · 2017. 12. 4. · Page 1 of 2 TRUST BOARD MEETING IN PUBLIC AGENDA 07 December 2017 at 9.30am ± 12.00noon Terrace Executive Meeting Room, Spice