TRUST BOARD MEETING IN PUBLIC AGENDA effective system of medical workforce planning? 5. An effective system of midwifery workforce planning? 6.Compliance with the Saving Babies' Lives

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TRUST BOARD MEETING IN PUBLIC

AGENDA

12 April 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

01/58 Opening and welcome

To note N/A Chair Verbal

02/58 Maternity Incentive Scheme To receive N/A Divisional Director Women’s

and Children’s services

Presentation

OPENING

03/58 Apologies for absence


04/58 Declarations of interests To note N/A Chair Paper

05/58 Minutes of the meeting held on 01 March 2018

For approval

N/A Chair Paper

06/58 Board action log from 01 March 2018 and previous meetings and decision log

To note N/A Chair Paper

07/58 Chair’s report

For information

N/A Chair Paper

08/58 Chief Executive’s report For information

N/A Chief Executive

Paper

PERFORMANCE

09/58 Integrated performance report – month 11

For information

and assurance

Trust Executive Committee

Chief Operating Officer

Paper

DELIVER A LONG TERM STRATEGY (BAF RISK 9)

10/58 Strategy update For information

and assurance


Deputy Chief Executive

Paper

GOVERNANCE

11/58 2018/19 corporate aims and objectives

For approval



Paper

12/58 Board assurance framework update

For information

All Deputy Chief Executive

Paper

AGENDA

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COMMITTEE REPORTS

13/58 Assurance report from Finance and Investment Committee

For information

and assurance

Finance and Investment Committee

Committee Chair/ Chief Financial

Officer

Paper

14/58 Assurance report from Clinical Outcomes and Effectiveness Committee

For information

and assurance

Clinical outcomes and effectiveness

committee

Committee Chair/Chief Nurse

Verbal

15/58 Assurance report from the Patient and Staff Experience Committee

For information

and assurance

Patient and Staff Experience Committee

Committee Chair/Director of

Human Resources

Paper

REPORT TO CORPORATE TRUSTEE

16/58 Assurance report from the Charitable Funds Committee

For information

and assurance

Charitable Funds

Committee

Committee Chair/ Director of

Communications

Paper

ANY OTHER BUSINESS

17/58 Any other business previously notified to the chair

N/A N/A Chair Verbal

QUESTION TIME

18/58 Questions from Hertfordshire Healthwatch

To receive

N/A

Chair Verbal

19/58 Questions from our patients and members of the public

To receive N/A Chair Verbal

ADMINISTRATION

20/58 Draft agenda for next meeting

To approve N/A Chair Paper

21/58 Date of the next board meeting in public: 03 May 2018 Lecture Room, Postgraduate Centre, St Albans Hospital


AGENDA

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the very best care for every patient, every day

Trust Board

Meeting 12th

April 2018

2

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aternity Incentive Schem

e presentation

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eeting in Public-12/04/18


Maternity Safety Strategy actions and Clinical

Negligence Scheme for Trusts (CNST) incentive

Scheme

Marcellina Coker

CD Obstetrics WACs Division

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What are the aims of the CNST incentive scheme and

why maternity?

• DoH ambition to reward actions to improve maternity safety

• Trial of the CNST incentive scheme for 2018/19.

• Discretionary

• Aligned to Intervention objective of Five year strategy: Delivering fair

resolution and learning from harm.

• Obstetric claims represent biggest area of spend (cost £500m in

2016/17) of the clinical negligence claims

• Obstetric claims represented 10% of the volume and 50% of the value

2016/17.

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What are the 10 maternity safety actions?

• 1. Use of National Perinatal Mortality Review Tool to review perinatal

deaths?

• 2. Submit data to the Maternity Services Data Set (MSDS) to the

required standard?

• 3. Transitional care facilities that are in place and operational to

support the implementation of the ATAIN Programme?

• 4. An effective system of medical workforce planning?

• 5. An effective system of midwifery workforce planning?

• 6.Compliance with the Saving Babies' Lives care bundle?

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What are the 10 maternity safety actions?

• 7. A patient feedback mechanism , such as the Maternity Voices

Partnership Forum, and that regularly act on feedback?

• 8. Evidence that 90% of each maternity unit staff group have attended

an 'inhouse’ multi-professional maternity emergencies training

session within the last training year?

• 9. Demonstrate that the trust safety champions (obstetrician and

midwife) are meeting bi-monthly with Board level champions to

escalate locally identified issues?

• 10. Reported 100% of qualifying 2017/18 incidents under NHS

Resolution's Early Notification scheme?

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Proposed Dates for completion

• June 2018

Completed Board reports with Board sign-off submitted to NHS Resolution

• July 2018

National Maternity Safety Champions and Steering group to confirm final results

• July 2018

Evaluation of scheme and confirmation of approach for 2019/20

• Aug 2018

NHS Resolution to confirm and pay discounts

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Thank you

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Last updated : 06 April 2018

Declaration of board members and attendees interests 12 April 2018

Agenda item: 04/58

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

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onflict of interest

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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

Paul da Gama

Director of Human Resources and Organisational Development

None

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


Katie Fisher Chief Executive None

Jeremy Livingstone Divisional Director of Surgery , Anaesthetics and

Cancer Jeremy Livingstone Ltd Present

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Arla Ogilvie Divisional Director for Medicine Private practice Present

Jonathan Rennison Non-Executive Director Change Management and strategy support with Kings College London

Trustee Rising Tides Ltd

Director of The Yellow Chair Ltd

Edgecumbe Consulting

Association of NHS Charities

The Teapot Trust - coaching

BNET (Britain-Nigeria Education Trust)

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


Don Richards Chief Financial Officer None

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

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01 March 2018 at 9:30am - 12.00noon

Executive Terrace Meeting Room, Watford Hospital

Chair Title Attendance

Professor Steve Barnett Chair Yes

Voting members

John Brougham Non-Executive Director Yes

Helen Brown Deputy Chief Executive Yes

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 Andy Barlow Divisional Director, Women’s and Children’s Yes

Paul da Gama Director of Human Resources Yes

Lisa Emery Chief Information Officer Yes

Mr Jeremy Livingstone Divisional Director, Surgery, Anaesthetics and Cancer

Yes

Dr Arla Ogilvie Divisional Director, Medicine Yes

Sally Tucker Chief Operating Officer No

In attendance

Louise Halfpenny Director of Communications Yes

Jean Hickman Trust Secretary (notes) Yes

Dr Matt Knight Consultant in Respiratory Medicine Yes

5

Tab 5 Minutes of the meeting held on 01 March 2018


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MEETING NOTES

Agenda item

Discussion Lead Dead-line


01.01 The chairman opened the meeting and welcomed the board.

02/57 Presentation on respiratory medicine

02.01 The chair welcomed Dr Matt Knight, consultant in respiratory medicine to the meeting and invited him to update the board on the work of the respiratory medicine service. Dr Knight explained that despite a significant increase in the number of patients over the past two years, the service had maintained excellent performance against the referral to treatment (RTT) standard. Key elements to this achievement had been the establishment of hot clinics and a transition to a full substantive team. Good working relationship had also been built with the clinical commissioning group. Dr Knight advised that plans to open a new respiratory centre, the development of a clinical fellowship programme and a referral management hub, together with improvements to the respiratory cancer service would further improve the service.

02.02 Phil Townsend thanked Dr Knight for the informative presentation and enquired whether the improvements were predicated on having good IT systems in place. Dr Knight responded that it was important to have quick, efficient IT and for all systems to link up with each other.

02.03 The board discussed key workforce changes that were required to bring about significant improvements and the importance of adapting jobs such as the development of nurse specialists.

02.04 The divisional director of surgery, anaesthetics and cancer raised the question of what the cancer division could do to support improvements to the respiratory cancer service. Dr Knight recognised that lung cancer was a highly complex area of medicine and suggested that improving the support infrastructure and multi-hospital disciplinary

working would help the service.

02.04 The medical director reminded the board that the current position was a significant improvement for the respiratory service following a disappointing rating in a Care Quality Commission report in 2015. The director of women’s and children’s division (a consultant in respiratory medicine) informed the board that there had been a change to the respiratory service’s financial structure and strategic driver over the past two to three years in response to a change in commissioning. The divisional director of medicine congratulated the service on its achievements and commented that every department must be responsive to change, in particular cultural changes such as working with other services.

02.05 The chair thanked Dr Knight for his excellent presentation and congratulated the respiratory team on the tremendous improvements, including gaining national recognition.

02.06 Resolution: The board noted the presentation.

OPENING


03.01 Apologies were received from the chief operating officer due to operational pressures.

04/57 Conflicts of interest

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

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Agenda item


05/57 Minutes of the meeting held on 01 February 2018

05.01 The minutes were agreed to be a true record of the meeting.

06/57 Board action log from 01 February 2018 and previous meetings and decision log

06.01 It was confirmed that the one outstanding action was on track to be completed within the required timeframe.


07.01 The chair presented his report and informed the board that he would be writing to thank the people mentioned in his report for their donations of time and effort to improving the experience of patients and to congratulate staff for their achievements.

07.02 In connection with an item relating to the appointment of Dr Simon Eccles as the national chief clinical information officer, the chief information officer advised that she would be meeting with him following the board meeting.

07.03 Resolution: The board noted the report for information.

08/57 Chief Executive’s report

08.01 The board received a progress report from the chief executive. She advised that staff had been managing well throughout a recent period of cold weather and assured the board that further business continuity arrangements were in place to reduce the operational risks from a further forecast period of extreme cold weather. This included booking local hotel accommodation to reduce the need for staff to travel to and from the hospitals. The chief executive reported that the low temperatures were having a negative impact on hospital buildings causing significant operational issues, including to the heating and water supply. She noted that the surgical department had been particularly affected.

08.02 The chief executive reported that the endoscopy service had received positive informal feedback on a recent JAG inspection. Inspectors had recommended a small number of actions and the board was assured that these would be completed within two weeks.

08.03 John Brougham brought the board’s attention to the approval of external support to establish a theatre scheduling tool and asked for an explanation on how this would improve theatre efficiency. The director of surgery, anaesthetics and cancer advised that the trust’s internal work streams looked in detail at all aspects of improving theatre efficiency and the external support was required to provide a focus on scheduling, with the aim of achieving 85% for theatre utilisation. He advised that this type of detailed work had been successfully undertaken in the past and would help to reduce costs by increasing daytime theatre use and reducing weekend working. John Brougham welcomed this initiative and requested for the finance and investment committee to receive a progress paper in due course. The chief financial officer reminded the board that a development session had been arranged on 14 March 2018 which would focus on the model hospital.

JL

06/18

08.03 Paul Cartwright enquired whether the temporary change to the use of beds on Delamare Ward at St Albans was having a positive impact on patient flow. The chief executive responded that there was a slight improvement, however the beds were not being utilised as much as

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Agenda item


they could be. She advised that theatre utilisation was increasing and assured the board that the executive was managing risk effectively to ensure that patient safety was not compromised.

08.05 Resolution: The board noted the report for information.

PERFORMANCE

09/57 Integrated performance report- month 10

09.01 In the absence of the chief operating officer, the board received a summary of the key areas of note from the chief information officer.

09.02 John Brougham was disappointed to note that the hospital standardised

mortality ratio (HSMR) had moved from ‘lower than expected’ to ‘as

expected’ and asked for assurance on the reasons for this recent change. The medical director responded that there had been coding issues in a number of cases and assured the board that this was under close investigation and the board would be updated on the outcome once it was completed. The chair commented that coding inaccuracies had been a previous issue and asked for clarification on the controls in place to address this. The chief executive advised that the issue was with the recording of the primary cause of death and assured the board that this was being reviewed and addressed by the executive team. The chief financial officer reminded the board of recent improvements to the coding process for co-morbidity cases.

09.03 Phil Townsend highlighted an increase of 3.1% from the previous month in lost supervisory hours and the chief nurse explained that this was due to the number of vacancies which resulted in wards sisters having to step into the staffing numbers. This meant that they were not able to continue to manage their usual work such as supporting junior staff, joining ward rounds and dealing with complex issues and complaints. She assured the board that there was mitigation in place to address the vacancy issue, including nurses working in bays supporting doctors on ward rounds, temporary staffing and the corporate nursing team working on wards. She provided further assurance that staffing levels were reviewed up to eight times a day in line with the safer care tool to ensure oversight and decisions relating to closing or not opening surge areas and supporting the skill mix for patient safety.

09.04 In response to Jonathan Rennison noting an increase in the number of pressure ulcers, the chief nurse was concerned by this trend seen in January. She assured the board that monthly test your care reviews were undertaken and themes and trends were carefully considered. She further assured the board that this was a focus at divisional performance reviews and for the quality and safety group, and a key focus was being undertaken in surgery where a marked increase had been seen. The chief executive pointed out that it was unrealistic to expect the trust to provide the same level of care when it was managing a large number of surge areas.

09.05 Ginny Edwards welcomed an increase in complaint responses from 52% to 76% in the previous month.

09.06 The chief financial officer updated the board on the financial position. He advised that the current deficit of £39.34m was £23.77m below plan at month 10, year to date. He advised that the trust had expected income to decrease in January 2018 due to a reduction in elective care; however this had been more than expected. Despite lower agency spending and an increase in the staffing bank, the chief financial officer advised that pay costs were £9.4m below plan year to date. Savings

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Agenda item


were in line with plan in month 10; however they remained £7.63m behind target. The chief financial officer advised that no confirmation of the ITFF application had been received from NHS Improvement. He concluded his report by advising the board that regrettably the trust was only able to pay 20% of its bills within the required 20 days. Paul Cartwright asked whether this was having a significant impact on small suppliers and the chief financial officer assured the board that small businesses were not being put at risk.

09.07 The chair reminded the board that it would be discussing the risks and actions involved in meeting the control total in the private session of the meeting.

09.08 Resolution: The board received the report for information.

10/57 Presentation by Mitie, facilities management company

10.01 The chair informed the board that contract negotiations were still ongoing; therefore it would not be appropriate to have a presentation by Mitie. He advised that the board would discuss progress of the contract in the private session of the meeting.

10.02 Resolution: This item was deferred until the contract with Mitie had received board approval.

11/57 Quality commitment

11.01 The chief nurse presented the quality commitment, which sets out how the trust plans to build and embed a culture of quality improvement across the organisation. She advised that the commitment linked with the trust’s quality priorities and values and had been developed through extensive stakeholder engagement. The board was informed that the strategy delivery board and the clinical outcomes and effectiveness committee had fully endorsed the quality commitment. The chief nurse advised that a central improvement hub had been established to provide expertise and support a consistent quality improvement methodology which had been developed by the Institute of Health Improvement (IHI). She reported that the first step to building quality improvement capability in the organisation would be a two-day workshop, facilitated by IHI, in April 2018. The chief nurse advised that collaborative working with the Royal Free London on reducing unwarranted variation would allow the trust to further explore quality improvement opportunities.

11.02 Ginny Edwards enquired when the board would see projects and timelines for transformational improvements and queried the process for staff to feed in ideas and receive formal feedback. The chief nurse advised that the central quality improvement hub would be formally launched in April 2018 and assured the board that the strategy delivery board and clinical outcomes and effectiveness committee would monitor progress of the quality commitment. She reported that a staff management of change process was underway across the quality teams, with new job portfolios to come into force at the beginning of May 2018. The chief executive advised that staff were already informally feeding through ideas and the quality commitment would provide a framework to formulate this.

11.03 Paul Cartwright welcomed the development of the quality improvement methodology and asked how pervasive the quality commitment would be. The chief executive confirmed that the commitment would be the framework by which the trust would manage all areas of its work.

11.04 The chair fully supported the quality commitment and asked what

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Agenda item


evidence the board would receive to demonstrate that it was having the desired impact. The deputy chief executive stated that measuring culture change was also a challenge but there were some tools that could be explored for use.

11.05 Resolution: The board approved the quality commitment.

12/57 Quarterly learning from deaths report

12.01 In line with national guidance, the medical director presented a paper to the board on the number of inpatient deaths in quarter three and those deaths which had been the subject of a case review. He advised the board that a new process had been established to comply with the guidance and reported that 446 inpatient deaths had been recorded in quarter three, two of which had been referred for structured judgement review. Both reviews had concluded that the treatment and management had led to no harm.

12.02 Ginny Edwards asked what action had been taken in response to the outcome of the reviews. The medical director confirmed that both cases had already been fully investigated prior to the judgement review and the trust had been in correspondence with the families in line with its duty of candour responsibilities.

12.03 It was acknowledged that the chair was the nominated non-executive director for learning from deaths and he confirmed he would discuss the requirements of the role with the medical director outside of the board meeting.

SB/ MVDW

04/18

12.04 Resolution: The board approved the report for publication, in line with national guidance.

13/57 Gender pay gap report 2017

13.01 The board received an annual report on the gender pay gap from the director of workforce. He advised that it had become mandatory for organisations with over 250 employees to publish data on gender pay gaps by 29 March 2018 and then annually thereafter. The board was assured that, although the report noted that on average female employees earned less and received lower bonuses than male employees, additional analysis suggested that this was as a result of the type of roles held by male and female workers.

13.02 The director of medicine raised concern that the report was misleading as it failed to take all variants into account, such as part time workers. As chair of the patient and staff experience committee, Ginny Edwards acknowledged this, but confirmed that the trust had no control over the report as the format was nationally prescribed. The chief executive assured the board that genuine gaps in pay and bonuses would be targeted and addressed by the trust executive committee.

13.03 The board discussed the process for clinical excellence awards and the medical director advised that he had reviewed and amended the process when he had taken up office to ensure it was fairer and reflected the makeup of the clinical workforce. The board agreed that any underlying issues with clinical excellence awards would be monitored by the patient and staff experience committee.

13.04 Resolution: The board approved the report for publication on the trust’s and government website.

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Agenda item


14/57 Bi-monthly corporate risk register review

14.01 The medical director presented a report on the position with regard to the corporate risk register. He noted that when the report was extracted, 22 risks were recorded with a score of 15 and above. The medical director highlighted a risk relating to a lack of back-up mammography facilities and assured the board that a full business case was due to be discussed by the trust executive committee in March. A second risk relating to the failure of a condensate tank in the boiler house at Watford was raised and the board was assured that robust mitigation would remain in place until a long term solution had been established. It was reported that a risk relating to a lack of anaesthetic machines and monitors had been de-escalated to reflect robust mitigation.

14.02 John Brougham noted that risk number 3120 should be aligned to the safety and compliance committee and not the finance and investment committee as stated.

MVDW

04/18

14.03 Resolution: The board received the report for information.

15/57 Assurance report from finance and investment committee

15.01 The board received an assurance report on the work of the finance and investment committee from John Brougham. He advised that the committee recommended that the board ratify an NHS revenue support loan to cover funding required for February 2018. It was also noted that the board would receive reports on the plans and risk to achieving the deficit forecast and an update on the 2018/19 financial plan in the private session of the meeting.

15.02 Resolution: The board received the report for information and assurance and ratified an NHS review support loan of £11.4m.

16/57 Assurance report from clinical outcomes and effectiveness committee

16.01 The board noted a report on the work of the clinical outcomes and effectiveness committee from Jonathan Rennison which had been received verbally at the February meeting.

16.02 Resolution: The report was received for information and assurance.

17/57 Assurance report from the safety and compliance committee

17.01 Jonathan Rennison presented a report on the work of the safety and compliance committee. He reported that the committee had reviewed a performance report in detail and, in particular, the areas of poor performance. The committee received an excellent bi-annual report on safeguarding and had been updated on the management of fire safety and medical devices. The committee had welcomed a letter from NHS England confirming that the trust was fully compliant with emergency preparedness, resilience and response (EPRR) and congratulated the team for this excellent achievement. A recommendation to appoint a data protection officer had been approved.

17.02 Resolution: The board received the report for information and assurance

18/57 Assurance report from the patient and staff experience committee

18.01 Due to the close timing of the patient and staff experience committee meeting, Ginny Edward provided a verbal update. She advised that the committee had reviewed mandatory training requirements for individual roles and a report on the gender pay gap. The trust’s results in the national staff survey had also been reviewed and a national

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Agenda item


workforce strategy consultation discussed. It had been agreed that the trust would officially respond to the consultation through the trust executive committee.

18.02 John Brougham enquired when the board would receive the outcome of the bi-annual nursing establishment review. The chief nurse confirmed that the frequency for board review had reduced nationally and the safety and compliance committee would receive a report in April 2018. John Brougham requested for the finance and investment committee to be made aware of any key recommendations or changes to the establishment.

18.03 Resolution: The board received the report for information and assurance.

19/57 Any other business

19.01 No other business was reported.


20.01 There was no representation from Hertfordshire Healthwatch in attendance.


21.01 There were no patients or members of the public present.


22.01 Resolution: The draft agenda was approved.

23/57 Date of the next board meeting

23.01 The next board meeting will be held on 12 April 2018.

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Agenda item 06a/57

Action log Part 1 – 12 April 2018

Ref No.

Action from agenda item

Action Lead for completing the

action

Date to be completed

Update

1 12.03/57 Chair and medical director to discuss the requirements of the role of nominated non-executive director for learning from deaths

SB/MVDW 04/18 Completed.

2 14.02/57 To align risk number 3120 in the corporate risk register to the safety and compliance committee and not the finance and investment committee as stated in the March report.

MVDW 04/18 Completed.

3 08.03/57 The finance and investment committee to receive a update paper on the outcome of a theatre scheduling tool.

JL 06/18 Due June 2018.6

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Agenda item: 06/58

Board

meeting/decision date

Decision reference

(from minutes)

Item presented to Board for action Comments/outcome

01/03/2018 15.01/57 Assurance report from Finance and Investment CommitteeRatified an interim revenue support loan

of £11.4m

01/03/2018 13.04/57 Gender pay gap report 2017 Approved for publication

01/03/2018 12.04/57 Quarterly learning from deaths report Approved for publication

01/03/2018 11.04/57 Quality commitment Approved

01/02/2018 13.05/56 Review of corporate governance structure

Approval of the current corporate

governance structure to continue for

2018/19, subject to the proposed

refinements

07/12/2017 17.01/54 Corporate governance meeting schedule Approval of 2018/19 corporate

governance meeting schedule.

07/12/2017 18.03/54 Assurance report from the Charitable Funds Committee

The corporate trustee approved a

recommendation to appoint Kingston

Smith to undertake a review.

02/11/2017 13.03/53 The Board approved the Hertfordshire health concordat Approved

02/11/2017 15.04/53 Board assurance framework Approved

05/10/2017 13.03/52 Assurance report from Finance and Investment CommitteeRatified a £1.4 interim revenue support

loan

05/10/2017 13.03/52 Assurance report from Finance and Investment Committee

Approved £1m capital expenditure

funding for the redevelopment of the A&E

department

07/09/2017 10.02/51The board aproved the NHS England emergency preparedness, resilience and response

annual assurance. Approved

07/09/2017 13.02/51The board approved the infection prevention and control annual report 2016/17 for

publication on the Trust website Approved

06/07/2017 16.04/50 The terms of reference and work plans for the board and committees Approved

06/07/2017 22.05/50The corporate trustee approved the recommended way forward to the future management

of the charity Approved

06/07/2017 18.02/50The board approved the annual accounts, annual report, governance statement and

quality account 2016/17. Approved

01/06/2017 15.03/49 Proposed monitoring arrangements for aims and objectives Approved the approach

01/06/2017 14.04/49 Outline business case for theatre reconfiguration Approved option E

01/06/2017 17.01/49 NHS self-certification 2017/18 Approved condition G6 (3)

BOARD AND CORPORATE TRUSTEE

DECISION LOG PART 1

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01/06/2017 18.02/49 Assurance report from Finance and Investment CommitteeRatified the terms and conditions of a

£42m interim revenue support loan

04/05/2017 20a.03/48 West Herts charity strategy Approved

04/05/2017 20b.02/48 Discretionary resources policy Approved

04/05/2017 15.02/48 An interim revenue support loan of £1.964k Approved

06/04/2017 16.02/47 Interim capital support facility agreement £7.5m Rattified

06/04/2017 11.04/47 Hospital Pharmacy Transformation PlanApproved as direction of travel for

pharmacy service.

06/04/2017 16.02/47 Deficit control totals for 2017/18 of £15.4m Approved

06/04/2017 14.02/47 Aims, objectives and principle risks. Approved

06/03/2017 15.02/46 The conversion of an IRWCF loan of £26.8m to an ISLF loan. Approved

06/03/2017 18.02/46 The 2017/18 Board and Committee structure and meeting schedule Approved

06/03/2017 17.02/46Recommendation to delegate responsibility to the Audit Committee to sign off the Annual

Accounts, Annual Report and Annual Governance Statement.Approved

06/03/201715.02/46

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

ApprovedApproved

06/03/2017 13.07/46 A graded approach to workforce metrics for future reporting. Approved

02/02/201712.01/45

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

02/02/2017

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

02/02/201712.01/45

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

requirements

Approved

12/01/201715.2/44 counter fraud policy

Approved

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Board

meeting/decision date

Decision reference

(from minutes)

Item presented to Board for action Comments/outcome

01/12/2016 10/43 Nursing, midwifery and allied health professions strategy Approved

03/11/2016 19/42c Update to terms of reference for the Board Approved

03/11/2016 18/42 The gifts, hospitality and sponsorship policy Approved

03/11/2016 13/42 Statutory annual public sector equality duty report 2015 Approved

03/11/201619/42a

Recommendation to reduce the frequency of Integrated Risk and Governance Committee

meetings

Approved

03/11/2016 12/42 Patient experience and carer strategy Approved

03/11/2016 19/42b Draft Board and Committee meeting schedule 2017/18 Approved

07/10/2016 14/41 Recommended changes to the BAF 2016/17. Approved

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

annum.

Approved

01/09/2016 23/40 Terms of reference for the Trust Executive Committee Approved

01/09/2016 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

07/07/2016 21/39 Updated Board Assurance Framework Approved

07/07/2016 .09/39 The quality account 2015/16 Approved

07/07/2016 18/39 The end of life care strategy Approved

07/07/2016 19/39

The Board received the updated terms of reference and work plans for the Safety and

Quality Committee and the Trust Board

Approved

07/07/2016 17/39Infection prevention and control annual report 2015/16 Approved for publication

07/07/2016 16/39Funding for external advisory support to develop a strategy outline case (SOC) for the

configuration of acute hospital service

Approved

05/05/2016 17/37The 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

07/04/2016 16/36

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

comments from Board

07/04/2016 17/36

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

BOARD AND CORPORATE TRUSTEE

DECISION LOG PART 1 2016/17

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rust Board M


Trust Board Meeting 12 April 2018

Title of the paper Chair’s report

Agenda item 07/58

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

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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: 07/58

Trust Board Meeting – 12 April 2018 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 2.1. As local elections will be taking place on 03 May 2018, the trust is now in a period called

‘purdah’. ‘Purdah’ came into force on 27 March 2018 and runs until the election has been completed.

2.2. During this pre-election time, the board meeting agenda will be confined to matters that need a decision or require oversight. Non-specialist acute trusts to receive a combined quality and use of resources rating

2.3. The Care Quality Commission’s (CQC) will now award all non-specialist acute trusts that undergo a use of resources assessment, a trust-level rating that combines quality and use of resources.

2.4. Use of resources assessments will be considered as a sixth key question alongside quality ratings. Like the CQC’s five quality questions, use of resources will be given a rating of outstanding, good, requires improvement or inadequate.

Spring Statement 2018

2.5. As the Chancellor had announced in 2017 that major tax and spending changes would be made at the Budget in the autumn; the Spring Statement contained no new policy announcements. It did however provide an update on the overall health of the economy, the Office for Budget Responsibility (OBR) forecasts on progress made since the Autumn Budget 2017.

2.6. The Chancellor hinted that there may be more money for the public sector in the

November Budget if public finances continued to improve. The outlook was more optimistic than that set out in the Budget in November, with the Chancellor unveiling a minor boost to the growth outlook and a fall in the borrowing forecast.

Funding to modernise NHS buildings and services

2.7. In March, Jeremy Hunt, the Secretary of State for Health and Social Care, announced

that forty NHS hospitals and community services would receive £760 million to modernise and transform their buildings and services in the year of the NHS’s 70th birthday.

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Tab 7 Chairs report


https://improvement.nhs.uk/resources/use-resources-assessment-framework/

2.8. The Shropshire, Telford and Wrekin sustainability and transformation partnership (STP) will receive £300 million to transform local hospital services. The remainder of the money will be awarded to 39 smaller projects, including:

£6 million to upgrade services of eight trusts across Yorkshire

£8 million for a new health and wellbeing centre to join up local NHS services in Kent

£13 million for two new urgent care centres in Newton Abbot and Torquay, and refurbishment of Torbay Hospital’s A&E department

several million pounds for local NHS services in London, including one project worth up to £11 million

2.9. The government is also releasing £150 million to support the NHS’s work to become more efficient. This additional money will be used to:

improve the use of a digital programme that helps the NHS use its workforce better

enable more efficient use of energy in hospitals, which could save the NHS £12 million a year in the first 3 years

improve pharmacy IT and administration systems to reduce medication errors and improve patient safety

Improving maternity care

2.10. The Secretary of State for Health and Social Care has announced that the majority of

women will receive care from the same midwives throughout their pregnancy, labour and birth by 2021. The first step towards achieving this will see 20% of women benefiting from a ‘continuity of carer’ model by March 2019. Research suggests that women who use this model are less likely to miscarry, to lose their baby or to have a premature baby.

2.11. To help achieve this, 3,000 extra midwives will be trained over four years. The plan is to have 650 more midwives in training next year with increases of 1,000 in the subsequent years.

2.12. There will also be further investment in maternity support staff, including:

professionalising the Maternity Support Worker (MSW) role. This is a defined role and national competency framework will be developed and a voluntary accredited register will be established to provide assurance to the public that they are appropriately trained to high standards

working with the Royal College of Midwives and other partners to develop new training routes into midwifery. This will help talented support workers to develop and move quickly to become registered midwives and help the midwifery profession attract and retain talented staff

3. LOCAL NEWS AND DEVELOPMENTS 3.1. Sadly, Katie Fisher will be leaving the Trust at the end of June 2018 to lead a healthcare

charity which provides specialised secure mental healthcare services to the NHS and the Ministry of Justice.

3.2. Katie has been a first class chief executive and will be sorely missed. Under her leadership the trust has been taken out of special measures, improved upon a wide range of key performance indicators and increased staff satisfaction rates in the last two national surveys. As well as the improvement in performance indicators, Katie has also supported the trust to become a clinically led organisation with a strong focus on quality.

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Tab 7 Chairs report


3.3. A campaign has begun to recruit a new chief executive and Helen Brown, the current

deputy chief executive, will act as chief executive from July 2018.

Opening of cardiac and MRI scanner suite

3.4. Richard Harrington, MP for Watford, officially opened a new cardiac imaging suite at Watford in March 2018. The suite, which was installed in April 2017, includes cardiac MRI and cardiac CT scanners offering access to advanced cardiac imaging technology in a refurbished environment.

3.5. Previously the trust was sending patients to other centres mainly in London for specific scans; however this new development means that these scans can now be performed in Watford, therefore improving the experience of patients.

Staff bank – flexible working pilots

3.6. In October 2017, the Secretary of State announced a pilot scheme which would focus on reducing agency spend and improve the experience of bank staff. This would include the use of mobile phone booking apps and prompter payment.

3.7. The trust has been recommended as a pilot site (in collaboration with the remaining trusts in the Herts Consortium). This will offer an opportunity for the trust to develop staff bank best practice, help reduce agency spend, and be recognised as a leader in the use of technology to deliver safe and efficient flexible workforce solutions.

Joint advisory group for gastro-intestinal endoscopy inspection

3.8. The endoscopy service at Hemel Hempstead and Watford Hospitals were assessed in March 2018 by the Joint advisory group (JAG) against national endoscopy standards of clinical quality, quality of patient experience, workforce and training. The JAG assessors were impressed with a number of areas of exemplary practice which they will use as a gold standard example to share with other endoscopy units.

3.9. The trust will receive a formal report on the inspection in due course.

Thank you 3.10. Thank you to the following people for their kind donations of time and effort to improve

the experience of our patients and staff

Isobel Mason, one of the few nurse consultants in gastroenterology in the country, who gave a highly informative and inspiring talk about nurse-led services at the Royal Free London NHS Foundation Trust

Beauty therapy students from West Herts College who offered beauty treatments to staff, volunteers, patients, carers and visitors at Watford hospital

Tate Recruitment who donated Easter eggs to children across various patient areas and to staff working over Easter in the emergency department

Carl Mitchell for raising over £2,000 by running a 12 mile ‘Tough Mudder’ race in aid of starfish ward

Recognising and celebrating our staff

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

meeting:

Aldenham ward and blue and yellow wards in the Acute Admissions Unit for achieving an ACE (accredited clinical environment) award

The stroke team and the employee relations team for being shortlisted for a Healthcare People Management Association award

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Tab 7 Chairs report


Michelle Brooks for organising a fundraising pampering evening in March 2018 in aid of the special care baby unit

Sarratt and Bluebell wards for organising an afternoon tea party for patients to celebrate nutrition and hydration week

The following overseas nurses for passing their objective structured clinical examination: - Ancey (Aldenham ward) - Arun (AAU L1 purple) - Jade (AAU L1 blue) - Rachana (Ridge ward) - Charissa (AAU L3 B/Y) - Angelique (Elizabeth ward)

4. BOARD UPDATE 4.1. The trust held a development session on 14 March 2018 as part of its board

development programme. The session provided an opportunity for board members to meet with the senior team at the Royal Free London NHS Foundation Trust to discuss partnership working.

5. KEY MEETINGS

Presented the ward accreditation certificates

Met with Bim Afolami, MP

Met with Mike Jackson, chair of Watford Labour party; Chris Ostrowski, parliamentary candidate for Watford and Jagtar Singh Dhindsa, mayoral candidate

Met with Manny Lewis, managing director, Watford Council,

Visited orthopaedic outpatient clinic and level 5 wards with Wendy Wilson, patient representative

Met with Collette Wyatt-Lowe, chair, Hertfordshire Health and Wellbeing Board

Met with Natalie Rotherham and Seamus Quilty, Hertfordshire county council’s health scrutiny committee

Attended the sustainability and transformation partnership chair’s meeting

Attended the Hertfordshire county council’s scrutiny quality review meeting

Met with the chair and CEO of West Suffolk NHS Foundation Trust

Presented two staff awards

RECOMMENDATION

5.1. The Board is asked to receive the report for information. Professor Steve Barnett Chair April 2018

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Tab 7 Chairs report


Page 1 of 7

Trust Board Meeting

12 April 2018

Title of the paper Chief Executive’s report

Agenda item 08/58

Lead Executive Katie Fisher, Chief Executive Officer

Author Jean Hickman, Trust Secretary


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 assurance that the trust executive is effectively managing the business of the trust.

Risk to Board Assurance Framework (BAF)





PR4a


PR4b


PR5a


PR5b


8

Tab 8 Chief Executives report


Page 2 of 7

PR7a


PR7b




PR10


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






Risks attached to this project/initiatives and how these will be managed 8



Page 3 of 7

Agenda Item: 08/58

Trust Board Meeting – 12 April 2018 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

Emergency pressures 2.1. Although we are officially in spring the trust continues to manage significant ‘winter

pressures’. The trust reached a critical situation in early March 2018 with no beds for new admissions and patient waiting unacceptable times in the emergency department and for planned surgery. The trust had 117 additional beds open in clinical areas, including unit, that are normally used as assessment areas in order to manage the ongoing demand. This meant that patients were being moved around to accommodate new admissions from the emergency department; leading to a need to adequately staff the areas with nursing staff being moved and the use of temporary staff to keep staffing at a safe level.

2.2. To address this and alleviate the pressure, in March 2018 the trust activated a total‘re-set’ approach to the admission and discharging of patients. This radical approach included arranging for every adult inpatient at Watford hospital to have a clinical review by a multi-disciplinary team; ensuring that patients are ready for discharge as soon as they are assessed as medically fit; and considering whether a patient could wait in the patients’ lounge rather than on a ward when they are ready to leave hospital

2.3. To support this approach, all non-urgent meetings were cancelled for a week to allow all

frontline staff to be out on the wards. 2.4. There was a concerted focus on ensuring that the patients’ lounge at Watford and the 18

reablement beds on De La Mare ward at St Albans were also being used effectively, in order to improve the patient flow.

2.5. This approach, combined with the use of additional consultants in the emergency department and ‘hot clinics’ (where patients receive instant assessment by a senior clinician) resulted in a reduction in admissions and an increase in the number of patients discharged. This has allowed the trust to close a number of ‘surge’ beds and to improve the four hour A&E target. Before the re-set, the trust had been admitting more patients than it had been discharging; however this trend is now reversing.

.

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Page 4 of 7

2.6. The trust executive committee is reviewing the lessons learnt from this exercise and

considering which actions have contributed to the improvement in order to sustain the progress.

2.7. This achievement was only possible due to the magnificent efforts of staff and their unwavering commitment to provide the very best care for patients in the face of relentless pressure.

New soft facilities management contract

2.8. Following a competitive tender process, the trust has entered into a contract with Mitie

Cleaning and Environmental Services Limited to provide a range of services including cleaning, catering, portering, pest control, linen and helpdesk services.

2.9. The services will extend across the three main hospitals, as well as a new physiotherapy outpatient unit in Abbotts Langley.

2.10. Under the contract, which started on 1 April 2018, 400 people are transferring to Mitie from the current service provider. Employees will benefit from a pay increase as all staff will receive at least the Real Living Wage, as well as a range of Mitie rewards which include staff discounts.

2.11. Mitie will be investing in new technology, including new digital software to support better communicate and robotic cleaning which uses a mapping system to guide it round the hospital, completing pre-programmed cleaning duties and freeing up staff to focus on more complex tasks. Patients will benefit from the latest in meal delivery with the introduction of a new heating and chilling unit which allows easy preparation of personalised menu choices for patients.

2.12. The board will receive a presentation on the services provided by Mitie in the private

session of the board meeting and will have an opportunity to sample some of the food received by patients. Non-emergency patient transport

2.13. Following East of England Ambulance Service being awarded a caretaker contract to provide non-emergency patient transport in Bedfordshire, Luton and Hertfordshire in 2017, the Service has set up a call centre which now operates at weekends. The trust is continuing to request that this is commissioned as a 24/7 service to allow the trust to efficiently manage its discharges and outpatient appointments.

2.14. East of England Ambulance Service will also be facilitating inpatient transfers to London trusts. Currently there is no transport provision for inpatients requiring an outpatient appointment, diagnostic or day case treatment at a London trust.

Paper switch off

2.15. In line with the trust’s policy on paper reduction, from 01 May 2018, the trust will no longer accept paper referrals for a first appointment with a consultant. All referrals to consultants will be made through the NHS Electronic Referral Service.

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Patient information service 2.16. Due to a focus over the past year on improving patient information, the trust now has an

extensive library of over 300 high quality leaflets available to patients and the public on the trust’s website.

3. LEADERSHIP CHANGES 3.1 Maxine McVey, deputy chief nurse left the trust in February 2018 after 19 years to take

up the post of deputy director of nursing at Frimley Health NHS Foundation Trust. David Thorpe joined the trust on 02 April 2018 from Colchester Hospital University NHS Foundation Trust as the deputy chief nurse.

3.2 Collette Manion, will join the trust on 14 May as the director of midwifery. Collette is

currently working at North Middlesex University Hospital NHS Trust and has extensive experience as a head of midwifery and a deputy chief nurse.

3.3 Karen Walker will take up the post of head of nursing for children’s services from 04

June 2018. Karen is a very experienced children’s nurse and has worked in a variety of senior roles as well as wider organisational roles at University College London Hospitals NHS Foundation Trust.

3.4 Dave Coley has taken up the post of Director of Procurement. He is based at the

Gatehouse, Welwyn Garden City. 4. COMMUNICATIONS REPORT

Media

4.1. The main recent coverage centred on reports about the launch of a new public

consultation on Hemel Hempstead Hospital’s Urgent Treatment Centre. Herts Valleys CCG is looking at the future of the facility. But although the public consultation could restore 24/7 opening times, critics say that there will be an inferior service to the one provided just 14 months ago. Additionally, the Gazette and Express reported that our maternity service has been given a significantly improved rating from new mothers. These women rated maternity services at Watford Hospital as: 9 out of 10 for labour and birth; 8.7 out of 10 for staff during labour and birth and 7.4 out of 10 for care in hospital after the birth.

4.2. Other articles and mentions in the media during February included:

Mike Penning called for the abolition of hospital car parking charges. He says it is “completely unacceptable” that patients, visitors, and staff, are forced to pay just to park their car.

The St Albans and Harpenden Review reported that plans to create a new community health facility have been given the green light. The new facility will house some of Hertfordshire Community NHS Trust’s (HCT) community health services. The services include those currently provided at St Albans Principal Health Centre on Civic Close, as well as the leg ulcer clinic and podiatry service located at St Albans City Hospital.

The Gazette and Express reported that the GPs out-of-hours service is no longer running in Dacorum. Patients now have to travel to Watford after 11.15pm, as part of a change branded a “clear deterioration” of services by patients. The newspaper states that this is a series of service reductions which go back a decade.

ITV News picked up on our story that a woman unexpectedly gave birth in a hospital car park after she was unable to get to the maternity unit on time.

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Communications data

Website

Month’s Figures 17/18

Month’s Figures 16/17

Total Quarter 1

Total Quarter 2

Total Quarter 3

Running Quarter 4

Running total 17/18

Total 16/17

Total Page Views

424,998 448,967 1,364,707 1,414,842 1,321,512 944,795 5,045,866 4,901,513

Number of unique visitors

37,248 39,674 106,195 107,937 110,278 81,181 483,897 370,658

Top five pages visited on internet site (excluding home page and vacancy pages): 1. Watford wards and departments

2. parking

3. About/contact

4. Services/pathology

5. About/Watford General Hospital (our hospitals page)

Internal Communications

February 2018

Total Quarter

1

Total Quarter 2

Total Quarter 3

Quarter 4 (to date)

Running total 17/18

Number of e-newsletters (e-update)

8 15 26 23 8 80

Number of CEO briefings

3 12 19 16 5 55

Number of Herts & minds newsletters

0 1 1 1 0 3

February 2018 Positive coverage Neutral coverage Negative coverage

National coverage 1 0 1

Coverage (Watford) 1 4 2

Coverage (Dacorum) 0 2 2

Coverage (St Albans) 1 0 0

Other local 0 0 0

Letters coverage 3 0 2

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Page 7 of 7

Freedom of Information

February 2018

Total Quarter

1

Total Quarter

2

Total Quarter

3

Running Quarter

4 (to date)

Running total 17/18

Total 16/17

Number of FoIs received

55 153 169 154 113 589 662

Compliance within 20 day deadline

70% 95.0% 88.6 88.6%

74% 82% 94.3%

No of FoIs received from media outlets

3 24 24 12 12 69 100

Social Media

Twitter

Followers Posts Likes Retweets

February 2018 6,155 117 789 445

The most popular Tweet was: “Congratulations to Samuel Van Emden who celebrated the end

of his leukaemia treatment by ringing the end of treatment bell with his family!” with 159 likes,

31 retweets and 4 comments

Facebook

Followers Posts Likes Reach Shares Comments

February 2018 1,593 64 567 69,837 426 20

The most popular Facebook post was: “Say hello to this bundle of joy who couldn't wait to get

here as she was born in our car park at Watford General today. Sending best wishes to mother

and baby and a HUGE thank you to our staff who helped out with the arrival of baby Austin!”

with 241 likes, 28 shares and it reached 5,881 people.

5. RECOMMENDATION

5.1. The Board is asked to receive the report for assurance that the trust executive committee is effectively managing the business of the trust.

Katie Fisher Chief Executive April 2018

8



Trust Board Meeting12 April 2018

Title of the paper Integrated Performance Report (February activity)

Agenda item 09/58

Lead Executive Sally Tucker, Chief Operating Officer

Author Jane Shentall, Director of Performance

Executive summary

(including resource implications)

The Integrated Performance Report covers the March reporting period (Februarydata). For this reporting period, the Board is asked to particularly note the following performance changes since the last reporting period:

Safe, Effective, Caring:∑ HSMR remains “as expected” although the rate has fallen from 101.4 to 97.5∑ Reduced % of patient safety incidents that were harmful, from 12.3% to 9.1%∑ Mixed sex accommodation breaches significantly improved, at 3 for the month ∑ 8 cases of Clostridium difficile reported, with a year to date total of 26 which is

above the ceiling target of 23∑ A&E (94.4%) FFT positive score is just below target (95%) while inpatient

(95.6%), Day Case (99.2%) and maternity (95.9%) are above target ∑ Drop in complaints performance (from 76.3%) to 36.6%∑ VTE risk assessments are improving, although at 92.7% are below target (95%) ∑ Combined C-section rates (elective & non-elective) remain within the ceiling

target (28%) at 26.25%∑ Fall in performance against both stroke indicators – 43.3%(target 90%)

admitted to Stroke unit within 4 hours, and 80% of patients spent 90% of their time there (target 80%)

Responsive:∑ RTT (incomplete) performance worsened again, to 85.1% (85.7% last month)∑ 41 x 52 week breaches were reported (last month 20)∑ Fewer patients not treated within 28 days (16) this month (vs 20 in January)∑ Diagnostic waiting time performance remains compliant at 99.9%∑ ED 4 hour wait performance deteriorated to 71.3% (72.3% previously)∑ Ambulance turnaround delays improved by 20% between 30-60 minutes and

delays over 60 minutes 16.8%∑ 2ww, 2ww breast symptomatic, 31 day first, 31 day subsequent, 62 day first and

62 day screening performance all above target.

Well Led:∑ Staff turnover (rolling 3 months) better than last month (17.1%) at 16.4%∑ Vacancy rate fell for the 3rd month consecutively and is now to 10.3%∑ % Bank and agency pay are within target∑ Appraisal rates have fallen further, now at 80%∑ Further improvement in FFT response rates for inpatients, day case and A&E

although all remain below target but improved on previous month with the exception of Maternity is above target (35%) at 59.9%.

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

9

Tab 9 Integrated performance report - month 11


Where the report has been previously discussed

Trust Executive Committee (Performance) 27.3.2018

Action required:

∑ The report is provided for information and discussion.



PR2 Failure to recruit to full establishments, retain and engage workforcePR5a Inability to deliver and maintain performance standards for Emergency

CarePR5b 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 programmesPR7b Failure to secure sufficient capital, delaying needed improvements in

the patient environment, securing a healthy and safe infrastructurePR8 Failure to engage effectively with our patients, their families, local

residents and partner organisations compromises the organisation’s strategic position and reputation.

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 objectivesTo deliver the best quality care for our patientsTo be a great place to work and learn


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 LedRisks 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 11


Integrated Performance

Report

March 2018

(February data)

1

9

Tab 9 Integrated perform

ance report - month 11

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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 worse than the national average (pages 4 & 14) • There were 3 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 but new harms were better than the national average (pages 4 & 20) • Complaints responded to within agreed timescales was worse than the 85% external performance threshold and the internal improvement trajectory (pages 3 & 15)• Clostridium difficile was worse than the monthly threshold (5 cases) and the year to date threshold (26 vs 22) (pages 3 & 16)

New to category this month:

Areas requiring performance improvement• A&E 4 hour wait performance was below standard (pages 5 & 30) • 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 Trust recorded forty-one 52 week RTT breaches (page 5)• Formal DToCs were below standard (pages 6 & 31)


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 were 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)


Areas of good performance • There were no cases of MRSA bacteraemia (pages 3 & 16)• Day case FFT % positive indicator was better than the standard (pages 3 & 36)• There were no medication errors causing serious harm (pages 4 & 18)• Maternity FFT % positive indicator was in line with the standard (pages 3 & 36)• No never events were reported (pages 4 & 16)• The percentage of patients receiving a caesarean section was better than the performance threshold (pages 4 & 24)• Patients spending 90% of their time on the stroke unit was equal to the performance standard (pages 4 & 14)

New to category this month:• HSMR mortality was better than the performance target (pages 3 & 13)• Inpatient FFT % positive indicator was better than the standard (pages 3 & 35)

Areas of good performance • The 2WW cancer indicator achieved the performance standard (provisional) (pages 5 & 27)• Cancer 62 GP and 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) • Diagnostic wait times achieved the performance standard (pages 5 & 26)• The cancer 31 first indicator is provisionally better than the performance standard (pages 5 & 28)

New to category this month:• The cancer breast symptomatic and the 62 day screening indicator achieved the performance standard (provisional) (pages 5 , 27 & 29)

Areas of good performance • The sickness rate was in line with 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)• Agency pay was better than target (pages 7 & 32)

New to category this month:• Maternity Friends and Family response rate was better than target (pages 7 & 36)

Executive Summary

Feb-18 13

Jan-18 11

Dec-17 11

Achieving

Feb-18 8

Jan-18 10

Dec-17 10

Not achieving

Better than

national

average

Feb-18 8

Jan-18 7

Dec-17 11

Worse than

national

average

Feb-18 9

Jan-18 10

Dec-17 5

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.

Feb-18 11

Jan-18 9

Dec-17 12

Achieving

Better than

national

average

Feb-18 8

Jan-18 7

Dec-17 8

Worse than

national

average

Feb-18 6

Jan-18 7

Dec-17 6

Feb-18 6

Jan-18 5

Dec-17 5

Achieving

Better than

national

average

Feb-18 6

Jan-18 5

Dec-17 5

Worse than

national

average

Feb-18 4

Jan-18 5

Dec-17 5

Feb-18 10

Jan-18 11

Dec-17 11

Not achieving

Feb-18 10

Jan-18 12

Dec-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 Dec-17 Jan-18 Feb-18 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 89.5 91.9 92.2 MD Aug-17 Y National 100 Aug-17G

HSMR - Total (Rolling three months) 100 96.2 101.4 97.5 MD Nov-17 Y National 100 Nov-17G

Crude Mortality Rate (Non elective

ordinary)**3.6% 3.4% 3.5% 3.3% 2.8% 3.6% MD Feb-18 Y National 2.91% (East

of Eng.)Nov-17

G

l 30 Day Emergency Readmissions - Combined * 4.0% 8.0% 6.8% 7.0% 7.3% 4.0% MD Feb-18 Y National 11.4% 2011-12G £

Marginal tariff reimbursement, possible

penalties

30 Day Emergency Readmissions - Elective * n/a 3.7% 2.3% 3.0% 3.0% n/a MD Feb-18 Y National n/aG £


penalties

30 Day Emergency Readmissions - Emerg * n/a 11.1% 10.8% 10.9% 11.0% n/a MD Feb-18 Y National n/aG £


penalties^

Number of patients with a length of stay > 14

days *tbc 352 355 316 3721 tbc MD Feb-18 Local n/a

G £Reduction in reimbursement vs largely

fixed costs. No penalty levied.

Staff FFT % recommended care tbd NHSI^ 61.5% 59.0% 64.5% 62.4% tbd NHSI^ DoW Sep-17 Y National n/aG

Inpatient Scores FFT % positive 95% 96.5% 94.7% 95.6% 93.8% 95% CN Feb-18 Y National 95.7% Jan-18G

A&E FFT % positive 95% 89.1% 93.5% 94.4% 91.9% 95% CN Feb-18 Y National 86.4% Jan-18G

Daycase FFT % positive 95% 97.8% 98.6% 99.2% 98.7% 95% CN Feb-18 Y National n/aG

Maternity FFT % positive 95% 100.0% 95.0% 95.9% 94.9% 95% CN Feb-18 N National 97.1% Jan-18G

l

% Complaints responded to within one month

or agreed timescales with complainant85% 52.0% 76.3% 46.8% 54.5% 85% CN Feb-18 N Local n/a

R

Complaints - rate per 10,000 bed days tbd NHSI^ 25.9 36.8 36.6 35.2 tbd NHSI^ CN Feb-18 N National n/aR

Reactivated complaints 3 8 4 76 n/a CN Feb-18 N Local n/aR

Proportion of complaints with verbal

communication at the beginning of the

process

88.5% 87.8% 77.6% 74.1% CN Feb-18 N LocalR

l Mixed sex accommodation breaches 0 10 164 3 235 0 CN Feb-18 N National57 Trusts

breachingJan-18

G £Penalties from CCG. £250 per day per

service user.

l Clostridium Difficile 1 1 6 5 26 22 CN Feb-18 Y National 2.5 average Jan-18G £

Penalties from CCG, fines from other

statutory authorities. £10,000 per case

above threshold.

MRSA bacteraemias 0 0 0 0 1 0 CN Feb-18 Y National n/aG £


statutory authorities. £10,000 in respect of

each incidence in the relevant month.

E. Coli Bacteraemia tbc 2 2 8 38 tbc CN Feb-18 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

4



l

u

Domain Indicator Target Dec-17 Jan-18 Feb-18 YTD Actual YTD TargetExecutive

LeadMonth

Included

in

Detailed

Reports

National

/ Local

National

avg.

National

avg.

Period

Trend

Data

Quality

RAG

Never events 0 1 0 0 4 0 MD Feb-18 Y National n/aG £


statutory authorities, prosecution^

Serious incidents - number* tbd NHSI^ 3 5 3 37 tbd NHSI^ MD Feb-18 Y National n/aG

% of patients safety incidents which are

harmful*n/a 8.6% 12.3% 9.1% 10.9% n/a MD Feb-18 Y National n/a

G

Medication errors causing serious harm * 0 0 0 0 1 0 MD Feb-18 Y National n/aG

l CAS Alerts: Number issued each month n/a 10 12 8 8 n/a CN Feb-18 Y National n/aG

CAS alerts not acknowledged within 48 hours 0 0 0 0 0 0 CN Feb-18 National n/aG

Number of falls* 96 123 131 1177 CN Feb-18 Y LocalG

Number of falls with harm* 14 22 18 222 CN Feb-18 Y LocalG

Number of G3 pressure ulcers (Hospital

acquired)0 4 9 3 31 0 CN Feb-18 Y Local

G

Number of G4 pressure ulcers (Hospital

acquired)0 0 0 0 1 0 CN Feb-18 Y Local

G

l

Safety Thermometer Harm Free Care (acquired

within and outside of Trust)*/**95.0% 93.0% 91.3% 91.5% 91.6% 95.0% CN Feb-18 Y National 94.1% Feb-18

G

Safety Thermometer % New Harm Free Care

(acquired within Trust)*/**tbd NHSI^ 97.7% 97.5% 98.9% 98.2% tbd NHSI^ CN Feb-18 Y National 97.9% Feb-18

G

Safety Thermometer New Harm Free Care:

Catheter & UTI New Harms*/**tbd NHSI^ 2 1 0 20 tbd NHSI^ CN Feb-18 Y National

WHHT 0.0

vs 0.29Feb-18

G

l VTE risk assessment* 95.0% 88.9% 91.2% 92.7% 91.3% 95.0% MD Feb-18 Y National 95.4% Q3 2017A

Caesarean Section rate - Combined* 28.0% 28.3% 25.4% 26.25% 27.6% 28.0% MD Feb-18 Y Local 26.7%Apr15-

Aug15 A

Caesarean Section rate - Emergency* 15.0% 18.3% 14.6% 15.9% 16.3% 15.0% MD Feb-18 Y Local 15.3%Apr15-

Aug15 A

Caesarean Section rate - Elective* 11.0% 10.0% 10.8% 10.3% 11.3% 11.0% MD Feb-18 Y Local 11.4%Apr15-

Aug15 A

Maternal deaths 0 0 0 0 0 0 MD Feb-18 N National n/aG

lPatients admitted directly to stroke unit

within 4 hours of hospital arrival *90.0% 46.5% 48.0% 43.3% 61.1% 90.0% COO Feb-18 Y National 60.2% Jul-17

G

Stroke patients spending 90% of their time on

stroke unit *80.0% 69.8% 82.0% 80.0% 82.4% 80.0% COO Feb-18 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

Domain Indicator Target Dec-17 Jan-18 Feb-18YTD

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% 69.2% 66.9% 65.1% 70.2% 90.0% COO Feb-18 Y Local 75.9% Jan-18G

l Referral to Treatment - Non Admitted* 95.0% 88.3% 87.5% 88.1% 88.7% 95.0% COO Feb-18 Y Local 89.0% Jan-18G

l Referral to Treatment - Incomplete* 92.0% 86.4% 85.7% 85.1% 88.4% 92.0% COO Feb-18 Y National 88.2% Jan-18G £

CCG penalty of £100 in respect of each

excess breach above the threshold

uReferral to Treatment - 52 week waits -

Incompletes0 0 20 41 0 0 COO Feb-18 National

1869 (all

Trusts)Jan-18

G

Diagnostic wait times 99.0% 99.8% 100.0% 99.9% 99.3% 99.0% COO Feb-18 Y National 97.7% Jan-18G £


excess breach above the threshold

l ED 4hr waits (Type 1, 2 & 3) 95.0% 77.4% 72.3% 71.3% 80.3% 95.0% COO Feb-18 Y National 85.0% Feb-18G £


excess breach above the threshold (cap

off 8% of attendances)

ED 12hr trolley waits 0 0 0 0 0 0 COO Feb-18 Y National371 (all

Trusts)Feb-18

G £ CCG penalty £1,000 per incidence

l

Ambulance turnaround time between 30 and

60 mins0 435 409 327 4,319 0 COO Feb-18 Y Local n/a

R £CCG penalty £200 per service user

waiting over 30 mins

l Ambulance turnaround time > 60 mins 0 153 166 138 1,792 0 COO Feb-18 Y Local n/aR £

CCG penalty £1,000 per service user

waiting over 60 mins

Cancer - Two week wait * 93.0% 94.7% 95.8% 97.1% 95.5% 93.0% COO Feb-18 Y National 94.9% Q3 17/18G £

CCG penalty breaches per qtr in excess

of tolerance is £200 for each breach.

Cancer - Breast Symptomatic two week wait * 93.0% 95.8% 92.1% 96.8% 94.0% 93.0% COO Feb-18 Y National 95.1% Q3 17/18G £


of tolerance is £200 for each breach.

Cancer - 31 day * 96.0% 96.7% 98.5% 100.0% 98.6% 96.0% COO Feb-18 Y National 97.7% Q3 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 Feb-18 Y National 99.5% Q3 17/18G £



Cancer - 31 day subsequent surgery * 94.0% 100.0% 100.0% 94.4% 99.0% 94.0% COO Feb-18 Y National 95.6% Q3 17/18G £



Cancer - 62 day * 85.0% 89.0% 86.5% 86.6% 87.5% 85.0% COO Feb-18 Y National 83.0% Q3 17/18G £



Cancer - 62 day screening * 90.0% 83.3% 81.8% 100.0% 88.4% 90.0% COO Feb-18 Y National 90.7% Q3 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

6



l

u


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 Feb-18 Y National n/aG

lNumber of patients not treated within 28 days

of last minute cancellation0 12 20 16 94 0 COO Feb-18 Y National

10 (avg. all

Trusts)Q3 17/18

G

u Delayed Transfers of Care (DToC)* 3.5% 2.1% 4.3% 4.1% 5.2% 3.5% COO Feb-18 Y National 6.0% Feb-16G

Delayed Tranfers of Care (DToC) beddays used

in month735 866 1,045 12,867 COO Feb-18 Y National n/a

G

l Outpatient cancellation rate 8.0% 10.6% 11.6% 11.9% 11.2% 8.0% COO Feb-18 Y Local n/aG

Outpatient cancellation rate within 6 weeks^ 5.0% 3.7% 4.7% 4.0% 4.1% 5.0% COO Feb-18 Y Local n/aG

l Patient initiated cancellations (all) 14.3% 11.5% 11.9% 12.7% COO Feb-18 Y LocalG

Hospital + Patient initiated cancellations (all) 24.9% 23.1% 23.7% 23.9% COO Feb-18 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


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% 16.4% 16.9% 16.3% 16.3% 12.0% DoW Feb-18 Y National 13.5% (Beds

and Herts orgs)Dec-15

G

Staff turnover rate (rolling 3 months) 12.0% 16.6% 17.1% 16.4% 15.6% 12.0% DoW Feb-18 Y National 13.5% (Beds

and Herts orgs)Dec-15

G

Nurse Band 5 Turnover Rate 25.6% 25.6% 25.6% 25.9% DoW Feb-18 Y Local n/aG

% staffleaving within first year (excluding

medics and fixed term contracts)19.6% 20.3% 20.3% 19.1% DoW Feb-18 Y National n/a

G

Sickness rate 3.5% 3.5% 3.5% 3.5% 3.2% 3.5% DoW Feb-18 Y National 3.8% (EoE

orgs)Dec-15

A

l Vacancy rate 9.0% 11.7% 10.9% 10.3% 11.8% 9.0% DoW Feb-18 Y National 11% (local

survey)Dec-15

G

l Appraisal rate (non-medical staff only) 90.0% 85.4% 83.8% 80.00% 80.0% 90.0% DoW Feb-18 Y National 85% (local

survey)Dec-15

G

l Mandatory Training 90.0% 86.9% 86.1% 86.1% 88.8% 90.0% DoW Feb-18 Y Local 86% (local

survey)Dec-15

A

% Bank Pay** 8% - 12% 9.8% 10.8% 10.6% 9.9% 8% - 12% DoW Feb-18 Y Local n/aG

% Agency Pay** 8.0% 7.3% 6.4% 5.85% 7.9% 8.0% DoW Feb-18 Y Local 11.4% (local

survey)Dec-15

G

Temporary costs and overtime as % of total

paybill** (Inc. unfunded beds)22.6% 17.6% 17.7% 16.9% 18.2% 22.6% DoW Feb-18 Y National n/a

G

Temporary costs and overtime as % of total

paybill** (Excl. unfunded beds)7.0% 5.5% 5.2% 7.2% DoW Feb-18 Y National n/a

G

l Inpatient FFT response rate 50.0% 15.9% 19.0% 26.9% 22.3% 50.0% CN Feb-18 Y National 23.3% Jan-18G

l A&E FFT response rate 15% 2.7% 3.4% 5.5% 4.4% 15.0% CN Feb-18 Y National 12.2% Jan-18G

Daycases FFT response rate tbd NHSI^ 25.7% 27.5% 32.8% 30.1% tbd NHSI^ CN Feb-18 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/a

G

Staff FFT % recommended work 66% 58.5% 51.1% 53.8% 52.8% 66% DoW Sep-17 Y National n/aG

Maternity FFT response rate 35% 32.3% 25.4% 59.9% 39.1% 35% CN Feb-18 N National 22.5% Jan-18G

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

*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


+ Staff FFT reports latest quarterly positions in monthly columns (eg. Q1, Q2 and Q3 = month 1, 2, and 3)

Wel

l Led


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Finance (Overview)

8

Operational performanceCurrent deficit of £43.67m is £27.71m adverse to plan as at M11 YTD. Unallocated CIP accounts for £11.33 of this, £7.58m due to NHS revenue, £5.71m to other revenue (mostly STF foregone), and £4.14m of pay costs (after above CIP element removed).

Recovery plans will continue to be pursued up to the year end and beyond, reflecting a move towards multi-period planning while retaining a necessary focus on near-term results and operational performance.

Savings and outlook for FY18Savings achieved at £8.91m up to M11, in line with plan, i.e. projects costed vs actual delivery), and behind target by £9.98m (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 £10.29m identified.

Achievement of the £13.7m is unlikely, although £10.3m represents a major achievement based on challenging circumstances. 2018/19 CIP planning continues and is well ahead of this time last year.

Operational performanceRevised forecast of £35m accepted by NHSI, compared to agreed 2017/18 control total of £15m. Base forecast of £46.6m reflects the impact of elective decisions in the last couple of months, operational factors including surge, and ongoing discussions with HVCCG.

£m Plan Actual Var

Surplus / (Deficit) (0.4) (4.3) (3.9)

£m

Surplus / (Deficit) (16.0) (43.7) (27.7)

Breakeven

£m % Budget

Medicine (0.1) (4)

Unscheduled Care (5.7) (37)

Surgery (9.1) (73)

Women's (1.9) (10)

BPPC Clinical Support 0.3 5

Estates & Facilities 0.7 3

Corporate 0.6 1

Other (12.5)

Total (27.7)

FY18 YTD Variance by Division

Financial Overview as at 28 February 2018

Statutory / Regulatory Duties

The Trust has a deficit plan of £15m

for FY18.

CRL The Trust has not exceeded its Capital

Resource Limit.

Month 11 Income & Expenditure

Year to Date

EFL The Trust has managed spend w ithin its

External Financing Limit.

10 Days' Cash Cash at 28/2/18 equated to 9 days'

spend

Month 11 performance - 12% on number,

12% on value (95% target)

Financial Risk Rating FY18

0

5

10

15

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

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 Fe b Mar

Savings £'000

Actuals

Target

0

20

40

60

80

100

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

Rolling BPPC Payment Performance

Target

No.

Value

-50

-45

-40

-35

-30

-25

-20

-15

-10

-5

0Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Income & Expenditure FY18 £m

Actuals

Plan

BaseForecastRecoveryForecast

3

GG

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Finance (I&E)

9

Statement of Comprehensive Income (I&E)

Engagement with Commissioners• Contractual HVCCG activity continues to form the bulk of all income. Negotiations around final 2017/18 are in the concluding stages, revolving around PBR vs Block considerations.• CQUIN involves formal monitoring and operational controls, assuming 90% achievement after adjusting for prior year disputes.• FY19 QIPP discussed in twice-weekly meetings.

Operational performanceNHS income was £7.6m below plan YTD (£1.7m below in month), with a favourable variance in Non-Elective (£2.8m) offset by Elective (£4.9m, primarily Surgery), Outpatients (£2.5m) and Other (£2.2m).Other income was £5.7m adverse YTD (£0.9m 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 (e.g. elective directive, tender outcomes), any STF income forgone as a result of missing the original control total of £15m, and winter pressures.Other service pressures clearly impact the Trust and are quantified where possible.

Budget Actual Var Budget Actual Var

Volumes

3,492 3,327 (165) Elective 42,806 39,690 39,633 (57) 38,198

3,978 3,519 (459) Non elective 49,525 45,340 45,515 175 45,563

37,580 33,645 (3,935) Outpatient 433,803 424,879 403,844 (21,035) 391,355

9,463 8,777 (686) A&E 117,791 107,837 107,093 (744) 107,027

4,493 3,657 (835) Elective 55,461 50,742 45,849 (4,893) 48,566

8,112 7,965 (147) Non elective 100,978 92,445 95,255 2,810 87,645

5,668 5,339 (329) Outpatient 70,191 64,234 61,741 (2,493) 64,479

1,288 1,257 (31) A&E 16,032 14,677 14,500 (178) 13,435

1,107 919 (188) Critical care 13,781 12,616 12,000 (616) 12,446

3,453 3,305 (148) Other NHS revenue 42,978 39,346 37,141 (2,206) 37,253

24,121 22,442 (1,678) TOTAL NHS REVENUES 299,421 274,061 266,485 (7,575) 263,824

22 (4) (25) Private Patients 259 237 208 (29) 231

1,314 389 (924) Other non-NHS clinical income 11,306 9,992 4,281 (5,711) 12,604

1,335 385 (950) TOTAL Non NHS Clinical 11,565 10,229 4,489 (5,740) 12,835

850 1,062 212 Education & Training 9,694 8,886 9,084 198 8,613

1,291 1,262 (29) Other Revenue 15,341 14,043 14,669 626 15,381

2,140 2,324 183 TOTAL OTHER REVENUE 25,035 22,929 23,754 825 23,994

27,596 25,151 (2,445) NET HOSPITAL REVENUE 336,020 307,219 294,729 (12,490) 300,652

£000's

Month 11 (Feb)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)

10

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 is helping to generate a wide range of CIP ideas alongside the means and expertise to implement them in the best possible way.

Operational performance Pay costs were £11.4m adverse YTD (Medical £4.2m adv, Other Clinical £1.5m adv, Sci / Tech / Prof £0.6m adv, Nursing £0.7m adv & Unidentified CIP £7.2m, offset by Non-Clinical £2.9m fav). Focus on agency management continues agency cost trend established in FY17, £1.1m behind plan YTD (see following slide).

Non-pay costs were £3.8m adverse YTD – Increased outsourcing and drugs overspends + CIPs were offset by favourable depreciation and clinical services.[Further detail is given in the main Finance Report.]

Outlook for FY18Current and recovery actions are continually assessed as part of general good practice alongside a formal process with NHSI. Mitigating actions, incluse of the Model Hospital and internal SDO are at various stages of progress.

Budget Actual Var Budget Actual Var

18,603 18,468 135 Permanent / Bank Staff 223,337 204,798 197,662 7,136 180,578

506 1,149 (643) Agency 6,227 5,690 16,961 (11,271) 25,007

(1,438) (1,438) Unidentified pay savings (8,466) (7,246) (7,246)

17,671 19,617 (1,945) TOTAL PAY 221,097 203,241 214,623 (11,381) 205,585

1,745 1,812 (67) Drugs 21,050 19,223 20,710 (1,488) 19,789

2,681 2,109 571 Clinical services 32,069 29,415 26,721 2,693 27,610

5,816 5,146 670 Non-clinical services 70,860 65,235 67,336 (2,101) 61,327

(859) (859) Unidentified non-pay savings (5,084) (4,085) (4,085)

9,383 9,068 315 TOTAL NON-PAY 118,896 109,787 114,768 (4,980) 108,727

542 (3,533) (4,075) EBITDA (3,973) (5,809) (34,662) (28,852) (13,659)

720 589 131 Depreciation & Amortisation 8,650 7,931 6,791 1,139 6,615

128 153 (25) Interest 1,545 1,416 1,655 (239) 1,682

72 50 22 Dividends Payable 872 800 561 239 1,623

(378) (4,325) (3,947) Surplus / (Deficit) (15,040) (15,956) (43,669) (27,713) (23,579)

Month 11 (Feb)Prior Year

Actual

YTD FY18

Budget

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11

Finance (Agency)Agency spend trajectory

Blue – 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

need to be to achieve target

expenditure of £17.0m. YTD

results M11 £1.1m behind plan

with acknowledgement that FY

plan unlikely to be achieved in

full (still approx £8m reduction

on 2016/17). Green shows

current actuals and forecasts.

Purple - 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 8A Month 9A Month 10A Month 11A 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 15,979

Trajectory based M11 1,860 3,438 4,996 6,741 8,163 9,772 11,355 13,090 14,541 15,813 16,961 18,351

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 17,000

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 39

Trajectory based M11 1,860 1,578 1,558 1,745 1,422 1,609 1,583 1,735 1,451 1,272 1,149 1,390

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

9



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Detailed reports

12

9



14 of 114T

rust Board M


Performance relative to targets/ thresholds

Executive lead Clinical lead Operational lead

Feb-18 4 4

Jan-18 3 5

Dec-17 4 4

Hospital

Standardised

Mortality

Ratio

(HSMR)*

Summary

Hospital

Mortality

Indicator*

Not achieving

Reporting sub committee - S&C &

COEC

Safe,

effective,

caring Achieving

Crude

mortality rate

(non-

elective)*

*Dr Mike Van der Watt

Tracey Carter

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 to

Mar 2013

Jul 2012 to

Jun 2013

Oct 2012 to

Sep 2013

Jan 2013 to

Dec 2013

April 2013

to Mar 2014

July 2013 to

June 2014

Oct 2013 to

Sept 2014

Jan 2014 to

Dec 2014

Apr 2014 to

Mar 2015

Jul 2014 to

Jun 2015

Oct 2014 to

Sep 2016

Jan 2015 to

Dec 2015

Apr 2015 to

Mar 2016

Jul 2015 to

Jun 2016

Oct 2015 to

Sep 2016

Jan 2016 to

Dec 2016

Apr 2016 to

Mar 2017

Jul 2016 to

Jun 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

For the 12 month period (January 2017 to December 2017), the Trust’sHSMR of 96.5 was in the ‘as expected’ range. The Trust is reviewingthe clinical coding of outlier groups to identify if the appropriatediagnosis and relative risk has been applied.

The Trust is 1 of 7 within the Shelford peer group of 11 that sit withinthe ‘as expected’ range.

The Summary Hospital Mortality Indicator’s (SHMI) latestperformance (for Jul 16 to Jun 17) was 92.16 and ‘as expected’ (band2), placing the Trust 23rd nationally.

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’.

9



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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


14

Emergency ReadmissionsCombined readmission rates, including both emergency and electiveadmissions, includes all patients with more than one admission to thehospital within a period of 30 days, regardless of whether the secondadmission was related.

Both elective and emergency re-admission rates have risen but thecombined rate remains lower than the national average

StrokePerformance against the 4 hour admission to the stroke unit target is43.3%, worse than 46.5% in the previous month.

The YTD figure of 61.1% remains above the national average of 60.2 % foradmissions to the stroke unit within 4 hours.

High attendance activity continues, resulting in capacity constraintsrestricting timely access to the stroke beds.

Stroke patients who arrive via pre-alert ambulances are immediatelyseen by the stroke team on arrival. Other potential stroke patientssometimes experience longer waits in ED, especially during times ofincreased capacity pressure. When the waiting time to be assessed in EDis long there is a resultant delay in timely referral to the stroke team forspecialist assessment.

9



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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 days69 new complaints were received in February, of which 33% (23) relate to Surgery, Anaesthetics and Cancer (SAC), 28% (19) relate to Medicine, 17% (12) relate to Emergency Medicine (EM), 16% (11) relate to Women’s and Children (WACS), 4% (3) relate to CSS, 1% (1) relate to Environment. There were none for Corporate or Finance this month. In 28% of all complaints the patient was unhappy with their treatment; half of these were in connection with unplanned care (ED, COE, General Medicine). This month, Trauma and Orthopaedics received the highest number of complaints overall. The next highest is communication with nearly 14% of all complaints (and again, T&O featured higher than usual this month) . Staff attitude was the next highest subject at 12% and two thirds of these related to the medical staff, again Trauma and Orthopaedics were the highest.

% Complaints responded to within one month or agreed timescales with complainant In February 46.8% of complaints were responded to on time. 56 responses were sent in total. There is a target to respond to 85% of complaints on time.

Complaints responded to on time, by division, are as follows:**NOTE – USC and Emergency Medicine reporting changed during this period.

Five complaints were reactivated in February. Each of the reactivated complaints relate to the patient being dissatisfied with their care. At the time of the original complaint, 2 of the 5 were responded to on time.

The number of complaints over 6 months old has reduced.

N/A denotes – no complaints valid for reply to this month.

Oct - 17 Nov – 17 Dec – 17 Jan - 18 Feb – 18Trust wide 60% 55% 52% 76% 47%

Medicine 91% 91% 100% 75% 60%USC/Emergency Medicine 35% 32% 31% 75% 43%

SAC 71% 43% 55% 56% 19%

WACS 33% 67% 22% 100% 100%

Environment 50% 100% N/A 100% 50%

CSS 100% N/A 100% 100% 100%

Corporate 100% 100% 100% N/A 50%

Target Feb 18

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

95% by Q4 77.6%

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

% of complaints taken longer than 6 months to investigate (figure taken at the end of Jan 2018)

>5% 3%

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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 0 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 4 2 2 8

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


Feb-18 2 4

Jan-18 4 2

Dec-17 3 3

Achieving Not achieving

Clostridium difficile Infection (CDI)6 cases were reported in February. The full year target ceiling for WHHT apportioned CDIis 23 – the year to date actual is 27.

The rybotyping for each of the 6 February cases are all individually different. 5 caseswere reported in Medicine, and the remaining case in Surgery at SACH. The SACH casewas identified on DLM Ward and linked by ‘time/date/place’ to the DLM case reported inJanuary. Both cases were reablement patients, but despite this rybotype results suggestthat transmission on DLM was not of concern.

Of the 5 cases in Medicine, 2 were on Tudor where rybotypes were different, thereforetransmission on Tudor is not of concern. The remaining 3 cases in medicine were onthree different wards. All have different rybotyping, once again supporting noassociation with each other and transmission was not of concern .

RCA’s have been undertaken for all 6 cases. Key learning from RCA’s relates toinappropriate sampling .

There has been agreement with Herts Valleys CCG that there was no identified lapse ofcare in 1 case of CDI. 4 further cases were submitted to HVCCG for consideration inJanuary, the outcome is awaited. A further 12 cases are to be presented to the HVCCGappeals panel on 21 & 28 March 2018. 3 cases were agreed on the 21 March as no lapsein care, bringing the total number of no lapses in care to 4.

The IPC team continue with antimicrobial rounds and weekly Clostridium difficile rounds.There is also increased targeted IPC support, audit, power training to key clinical areas.

MRSA bacteraemia (MRSAb)The full year target ceiling for MRSAb is 0 avoidable cases. A pre-48hr MRSAb wasreported in January. A CCG lead Post Infection Review (PIR) has been completed withWHHT support and this has been assigned to ‘Third Party’.

E. Coli bacteraemia (E colib)8 cases of post 48hrs E colib were reported in February, up from 2 the previous month.The CCG’s target this year is a 10% reduction equating to 36 cases. There is no target forWHHT. The IPCT intend to increase the organisation’s focus on E.Coli bacteraemias,deploying a similar strategy/process and focus to that of C.diff and MRSAb. The IPCT isrepresented on the WHHT continence group & supports the review of post 48hrs E colibRCAs.

Never eventNo never events were recorded in February 2018.

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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 Incidents

3 Serious Incidents (SIs) were declared in February 2018, 2 fewer than in January 2018• 1 in emergency medicine relating to a safeguarding allegation• 2 in the Medicine division – one fall and one related to a hospital acquired infection.

At the end of February 2018 the Trust had 29 open SIs, of which 17 had been completed andwere with commissioners pending formal closure on StEIS. At the end of February 2018there were 12 ongoing SI investigations, all of which were within the deadline forcompletion.

Learning from SIs

The 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 therelevant clinical and management teams prior to the action plan being completed. Therewere 2 45-day meetings held in February 2018.

Each action plan is developed, signed off and monitored by the division leading theinvestigation into the incident.

The SI review group (SIRG), chaired by the Medical Director, review all closed SI action planswhere senior divisional representation provides assurance and evidence that actions havebeen implemented before the SI is formally closed internally. The last SIRG meeting tookplace in February 2018. Five action plans were reviewed and 2 of these were closed; theoutstanding evidence for those action plans which were not closed will be followed upas part of the SIRG action log. A further 5 action plans were closed in the SIRG action log– these are action plans which had been discussed at SIRG before but not closed at thetime due to outstanding evidence. The next SIRG meeting is scheduled to take place on19 March 2018.

% of patient safety incidents which are harmful

9.12% of incidents reported in February 2018 were recorded as harmful, a reduction from12.3% in January 2018.

There has been a decrease in the number of incidents scored as moderate or above from 33reported in January 2018 to 19 reported in February 2018. Of those 9 still require harmvalidation and are therefore subject to change.

Medication incidents causing serious harmNo medication errors were reported as causing serious harm in February 2018.

9



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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 6 10 12 8

b) CAS alerts target 0 0 0 0 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 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


Feb-18 1 4

Jan-18 1 4

Dec-17 1 4


CAS alertsAll alerts issued by CAS in February 2018 were acknowledged within the 48hr deadline.

8 alerts were issued in February 2018: • 3 Estate & Facilities alerts • 5 Medical Device Alerts .

1 of the Medical Device alerts is now closed and was not applicable to the trust. The remaining 4 Medical Device alerts have been sent to the divisions and actions are underway.

All of the Estate and Facilities alerts actions have now been completed and are awaiting sign off.

There were no breaches during February 2018 and all alerts with deadlines were closed on time.

VTE There has been some improvement in VTE risk assessment compliancebut more work is required to target non-compliant areas.

Issued by CAS 8

Breached n month 0

Currently overdue 0

CAS alerts not acknowledged within

48hrs 0

9



20 of 114T

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Hospital

acquired

pressure ulcers

Falls and falls

with harm

0

5

10

15

20

25

30

35

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 February 21 new pressure ulcers were recorded, affecting 19patients:• 1 x grade 1• 17 x grade 2• 3 x grade 3

The avoidability of the grade three pressure ulcers has not yet beenconfirmed due as RCAs are underway but not yet completed.

The grade 2 pressure ulcers are validated by the Matrons for the clinical areas but not differentiated between avoidable and unavoidable. The number recorded is an improved picture from January (22).

A Trust wide improvement plan is in place to ensure continuing focus onreducing pressure damage as part of harm free care. A revised BestShot care plan is in place. The Harm Free Care team are linking withDivisions to refocus support. Skin Champion training days have beenorganised.

High Risk prompt posters are being trialled in surgery. The educationteam support key areas with tissue viability competencies for staff.Enhanced support and focus with the surgical division is underway.

Some significant improvements have been made, with over 36%reduction in grade 3 pressure ulcers between April and December 2017.

Falls and falls with harmIn February there were 129 inpatient falls with 18 resulting in harmacross 18 clinical areas, one resulting in severe harm an decrease fromJanuary. Falls with harm remains low in comparison to numbers of falls.

The campaign to address falls continues with the creation of FallChampions, and with the multidisciplinary falls group.

Joint working with Community teams is in place, reviewing falls andcommon themes.

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21 of 114T

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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

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

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

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

Harm Free Care Actual Harm Free Care national average

20

Adult Safety ThermometerThe Adult Safety Thermometer is a measurement tool for improvement thatfocuses on the four most commonly occurring harms in healthcare: pressureulcers, falls, UTI in patients with a catheter and VTEs. Data is collected through apoint of care survey on a single day each month on all patients. ‘Harm free’ care isdefined by the absence of harm in these four areas. In February, Harm Free Carewas 91.5%, below the national target of 95%. This includes harms acquired bothinside and outside of the Trust.New Harm Free care (harms acquired in the Trust) for February 2018 was 98.9%,which is above the national average of 97.9%.

Nine Month Review of Harms.Since August no patient has experienced more than 1 harm. There has been adecrease in February in the safety thermometer numbers for new pressure ulcers,decreasing from 7 to 4. Old pressure ulcers have increased from 34 to 40.An increase has been seen in Falls but falls with harm has remained at 1.

Children and Young People's Services Safety ThermometerHarm includes patients with a PEWS completed: triggered but not escalated,extravasation (leakage of a fluid out of its container), patients in pain at the timeof survey and any pressure ulcer or any moisture lesion. Harm free care was100% in January for Acute Children’s Services, compared to 85.7% nationally. Ananalysis of the February 2018 survey demonstrated that all patients had a set ofobservations and had been assessed for an Early Warning Score in the last 12hours. Of those patients with an intravenous (IV) device, extravasation was notobserved in any patient . There were no reports of pressure ulcers or moisturelesions and no patient reported pain at the time of survey.

Harm Free Actions• Urology Steering group monitoring E-coli in conjunction with Infection

Prevention and control with continued monitoring of cathethers• Focus on the Pressure Ulcer improvement plan with Divisions.• Collaborative working with community on harms.• Falls collaboration with community teams• Falls Lanyard cards being brought re lying and standing blood pressure• Harm free Care tweets with key messaging• Targeted ward teaching• Implemented pain assessment recording on PEWs charts.

Indicator Jun17 Jul17 Aug17 Sep17 Oct17 Nov17 Dec17 Jan18 Feb18

Number of patients with two

harms 1 1 2 - - - - - -

New pressure ulcers 3 4 5 5 8 6 5 7 4

Old pressure ulcers 34 51 56 50 27 26 25 34 40

Number of falls 3 9 13 14 10 12 13 9 18

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

Catheters 74 117 86 99 114 107 87 89 98

Catheter & New UTI 1 5 4 3 - 2 2 1 -

New VTE 2 3 3 4 2 7 3 5 1

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21

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

Safety Alerts – There has been a slight decrease in February ( 51 ) compared with January (56 ). Safety alerts are mainly due to the number of falls, pressureulcers, and the percentage of extremely likely Friends and Family response rates in clinical areas. The areas with a high numbers of falls are Bluebell, AAUBY3Sarratt, Tudor and Stroke. Sarratt (5) and Langley (3) had the highest number of pressure ulcers.Process Alerts: February showed a reduction to 116 from January (131). The majority of alerts are due to overall Test Your Care results, 12 of 35 clinical areas’results were 90% or lower. There appears to be a direct link between process – risk assessment and care planning and an increase in safety outcomes inrelation to pressure ulcers, demonstrated by the Safety thermometer data.Summary:• Paediatrics - no safety alerts.• Maternity - no safety alerts.• Ten clinical areas are demonstrating a higher trend of alerts for February compared to January.• Surgery have seen a drop in alerts for February• The staffing slide outlines the impacts across ward areas related to vacancies and lower fill rates and the opening of surge areas.

What actions have been taken to improve performance

• Trial of text messaging for patients attending ED for feedback for FFT. Awareness of FFT raised across the Trust through the leadership academy programme• Introduction of speciality specific FFT forms in Outpatients .• Reviewing support mechanisms for staff such as care certificates, Band 6 and Band 7 development courses.• Targeted ward teaching on Falls prevention and management• Bed rail audit to be shared for learning• Falls lanyard cards for lying/ standing BP – being purchased• Multi disciplinary teams reviews in clinical areas with high numbers of falls• Targeted training in relation to Pressure ulcers with wards – purchased a body map that highlights pressure points• Pressure Ulcer focus with Surgery identifying support and actions• 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• Safer Care tool being implemented.• Ward Accreditation being undertaken by all ward areas

Changes in outcomes

• Improvements have been made with a >36% reduction in grade 3 pressure ulcers during April – December 17 compared to 2016.• Falls with harm has remained low

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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

%12

%10

%11

%10

%

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%

19%

17%

18%

15%

16%

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

20

40

60

80

100

120

140

160

180

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 rateThe caesarean section rate for February remains within required parameters.

The policy regarding how to manage women who require C Sections has beenwritten and is to be shared with consultants and Midwifery staff for final andagreement. It will then go through the Trust ratification process.

Mixed sex accommodation (MSA)The number of reported breaches decreased significantly in February.

The monitoring and management of patients requiring step down from ITUis reviewed daily as part of the regular operational management meetings,with the intention of reducing where possible, the number of mixed sexaccommodation breaches that occur. Advance planning for complex patientsrequiring side-room capacity is reviewed as part of these meetings.

The Trust policy on mixed sex accommodation has been reviewed and ratified.

The completion of the RCA template provided by HVCCG is being undertaken inITU and the CCG are supporting the Trust with regular monitoring visits.

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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%

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

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 1 0 20 41

26 < 52 701 657 528 358 349 358 347 347 455 550 492 636 649 761 892 984 1,03 987 990 892 964 884 782 659 661 647 625 748 892 993 921 935 1231 1405

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 2017 2157 2115

<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 20780212182217822550226292274922580222432150621131

% 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% 88.3% 86.4% 85.7%

82%

84%

86%

88%

90%

92%

94%

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%

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

Performance Mean Upper control limit (3 sd)

Lower control limit (3 sd) Target Trajectory

25


Feb-18 5 2

Jan-18 5 2

Dec-17 5 2


RTTFebruary’s performance, at 85.06%, shows a further decrease. The most recentnational data available (January) shows that the Trust’s performance that month wasbelow the national average (88.2%). Performance at the L&D (91.0%) and RFH (83.0%)was also below the national standard of 92%. The median waiting time at WHHT (iethe weeks half the patients on an RTT pathway were waiting) was worse than thenational position (8.0 vs 7.6 weeks) and worse than the 92nd percentile wait time(23.1 vs 21.3 weeks).

Although urgent care demand is starting to ease, the impact on performance overrecent months has been significant and recovery will take some considerable time.This has been the most significant factor in the number of 52 week breaches, whichhad increased to 41 at month end. The majority of these breaches are inOrthopaedics.

Service18 Weeks

Plus

% Under 18

WeeksService

18

Weeks

Plus

% Under 18

Weeks

GENERAL MEDICINE 0 100.00% CARDIOLOGY 74 95.48%

ANAESTHETICS 0 100.00% ORTHOTICS 8 95.38%

CRITICAL CARE MEDICINE 0 100.00% GASTROENTEROLOGY 57 95.17%

PAED CLINICAL HAEMATOLOGY 0 100.00% GYNAECOLOGY 43 95.06%

STROKE MEDICINE 0 100.00% PAED EPILEPSY 3 95.00%

TRANSIENT ISCHAEMIC ATTACK 0 100.00% PAED ENDOCRINOLOGY 2 94.59%

MEDICAL ONCOLOGY 0 100.00% PAEDIATRICS 39 94.41%

NEONATOLOGY 0 100.00% RESPIRATORY MEDICINE 27 94.38%

OBSTETRICS 0 100.00% PAED GASTROENTEROLOGY 7 93.64%

GYNAECOLOGICAL ONCOLOGY 0 100.00% COLORECTAL SURGERY 32 92.45%

ORTHOPTICS 0 100.00% UPPER GI SURGERY 6 92.00%

ORTHODONTICS 1 98.57% HEPATOLOGY 5 90.74%

BREAST SURGERY 6 98.40% PAED OPHTHALMOLOGY 15 90.20%

PAED DERMATOLOGY 1 98.15% RHEUMATOLOGY 44 90.16%

GERIATRIC MEDICINE 3 97.30% ORAL SURGERY 138 87.66%

PAEDIATRIC UROLOGY 4 97.26% NEUROLOGY 131 86.87%

NEPHROLOGY 1 97.22% VASCULAR SURGERY 25 84.18%

CLINICAL ONCOLOGY 1 96.88% ENT 312 83.82%

PAED CARDIOLOGY 1 96.77% UROLOGY 248 80.35%

DIABETIC MEDICINE 3 96.63% TRAUMA & ORTHOPAEDICS 804 76.68%

OTHER 2 96.23% OPHTHALMOLOGY 686 72.35%

CLIN HAEMATOLOGY 10 95.74% GENERAL SURGERY 541 71.97%

DERMATOLOGY 85 95.65% PAIN MANAGEMENT 220 70.86%

ENDOCRINOLOGY 12 95.56% Total 3597 85.06%

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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

5

10

15

20

25

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 16 breaches of the 28 day rebooking requirement. These were in GeneralSurgery, Orthopaedics, ENT, Ophthalmology and Oral Surgery. Breaches were theresult of capacity (bed) pressures, equipment availability and patient choice.

Hospital cancellations – patients cancelled within 6 weeks and overall

Short notice, hospital initiated cancellation remains below the Trust tolerance (5%) at4.7% (excluding valid cancellations and patient initiated cancellations).

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

Diagnostic wait times

Performance against the 6 week waiting time standard has been maintained,..

All cancellations Under 6 weeks All cancellations Under 6 weeks

11.9% 4.0% 11.9% 9.8%

Total cancellations: 23.7%

Hospital initiated Patient initiated

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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 February is compliant at 97.1%

Breast symptomaticThe provisional position for February is compliant at 96.8%. There were 155 cases and 5 breaches.


Feb-18 6 1

Jan-18 6 1

Dec-17 6 1


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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%

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 - 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 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

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

80%

85%

90%

95%

100%

Ap

r

May Ju

n

Jul

Aug Se

p

Oct

Nov

Dec Jan

Feb

Mar

Ap

r

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

28

31 day first

The position for February is currently compliant at 100%.

31 Day subsequent – Drug

The position for February is provisionally compliant at 100%

31 day subsequent –Surgery

Performance is compliant at 94.4%

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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

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 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 1 1 2 3

Cancer 62 day PTL (total) 1466 1338 1284 1331 1312 1456 1521 1720 1392 1251 1254 1475 1425 1622

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 February is compliant at 86.6% , with 58 treatments and 7.5 breaches. More treatments are expected to be added and some breaches are still to be validated. The final position is expected to be compliant.

General themes:• Some delays within MDTs although most are now having a weekly clinical

review with clinician • Insufficient number of patients seen in the first 7 days • Long delays in obtaining information from tertiary centres – there is a plan to

implement conference calls with more partners.

Actions: The focus on PTL tracking continues with training and setting up tertiary centre conference calls.

104 day waitsActive – in February there were 3 patient pathways >104 days; 2 x H&N 1 x Urology.

Closed – 3 pathways over 104 days were closed in February2 H&N pathways (1 was on the 62 day pathway and the other consultant upgrade)1 x Lung (on 62 day pathway)

62 day screening Performance is provisionally compliant at 100 %

Tumour type Jan Feb

Breast 92 91.7

Gynaecological 100 100

Haematological 100 -

Head and Neck 50 0

Lower Gastrointestinal 64.7 66.7

Lung 40 60

Sarcoma 100 100

Skin 97.2 100

Upper Gastrointestinal 84.6 81.8

Urological 80 83.3

Total 86.5 86.6

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30

Responsive


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

Sally Tucker Dr Rachel Hoey Divisional managers

Feb-18 1 4

Jan-18 1 4

Dec-17 1 4

A&E

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

Ambulance

turnaround

time

Emergency flow indicators

- A&E, ambulance

turnaround and DToC Achieving Not achieving

70%

75%

80%

85%

90%

95%

100%A

pr

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18


0

100

200

300

400

500

600

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

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

A&E performance in February remained at a similar level at 72.1% compared to 72.3%the previous month. Minors performance fell to 88.5% from 89.6%. CED performanceshowed signs of recovery with performance at 92.8%, up from 90.8%. February saw ahigh number of flu admissions constraining flow through the hospital.

There was an extended Business Continuity Incident in the month, due to ongoingcapacity issues.

Work is underway to clarify pathways and improve compliance with the 30 minutetarget for Internal Professional Standards (review of A&E patients by specialty teams).Streaming of patients is occurring much earlier in the patient pathway althoughactivity is limited when assessment areas are used for bedded patients at times ofpeak pressure.

Focus continues on ensuring full use of the Emergency Surgical Assessment Unit(ESAU), Medical Assessment Area (MAU), Ambulatory Care (ACU) and Frailty,although at times of increased pressure and capacity issues these are used as beddedareas which significantly limits streaming opportunities. ACU has been re-located tocontinue to provide this service.

The ambulance response times project has continued to impact positively on handover times with regular meetings with EEAST and new ways of working have beenimplemented. Work is on-going to ensure a consistent approach to the STARRprocess. The Directorate continues to try and provide Trust paramedics to supportimproved off load times.

An activity comparison of the current financial period with the same period last year has shown:• Type 1 attendances are up by 1.2%.• Ambulance arrivals are down by 4.7%.• Admission rate from A&E (excluding ambulatory and frailty) is unchanged.• Discharges (Trust wide) are up by 3.7%

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31

Delayed Transfers of CareDToC patients represented 4.1% of occupied beds in February, a slightdecrease from 4.3% in January, measured using the nationally reportedmethod. This is based on a snapshot of the number of patients waiting at apoint in time in the month, expressed as a percentage 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. InJanuary DToC patients consumed 1045 bed days, the equivalent of 37.3 beds.

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.

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 developed 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 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

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

Nov-17

Dec-17

Jan-18

Feb-18

Total number of beds used by DToC patients 41.2 32.7 31.8 43.2 45.0 41.3 35.1 35.2 42.7 47.3 52.8 51.6 47.9 47.6 44.0 37.5 38.3 35.3 32.9 23.7 27.9 37.3

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

DHSS Days 18 15 11 18 19 16 12 16 21 23 28 27 28 27 18 20 21 19 16 12 16 24

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

Beds used by DTOC patients: DHSS vs NHS

9



33 of 114T

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 vacancy rate showed a decrease to 10.3% in February (from 11.7% inDecember). Whole time equivalent (wte) staff in post increased by 30wte overFebruary, to 4331wte, while the establishment remained constant. The vacancy ratefor qualified Nursing & Midwifery posts decreased in February, from 14.5% to13.9%. For Band 5 Nurses, the rate reduced from 17.7% to 16.3%. However, this rateincludes nurses who are awaiting their PIN numbers, once these staff are taken out ofthe staffing numbers, the rate is 27%. Recruitment activity has continued to build up alarge pipeline of new N&M. There are approximately 160 ‘pipeline’ overseas nurses,of which 31 are due to start by mid April. A further overseas recruitment trip is set forIndia in May. WHHT is working with NHSI to reduce the turnover rate within Band 5nursing, and rates have reduced over the last 5 months, from over 27% to 22.9%currently. The 12-month rolling turnover rate for registered nurses and midwives is17.1% which has decreased from 17.5% last month. The overall Trust turnover rate is16.3%, an decrease from last month (16.9%). WHHT has the eighth highest turnover(of 11 organisations) compared to Herts & Beds peers and is above the regionalaverage of 15.9%, although this is largely due to band 5 nurse turnover. Over the last2 years, turnover has shown a modest downward trend, although Band 5 nursing asnoted above, is relatively high.

% Bank and Agency ExpenditureAgency spend in February decreased to £1.15m (£1.27m in Jan). This spendrepresented 5.9% 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. Renewed work continues to reduce agency costs via the AgencySteering Group, and through partnership working across Herts & Beds, with theshared staff bank being the latest initiative. Work is also being undertaken withLondon NHS organisations to help benchmark agency rates. YTD spend of £15.8m isabove the trajectory required to meet annual targets, with a M11 projected totalagency expenditure of £18.4m compared to a required total (set by the Trust) of£17.0m. This compares favourably though to the cap set by NHSI in2017/18 ofc£24m. Bank spend as a percentage of payroll is currently 10.6%.

Sickness rateThe sickness absence rate remains low at 3.32%, and is in line with the Trust target of 3.5%. The Trust is currently well below the Herts & Beds average of 4.3% at the end of Quarter 3. 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 just over 3.1% in the current year to date.


Feb-18 3 4

Jan-18 3 4

Dec-17 2 5


9



34 of 114T

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 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

Essential training Mandatory Training Performance Mandatory Training Target

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

Aug

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

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

Number of staff % of new staff

33

Appraisal – non medical staffFebruary’s rate, at 80%, is below the 90% compliance rate for the fourth monthrunning. There continues to be a significant challenge in maintaining focus andensuring appraisal dates are aligned to staff increments, particularly given the activitydemands on staff over the Winter period. HRBPs continue their work with Divisionsto develop trajectories and monitor and achieve compliance consistently above the90% target. The next month has significant numbers of staff requiring anappraisal,(167) and so it is important that these are taken account of in plans over thenext month HR Business Partners are also working with managers, producing bi-weekly reports to support the transition to effective alignment of appraisals toincrements and to plan the completion of all outstanding appraisals. Currently 34% ofstaff incremental dates are aligned to appraisal dates

Mandatory training Mandatory training compliance is currently at 86%, the same as last month. TEC havebeen provided with an overview of issues related to the reporting of mandatorytraining data and the impact on the compliance figures. A working group has been setup to manage this work and has started to put in place actions that address theallocation of core training needs to job roles recorded in ESR and address complianceof new starter overseas Nurses, Junior doctors on rotation and Consultants. The newHead of Education, Learning and Development has taken over this group and anupdate on progress will be given shortly. The working group is reviewing options toaddress the above issues.

Number of staff leaving within first yearThe overall rate was 19.8% in February, an decrease compared to last month. A year ago the figure was 18.7%.

The Trust is closely monitoring staff leaver information via the web-based exit leaversystem, particularly regarding reasons for leaving. The latest summary (Q3) has justbeen reported onto the Divisions as part of their workforce reports. The key reasonfor leaving remained unchanged, being career related and personal growth. Thereconnect sessions following corporate induction continue, bringing new startersback together and offering an opportunity to resolve any issues and gatherinformation to further improve staff experience in the first year in post. Otherinitiatives include a flexible pool, rotation schemes and using retention conversationsto help reduce staff leaving for career reasons unnecessarily. Also commencing is akey piece of work called ‘Careers Matters’, a best in class careers advisory service.Key work is also under way to support retention of Band 5 nurses, where there is thehighest turnover, although as stated this has fallen over the last 6 months. Fromaround 29% to around 23% currently. This also forms a part of the Nursing retentionproject with NHSI, where Band 5 nursing leavers have been identified as a keyworkforce to seek to improve engagement with and reduce turnover.

9



35 of 114T

rust Board M


34

The Board Assurance Framework shows key workforce indicators in the context of current performance, performance 12 months and 3 months ago, Trust workforce targets, the distance to these targets and a RAG rating based on 5 scales. It also has benchmarking data taken from NHS healthcare providers in the Hertfordshire and West 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 amber andbrown until performance is over 80% from the target when the RAG rating is red. If 2indicators are rated red, then the overall rating is red. If all indicators are rated green,or one is amber then the overall rating is green. Any other combination is amber.

The performance indicators were changed for November to reflect more relevant anddetailed areas of the workforce. The new indicators include Band 5 Nurse Vacancy, andBand 5 Nurse Turnover, reflecting the focus on recruitment and retention inconjunction with NHSI. Nursing Band 5 vacancy and turnover areas are identified as theTrusts highest workforce risk factors. WHHT is working with NHSI to reduce theturnover rate within Band 5 nursing, and rates have reduced over the last 5 months,from over 27% to 22.9% currently. For vacancies, the vacancy rate for qualified Nursing& Midwifery posts decreased in February, from 14.5% to 13.9%. For Band 5 Nurses, therate reduced from 17.7% to 16.3%. However, it should be noted that this rate includesnurses who are awaiting their PIN numbers, once these staff are taken out of thestaffing numbers, the rate is 27%.

Appraisals are below target at 80% and mandatory training compliance is 86%. Theconfidence for data accuracy for training compliance is rated amber, work is ongoing toensure complete accuracy.

The Trust has achieved its target of a sickness rate less than 3.5% (3.32%)

The current agency pay bill percentage is 5.9%, below the 8% target.

The 12 month turnover rate is 16.3%, which has increased slightly compared to 3months ago, but is slightly lower than one year ago. It is also above the benchmarkaverage.

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

Benchmark averages are taken from Q3 17/18 data and are from 11 nearby NHSorganisations.

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 % of paybill has changed from 10% to 8% as this reflects the Trust’s NHSI agency target

Workforce BAF scorecard

9



36 of 114T

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

Inpatients

There has been a noticeable improvement in the response rate and in those notrecommending the Trust, with a more modest increase in the recommended rate.

A&EResults have improved again this month, in all aspects, with a higher response rate andnumber of patients recommending the Trust and a reduction in the number notrecommending the service.

Staff Staff Friends and Family test for Q4 ran between 26 February – 5th March 2018.

Over 650 questionnaires were completed and results are to be reviewed at the beginningof May. These will be looked at in relation to both previous friends and family results andthe recent staff survey results.

In the meantime consideration is being given to using staff friends and familyquestionnaires as part of the ward accreditation process and in an attempt to align staffand patient experience.

Well led

Feb-18 0 3

Jan-18 0 3

Dec-17 0 3


9



37 of 114T

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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

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

OutpatientsThere has been a further increase in responses and the recommended rate and nochange in those not recommending the Trust.

Maternity Question 2There has been a significant improvement in response rates with correspondingimprovement in the recommended rate and reduction in number of those whowould not recommend.

9



38 of 114T

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37

Safer staffingIndicator Performance (February) Threshold Trend Forecast next month

% Nursing hours versus planned 91.0% >95% Up >95%

Care hours per patient day 7.7 n/a Stable 7.2

Indicator by shift and skill mix Shift RN Care staff

% Nursing hours versus planned Day 78.3% 112.9%

Night 85.8% 103.2%

Care hours per patient day All 4.6 3.2

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

Shared bank approach across four Trusts commenced 31st July. Project plan to address the retention rate of band 5s External Visit requested by Chief Nurse looking at Safe Staffing now

rescheduled for April 2018. Safe Care has now been Implemented in Adult and Paediatric inpatient

wards

What is causing the variance

Overall the Trust % fill rate for February was 91%, an increase of 0.4% from last month and below the national threshold of 95%. The fill rate within Medicine was 95.4%, an increase of 3.5%from last month. In Surgery the fill rate was 82.8%, a decrease of 8.2% from last month. Overall the fill rate in WACS was 92.5%, an increase of 6.2% from last month. On further analysismaternity fill rates were 96.7%, an increase of 1.3% from last month and paediatrics fill rate was 84.7%, an increase of 12.9% from last month. The low fill rates in paediatrics are mainlynursery nurse shifts day and night due to recruitment and retention. This is currently being reviewed by the Head of Nursing as part of the establishment review, covering skill mix and roleredesign. The number of shifts rag rated green were 44.6%, a decrease of 22.9 % from last month. 53.6% of shifts were rated amber, a decrease of 22% from last month. 35 shifts were ragrated red, a decrease of 0.9% from last month. A total of 4 red flagged shifts of less than 2 registered nurses were recorded. No harm to patients was reported and mitigations were put inplace, e.g. moving staff to the areas, supervisory band 7s working, specialist and corporate nursing education supporting staffing in order to maintain patient care and safety, and datix formswere completed. A total of 184 shifts (30.5%) were red flagged for registered nurses more than 8 hours less than planned. A number of areas have fill rates below 80% - Flaunden and Oxhey.From 12 February onwards, the Trust was in Business continuity having surged in to a number of areas in the organisation such as - MAU, COB, ESAU, Ambulatory Care, Cath Lab, New CDU, OldCDU, Castle. Oxhey, Tudor and Elizabeth had additional patient beds opened. Patients were cared for in these areas through redeployment of substantive staff and temporary staff from NHSP(bank and agency). A Total of 77, 556 hours requested via NHSP with overall fill rate of 84.4% (41.9% NHSP and 42.5% agency). Enhanced care needs continue to be provided by the Trustenhanced care team and bank/agency. Overall Trust Supervisory Hours lost in October was 33.9%. Safe care has now been implemented in all the adult and paediatric inpatient areas andpatient acuity and staffing is now reported daily . Care Hours per patient day continue to be reported monthly as part of UNIFY.

96.2%

96.9%

97.6%97.3%

94.3%

95.2%95.0%

93.0%

90.9%

92.2%

90.9%90.6%

91.0%

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%

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

9



39 of 114T

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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 February, 94 referrals were made to the Trust Specialist Palliative Care Team. Of the 94 patients referred, 55 did not have capacity to make decisions about Advance Care Planning (ACP), seven referrals were inappropriate/discharged back to the ward before ACP completed and for seven patients the ACP was not appropriate to be discussed.Therefore of the 25 patients appropriate for ACP all 25 had an identified PPD.

There were four patients who died in hospital although home was their preferredplace of death. This was due to a delay in C/C Process (Funding) for one patient and anunexpended deterioration for the other three patients.

Q1

2015/

16

(avg

per

mont

h)

Q2

2015/

16

(avg

per

mont

h)

Q3

2015/

16

(avg

per

mont

h)

Q4

2015/

16

(avg

per

mont

h)

Q1

2016/

17

(avg

per

mont

h)

Q2

2016/

17

(avg

per

mont

h)

Q3

2016/

17

(avg

per

mont

h)

Jan-

17

Feb-

17

Mar-

17

Apr-

17

May-

17

Jun-

17Jul-17

Aug-

17

Sep-

17

Oct-

17

Nov-

17

Dec-

17

Jan-

18

Total referrals 63 59 67 71 75 69 78 98 111 120 103 96 108 84 72 90 120 112 93 94

-

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

Q1 201

5/16

(avg

per mo

nth)

Q2 201

5/16

(avg

per mo

nth)

Q3 201

5/16

(avg

per mo

nth)

Q4 201

5/16

(avg

per mo

nth)

Q1 201

6/17

(avg

per mo

nth)

Q2 201

6/17

(avg

per mo

nth)

Q3 201

6/17

(avg

per mo

nth)

Jan-17

Feb-17

Mar-17

Apr-17

May-17

Jun-17

Jul-17

Aug-17

Sep-17

Oct-17

Nov-17

Dec-17

Jan-18

Nursing Home 0 3 5 6 5 6 2 3 11 9 6 6 5 4 5 2 5 4 5 8

Hospital 0 3 4 6 10 5 9 19 20 17 6 16 3 6 10 8 6 10 3 1

Hospice 0 11 15 12 10 13 1 15 7 8 12 10 10 9 8 6 16 14 23 14

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

Impaired capacity to state a preference 12 14 13 22 17 12 23 35 28 27 23 29 29 23 21 20 26 18 47 42

% 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% 77% 100% 100%

0

10

20

30

40

50

60

70

80

90

0%

20%

40%

60%

80%

100%

120%

Nu

mb

er

of

refe

rral

s b

y id

en

tifi

ed

pre

fere

nce

Pe

rce

nta

ge o

f re

ferr

als

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

9



40 of 114T

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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

39

Domain a Indicator a

Data

Quality

RAG

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

Safe, Effective, CaringDischarges between 8am and 12pm*

(main adult wards excl AAU) A

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 Hospital Acquired Pressure Ulcers - Grade 3A

Safe, Effective, Caring Number of Falls*A

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

Well Led Mandatory TrainingA

1. Potential for reporting inconsistencies on ESR in certain staff

groups A project group has been set up to investigate and correct

reporting issues Feb-18

9



41 of 114T

rust Board M



Title of the paper Strategy update

Agenda item 10/58

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 outlines 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. Royal Free London Group / WHHT partnership 8. Pathology


Updates on specific issues have been provided to the trust executive committee and other relevant forums.

Action required:

The Board is asked to receive the report for information and assurance.





PR4a


PR4b


PR5a


10

Tab 10 Strategy update


PR5b


PR7a


PR7b




PR10


Trust objectives To deliver the best quality care for our patients





Continuous improvement in care pathways.

Improved physical environment from which care is provided.

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

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.

10



Agenda item: 10/58

Trust Board Meeting – 12 April 2018 Strategy Update Presented by: Helen Brown, Deputy Chief Executive

1. Purpose

1.1 This report provides an update on the current position in relation to a range of longer-term service changes and strategic developments.

2. Your Care Your Future ~ integrated care and pathway re-design

2.1 The Trust continues to work with partners on the redesign of a range of planned and unplanned care pathways.

2.2 Over the past 2 months the primary focus has been on working with HVCCG to agree the activity impact of pathway changes planned for 2018/19 as part of the negotiation of the 2018/19 contract (Quality, Innovation, Prevention and Productivity (QIPP) elements). A brief summary for each pathway is attached as appendix one for information.

2.3 This years QIPP has focused on three key areas

Review of local prices, including a locally agreed ambulatory care unit tariff.

Pathway redesign and /or transfer of commissioning (either through multi provider partnerships or open market tendering)

Volume reductions through a combination of GP demand management schemes, application of low priority treatments and agreement of first to follow up ratios

Application of six key questions to each scheme along with defined activity schedules and associated finances has enabled 15 of schemes to be agreed with a commitment to a plan to agree further schemes in year as contract variations

2.4 There are three active procurements in process for development of community services - dietetics, ophthalmology and ENT. All procurements will see a reduction in WHHT outpatient commissioned activity through PbR. Bid/no bid decisions require rapid turnaround as a result of tight procurement timetables set by HVCCG (tender process launched 26th March 2018 with a submission deadline of bids by the 4th May 2018). The dietetics procurement has a relatively limited impact for the Trust. There a more significant

10



implications for ENT & Ophthalmology services. The surgical division is preparing a briefing paper to TEC on the 11th April to support bid / no bid recommendation - a verbal update will be provided to part 2 of the Board on the 12th April.

2.5 The new community gynaecology service went live as planned on 03/04/18. WHHT, RFH and Luton and Dunstable clinicians are working through a sub contract arrangement with the Hertfordshire Community Gynaecology service led by Dr Kedia.

3. Stroke

3.1 Work has continued with HVCCG with a view to WHHT taking the overall co-ordinating lead across a WHHT and HCT provider partnership for the delivery of an integrated stroke pathway.

3.2 The focus over the past month has been to confirm the level of funding associated specifically with stroke care, to inform negotiations regarding future affordability and service development options.

4. Vascular

4.1 Work continues with E&NH Trust to develop the operating model and implementation plan for the vascular hub, with the current focus being to consider clinical pathways for complex vascular patients requiring care at the hub site and also the associated care pathways f

4.2 or spoke sites.

4.3 Internally, a paper has been reviewed by the Clinical Advisory Group regarding the implications for vascular services and for other clinical specialties. A more detailed update will be provided to the Trust Board once the work is further progressed.

5. Your Care, Your Future - strategic outline case (SOC) for the redevelopment of acute hospital services

5.1 The main acute transformation / redevelopment SOC continues to be 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.

5.2 A meeting is scheduled with NHS Improvement for 1st May 2018, at their request, to discuss the strategic outline case and gain their feedback as to the approach proposed. A verbal update will be provided to Board members on the outcome of this discussion at the May 2018 Board meeting.

5.3 Meanwhile, the strategy team have also further developed interim plans, following a successful bid for additional capital funding via the Independent Trust Financing Facility. A paper has also been submitted to the Clinical Advisory Group to confirm principles for investment during 2018-19 with external support currently being sought to help expedite business case development to ensure the programme can be taken forward in a timely way.

5.4 Finally, a clinical engagement event was convened at the start of the month, to which all clinical leads were invited and at which experience from the new hospital development at Chase Farm was shared, along with discussion regarding the development of future clinical pathways.

10



6. Hemel Hempstead strategic outline case (SOC)

6.1 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.

6.2 The target timeline for the SOC completion has slipped by approximately 6 weeks. It is anticipated that the SOC will be finalised for review by FIC in June or July 2018, followed by Trust Board review in July or September.

7. Car Parking Strategic Outline Case

7.1 Formal confirmation of NHS I approval of the Car Parking Strategic Outline case was received in February. The approval letter set out expectations of issues to be covered within the outline business case. The letter has been shared with Watford Borough Council and the team continue to meet with the LABV to progress the detailed work required for OBC.

7.2 The business case recognises the significant improvement in car parking facilities that will be available to staff and patients, but seeks to ensure any price changes are reasonable.

7.3 Subject to all issues being resolved satisfactorily with the LABV the OBC will be presented to the FIC in April 2018, followed by Trust Board review in May 2018.

8. Pathology 8.1 The pathology SOC approved by the Board in November has been submitted to NHS I for

review and approval. Responses to a series of clarification questions have also been submitted. Work on the outline business case has commenced at risk.

8.2 The key issues for the development of the OBC will be recommending an option for service delivery that is capable of matching all likely options for future acute service redevelopment. The OBC will also consider in more detail the types of collaboration that might best suit the Trusts model of care, should collaboration become a likely option.

9. Royal Free London (RFL) partnership

9.1 A joint Board development session was held with the RFL on the 14th March 2018. A progress update on the overall development of the group model was provided by Dominic Dodd, RFL group chairman and Board members received updates on progress with the current workplan. The future development of our partnership was discussed and agreement in principle was made that WHHT would become a formal clinical partner to the RFL group during 2018/19, subject to a further dialogue with staff on the implications and expected benefits.

10



9.2 It was noted that clinical partners retain a fully autonomous board and leadership team and that this is not a step on the road to a full merger or acquisition. The Group model is based on NHS organisations collaborating to deliver improvements in the quality and sustainability of local services. At the heart of the group model is a shared commitment to reducing unwarranted clinical variation through the development and implementation of best practice clinical pathways across the group. There are also significant opportunities for WHHT to accelerate its digital transformation programme through working with the RFL Global Digital Exemplar.

Helen Brown Deputy Chief Executive April 2018

10




Title of the paper

Corporate aims and objectives 2018 - 2020

Agenda Item 11/58

Lead Executive

Helen Brown, Deputy Chief Executive

Author(s)


Executive Summary

Following a board seminar discussion in February 2018 and review by the trust executive committee in March 2018, the board is asked to consider the attached draft aims and objectives for 2018 – 2020. Jane Shentall, Director of Performance, will review the reporting arrangements to ensure that the objectives are reflected in the integrated performance report and a progress tracking mechanisms is established. The board assurance framework is currently being re-developed and will reflect the primary risks to delivery of the objectives. The BAF will be presented to the board in June 2018.

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

Board development session – February 2018 Trust executive committee – March 2018

Action required:

The Board is asked to approve the 2018-2020 aims and objectives

Links to the board assurance framework





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

11

Tab 11 2018/19 corporate aims and objectives


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

[Double click on the box to mark as appropriate]





11



OBJECTIVE Detailed objectiveLINKED STRATEGIES &

ACTION PLANS

Metrics / monitoring

mechanismBOARD ASSURANCE

Lead

Executives

1.1 To sustain expected or better than expected

performance on key mortality indicators (SHMI and

HSMR)

Learning from deaths action

planSHMI & HSMR CoEC MvDW

1.2. Top quartile performance for harm free care by

2020Quality Account

Nationally specified harm free

care metrics CoEC MvDW / TC

2.1 Working with the RFL group, implement a

minimum of 8 standardised ‘ in hospital’ pathways per

year, with demonstrable improvement in consistency of

care and improved outcomes.

Royal Free Partnership

Work Plan

Pathway specific metrics to be

agreed on a pathway by

pathway basis

MvDW

2.2 To work with partners to redesign ‘end to end’ care

pathways, integrate care and reduce unnecessary visits

to hospital for our patients. (Full programme to be

agreed with the CCG via the QIPP Board)

Joint QIPP work plan HB

2.3 To develop patient centred planned and

ambulatory care pathways [note 1]ST

a. surgical and cancer services – maximising the St

Albans City Hospital site. JL / AD

b. medical services – maximising the Hemel

Hempstead General Hospital site. AO / AD

c. women's and children's services AB / AD

3.1 Develop / commission QI training programme for

clinical and support staff to ensure consistent QI

approach embedded across the organisation and staff

skills and capability strengthened.

Quality Account

Number of staff trained in wHw

QI methodology (detailed

metrics TBC)

CoEC TC

3.2 To roll out our ward accreditation scheme to all

wards in 2018/19. All wards achieving ‘silver’ by 2020.Quality Account

% Wards achieving silver rating

or higher.CoEC TC

4.1 Business case, agreed way forward and

implementation IT infrastructure improvement. FIC

4.2 Business case approved and funding secured for

implementation of an Electronic Health Records.FIC

4.3 Implement scanning and electronic document

management for medical records. (One year

programme commencing Q2)

CoEC

4.4 Implement digital dictation / voice recognition.

(Phased programme over 2 years). CoEC

4.5 Implement electronic order communications for

pathology (March 19) CoEC

4.6 Implement remote access to radiology and other

specialty images. (March 2019) CoEC

4.7 Meet the compliance requirements of GDPR and

appoint data protection officer (May 2018) GDPR implementation plan

Information governance

breachesS&C

6.1 Work with divisions and specialties to agree

research activity giving equality of access to research

6.2 Exceed Clinical Research Network Recruitment

targets6.3 Increase income from NIHR commercial research

(target 20% increase over 2 years)NIHR research income

6.4 Increase applications to funders of research,

particularly the NIHR and NIHR partner grants

(minimum 3 bids per annum).

Number of applications for

research grants

#

#

#

#

7.1 To achieve improved scores in the 2018 & 2019

staff surveys for the following questions, aiming to be

top quartile by 2019:

To increase the percentage of staff believing that

the organisation provides equal opportunities for

career progression or promotion to 86%

Maintain staff survey question on ‘Does your

organisation take positive action on health and well-

being’ at above 90%. Improve ‘I look forward to going to work’

question to 65%

Increase satisfaction with the opportunities for

flexible working patterns question to 60%

Improve ‘I would recommend my organisation as

a place to work’ question to 63%

Improve ‘If a friend or relative needed treatment

I would be happy with the standard of care provided by

this organisation’ question to 66%

CoECOverarching metrics to be

defined (e.g. % non face to face

OP activity, split of activity by

site) & specific metrics to be

agreed on a pathway by

pathway basisTrust Strategy / Interim

estate strategy

#

#

#

#

#

#

#

To implement & embed our ‘quality commitment’ and ‘west

Herts way’ quality improvement methodology

AIM

ON

E: B

EST

QU

ALI

TY C

AR

E

1

.

To deliver excellent clinical outcomes for our patients

- mortality

- harm free care

Full suite of quality and outcome indicators reported in the

Integrated performance report.

2

.

To implement best practice, integrated care pathways and

reduce unwarranted clinical variation in care and outcomes.

#

#

#

#

#

#

#

To improve our IT and move towards full digitisation.

IT strategy implementation

plan (to be developed in

Q1)

Business cases to set out

expected benefits and

measures. Post project reviews

to report on benefits delivery.LE / SG

CoEC ST/AO/JL

AIM

TW

O: A

GR

EAT

PLA

CE

TO W

OR

K A

ND

LEA

RN

#

#

#

#

#

#

#

To further develop the Trust’s participation in Research and

DevelopmentR&D work programme

CRN recruitment numbers by

division / specialty

CoEC MvDW

To have happy, healthy, well supported staff who feel able to

deliver great care and ‘make a difference’ in an inclusive

environment and to be a clinically led organisation.

#

#

#

#

#

#

#

To improve our emergency care pathway and discharge

processes.

5. Implementation of Emergency Care transformation

programme including SAFER discharge.

Emergency Care

Transformation Plan

ED capacity breaches

% streaming (admitted and non

admitted)

Internal professional standards

% performance

Bed capacity breaches

% discharges via discharge

lounge

Reduction in IP LOS > 21 days

Workforce Strategy & staff

survey action plan

Medical engagement action

plan

Annual staff survey results &

local temperature checks.

Analysis of key questions in staff

survey by professional group

(Band 8a and above).

PSECMvDW, TC,

PdG

11



7.1 To improve scores for senior clinical staff in the

2018 and 2019 staff surveys for the following

questions:

- I am able to make improvements in my work area

(57% org and 55% sector)

- Senior managers here try to involve staff in important

decisions. (38% org / 33% sector)

- Senior managers act on staff feedback. (38% org / 31%

sector)

#

#8.1 To reduce the overall trust vacancy rate to 9%

Recruitment & Retention

action planIPR metrics PSEC PdG

8.2 To reduce the vacancy rate for Band 5 nurses to

16%8.3 Turnover rates to reduce to 14% by 01/04/19

and 12% by 01/04/20

8.4 To have in place a number of ‘new’ roles:WTE ANPs

WTE Nurse associate roles

16-20 new Advanced Nurse Practitioners –

Creation of 30 new Nurse Associate roles

15 new support ODP roles

#

#

9.1 To become a University Hospital Status by April

2020. (to be developed) University Status achieved PSEC MvDW / PdG

9.2 Apprenticeships: To be drawing down at least 80%

of the apprenticeship levy by 31/3/2020, with

apprenticeships available to both existing and new staff

in both clinical and non-clinical fields. To have a pass

rate in line with national requirements.

Apprenticeship Levy Action

PlanApprenticeship Levy draw down PdG

9.3 Educational Compliance: To maintain core and

essential training levels at 90% Workforce Strategy

Core and essential training %

compliancePdG

9.4 Leadership and Management Sessions: To have in

place clear development options for every banding of

role within the Trust.

Workforce Strategy

Numbers of staff accessing

leadership and management

training by grade

PdG

9.5 To have instituted a coaching service within the

Trust that provides, on demand, leadership,

professional and/or career coaching to all staff

requiring it, either on self or manager referral with

coaches to be drawn from volunteers within the Trust,

trained and supervised to ICF standards and the service

underpinned by Trust policy.

Workforce Strategy

WTE staff who have received in

house coaching

Number of sessions coaching

per month

WTE staff trained to provide

coaching

PdG

9.6 specific staff survey metrics relating to

development Workforce Strategy


survey by professional group PdG

10.1 Deliver our in year financial plan. Finance planYear end financial outturn vs

plan.FIC

10.2 Demonstrate year on year improvement in the

Trust’s underlying financial position and performance

against key value for money metrics. ( E.G. model

hospital, Carter metrics)

CIP

Improvement of Underlying

deficit (vs Plan).

Key metrics TBC

FIC

11.1 proactively communicate and engage with local

communities and stakeholders in the development and

delivery of services, continuing to build confidence and

trust of the local community.

stakeholder strategy stakeholder strategy metrics

PSEC / Acute

Redevelopment

Programme Board

11.2 Demonstrate active engagement in the HWE STP STP programme n/aTrust Board All

11.3 Continue to actively participate in and support the

development of the West Hertfordshire provider

collaborative.

n/a n/a Trust Board DR

11.4 Work with HVCCG to test new contractual forms

that share risk and support innovation. QIPP plan

% contract income covered by

new contracting modelsFIC DR / FG

11.5. To formalise our partnership with the Royal Free

Group and deliver the agreed work plan.

(see also objective 2.1)

Royal Free Partnership

Work PlanAs set out in RFL benefits log. Trust Board HB / all

12.1 Deliver 2018/19 priority one capital programme. Capital programmeCapital expenditure vs plan

Estate compliance metricsFIC HB / PH

12.2 Development control plans and business cases to

deliver the strategic priorities set out within the interim

estate strategy. Secure funding via STP and ITTF

applications and explore full range of alternative

funding options. (ED phase two, Theatres FBC, neonatal

& maternity, business cases to optimise WGH, SACH

and HHGH.)

Interim estate strategy

implementation plan

DCPs x 3

Agreed programme, business

cases completed & additional

funding secured

Trust Board HB

12.3 New multi-storey car parking at WGH (business

cases completed and approved, construction

commenced. Target opening 2020.)

Interim estate strategy

implementation plan

Multi-storey car park @ WGH in

construction phase by 2020. FIC DR

12.4 Outline business case/s, approvals and agreed

way forward for long term redevelopment of our

hospitals.

Programme Plan to be

developed following SOC

approval.

Business cases approvals & clear

programme in place for WGH,

SACH and HHGH.

Trust BoardHB

[i] Links / co-dependent with capital and interim estate strategy.

To become an excellent organisation for employee development.

AIM

TW

O: A

GR

EAT

PLA

CE

TO W

OR

K A

ND

LEA

RN

To have happy, healthy, well supported staff who feel able to

deliver great care and ‘make a difference’ in an inclusive

environment and to be a clinically led organisation.

Workforce Strategy & staff

survey action plan

Medical engagement action

plan

Annual staff survey results &

local temperature checks.


survey by professional group

(Band 8a and above).

PSECMvDW, TC,

PdG

To reduce vacancy rates & reduce our reliance on agency

workers.

AIM

TH

REE

:

IMP

RO

VE

OU

R

FIN

AN

CES

#

#

#

#

#

#

To deliver best value care. DR

AIM

FO

UR

: A S

TRA

TEG

Y F

OR

TH

E FU

TUR

E

#

#

#

#

#

#

#

To work with local stakeholders and partner organisations to

identify where, by working together, we can improve care for

our patients.

#

#

#

#

#

#

#

To improve the quality of our estate & implement our service

driven estate strategy

11



Trust Board Meeting

12 April 2018 Title of the paper

Board Assurance Framework 2017/18 - closure report

Agenda Item

12/58

Lead Executive


Author(s)

Jean Hickman, Trust Secretary

Executive Summary

The aim of this paper is to assure the board on the progress made to mitigate the strategic risks within the board assurance framework (BAF) during 2017/18.

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

All lead committees

Action required:

The board is asked to note the progress made to meeting the actions within the BAF.

Links to the board assurance framework





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

12

Tab 12 Board assurance framework update




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]

12



Agenda Item: 12/58

Trust Board meeting – 12 April 2018

Board Assurance Framework 2017/18 – closure report Presented by: Helen Brown, Deputy Chief Executive

1. Purpose

1.1 The aim of this paper is to provide an update on the key strategic risks to the trust delivering its aims and objectives. The paper provides the board with an overview of the latest position at the end of the 2017/18 financial year with regard to the progress made to mitigate the strategic risks within the board assurance framework (BAF).

2. Background

2.1 A BAF is a framework of the strategic and operational objectives across the trust and provides a totality of assurance activity relating to the organisation’s principal risks.

2.2 The responsibility for each principal risk is assigned to an individual executive with oversight by a designated lead committee. Risk scores are graded from blue (completed and embedded) to red. All actions required to mitigate risks to gaps in controls and assurance are drawn into a spreadsheet to make the data accessible and manageable.

3. BAF 2017/18

3.1 During 2017/8, the overall BAF was reviewed by the board in June and November 2018. The board approved the following changes to the principal risks: PR1. Failure to provide safe, effective, high quality care. The responsibility for this principal risk was shared between the safety and compliance committee and the clinical outcomes and effectiveness committee. PR5b. Inability to deliver and maintain planned care standards. The RAG rating increased from amber to amber/red to reflect a deteriorating RTT picture. PR7b. Failure to secure sufficient capital, delaying needed improvements in the patient environment, securing a healthy and safe infrastructure. The RAG rating was reduced from red to amber/red to reflect a review and recommendation by the project appraisal unit around capital spend authorisation. PR8. Failure to engage effectively with our patients, their families and local residents and partner organisations compromises the organisation’s strategic position and reputation. The responsibility for this principal risk was moved to the patient and staff experience committee.

12



3.2 Lead committees regularly reviewed the delivery of BAF actions within their area of responsibility in 2017/18 and escalated areas of concern to provide the board with assurance on the progress being made. The actions from 2017/18 have either been closed or will be carried over to the 2018/19 BAF.

3.3 Please see the table below for a summary of the status of the actions.

3.4 Please see appendix 1 for full details of the actions that have been achieved.

3.5 Appendix 2 details the actions which were partially achieved or not achieved. Four actions were not achieved: Action 73 and 74. Business case and implementation plan for funding to update the

intranet to be reviewed

These actions was not achieved due to financial resources and capacity constraints within IT and communication teams. Action 75. Bi-annual updates on trend analysis of communications to the Trust

Board.

This was not achieved due to a lack of resources in the communication team.

Action 77. Secure approval for acute SOC from HVCCG, STP, NHSI and DHSC and the Treasury. The trust is awaiting to receive confirmation of approval of the SOC from NHS Improvement (NHSI). A meeting with NHSI and NHS England is scheduled for 01 May 2018.

3.6 Two actions were not rated as they were either dependent on the completion of another

action. One action relating to an audit of clinical guidelines and practices was closed as the trust follows national guidance and therefore the audit was not required.

4. BAF 2018/19

4.1 In quarter 4 of the 2017/18 financial year, the board commenced a comprehensive review and refresh of its BAF to offer greater assurance that major risks were being tracked appropriately. The newly formatted BAF will reflect the primary risks to delivery of the trust’s 2018-2020 objectives. A number of actions that have not been achieved in 2017/18 will be carried over to the 2018/19 BAF and further relevant actions will be added. The 2018/19 BAF will be presented to the board for approval in June 2018.

4.2 Robust management of the 2018/19 BAF will continue with lead committees providing

regular assurance to the board on the delivery of BAF actions within their area of responsibility.

4.3 Following approval of the 2018/19 BAF in June, the board will receive a status report in October and March 2018 on any recommended changes made by the lead committees, progress of actions that have reached their due date and a forward look to escalate any actions with future due dates where there is a risk to delivery.

Action achieved Partially achieved Not achieved Actions carried over

55 25 4 30

12



5. Recommendation

5.1 The board is asked to note the closure of actions from the 2017/18 BAF and the plans in place for the 2018/19 BAF.

Helen Brown Deputy Chief Executive

April 2018 Appendix 1. Actions that have been achieved. Appendix 2. Actions that have been partially achieved or not achieved.

12



ref PR actions / milestones owner 1 owner 2due date

(original)

date

completeupdate as at April 2018 Status

Carried

forward

1 1Review & update KPI's for Board IPR

regarding complaintsCNO Jul-17 Sep-17

Narrative updated on the IPR to show divisional

overview and performance. Charts also

updated, main KPI’s not changed. Updated for

September Board.

Achieved No

3 1Review complaints team management

capacity and roles and responsibilitiesCNO Jul-17 Jul-17 Team roles and responsibilities reviewed Achieved No

4 1Implement recommendations from review

of complaints teamCNO Oct-17 Oct-17

Processes changed to comply with responding

to all complaints within the required 25 working

days. The policy and datix reviewed and

updated to make the above mandatory.

Achieved No

5 1

Joint audit of quality of complaint

responses with Hertfordshire

Healthwatch.

CNO Nov-17 Mar-18This work has been completed by Healthwatch

and a final report received. Achieved No

6 1

Finalise QIP update to reflect all new

actions following receipt of CQC report for

Sept 15

CNO CIO May-17 Jun-17

All new actions and change forms completed

and approved by TEC. Divisional reviews of all

musts and should with a full QIP refresh.

Achieved No

7 1

Updated QIP reporting format via safety

and compliance sub committee to Board

and Oversight committee

CNO Jun-17 Jun-17 New reporting via PM3 in place. Achieved No

8 1

Develop process to track actions from SIs

via divisional performance review

meetings

CMO CNO Jun-17 Jul-17 Scheduled commenced in July 2017 Achieved No

9 1

Audit effectiveness of SI Review group to

provide assurance that all SI action plans

are implemented and embedded. (Report

to Safety & Compliance Committee)

CMO CNO Feb-18 Sep-18

Report established and presented at each SI

Review Group meeting. This provides a RAG

rated overview of all open SI action plans to

indicate their current status and whether

additional action is required in respect of

reviewing and closing the action plans.

Achieved No

10 1Implement Datix tracking mechanism for

moderate harm incidentsCNO CMO Jul-17 Jul-17 Completed Achieved No

11 1

Trajectory to deliver improvements in

clinical guidelines from May baseline (54%)

to be developed.

CMO CNO Jun-18 Jul-17Trajectory developed and signed off by the

Policy Review group in July 2017Achieved No

14 1MCA / Best Interests training programme

and schedule to be finalisedCMO

DD

SurgeryJun-17 Dec 17

MCA / Best interests training in place as part of

core training programme. Achieved No

15 1MCA / Best Interests training programme

delivered (six month progress report)CMO

DD

SurgeryJan-18

Reported via Workforce IPR to PSEC.

Compliance 82% (Feb 18)Achieved No

18 1

New learning from deaths policy finalised

and adopted.

(dependent on national guidance being

finalised)

CMO Dec-17 Dec-17

Trust policy ratified and published.

SJR training for clinicians has started with 2

further dates scheduled.

Trust Mortality dashboard as regular board

agenda item to start Feb 2018

Achieved No

19 1

A learning from deaths action Plan to

address requirements - report via

outcomes & effectiveness committee.

(dependent on national guidance being

finalised)

CMO Jun-17 Jun-17

Action plan in respect of the national guidance

submitted and approved at June 2017 Mortality

Review Group.

Achieved No

20 2

Divisional staff survey action plans in place

to drive continued improvement in

engagement

DWF Jun-17 Jun-17Plans are now in place for all divisions and being

managed via Divisional Performance Reviews. Achieved No

21 2

Review & agree (revised) internal targets

for appraisal and mandatory training -

benchmark with organisations rated

'outstanding' by CQC

DWF Jun-17 Jun-17Completed and as a result targets have been

adjusted.Achieved No

22 2Funding for CPD activity agreed and

programmes being implemented.DWF Sep-17 Sep-17

Transformation commissioned to benchmark

clinical staffing levels. Achieved No

23 2Equality and diversity action plan approved

via patient and staff experience committeeDWF Sep-17 Sep-17

Action plan approved by patient and staff

experience committeeAchieved No

BOARD ASSURANCE FRAMEWORK ACTION TRACKER 2017/18

Closure report

Appendix 1

12




(original)

date


Carried

forward

24 2

Plan in place to address high level of

agency use within surgery and in particular

anaesthetics.

DWF Aug-17 Aug-17

Action plan in place in relation to theatre

staffing including apprenticeships, recruitment

events, clinical supervision, induction, ‘rescue’

interviews.

Anaesthetic Consultant business case for

recruitment of an additional 12 consultants

approved by TEC in August 2017.

Achieved No

25 2Progress review against agency plan via Pt

& Staff experience committeeDWF Feb-18 Feb-18

Recruitment plan is in place and being managed

by the divisional management team with

support from the HR BP.

Achieved No

26 2

Strategy / implementation plan developed

to maximise opportunities from

apprenticeship levy for approval via Pt &

Staff experience committee

DWF Oct-17 Oct-17Full work plan in place with steering group to

manage apprenticeships.Achieved No

28 2Agreed programme of management

development in placeDWF Oct-17 Oct-17 Programme in place Achieved No

29 2 Launch of 'shared' bank with STP partners DWF Dec-17 Oct-17 Shared bank has been launched Achieved No

30 3Finalise priority one capital programme

(funded internally) Dir Env May-17 May-17 Capital programme finalised Achieved No

31 3

Develop implementation plan with

milestones for tracking capital programme

via Estates Steering Group

Dir Env Jul-17 Jul-17 Implementation plan finalised Achieved No

32 3Agree priority 2 schemes for inclusion in

ITFF applicationDCEO Jul-17 Jul-17

A list of Priority 2 schemes was put forward for

inclusion within ITFF.Achieved No

33 3Technical Advisor to be confirmed for

management of confined spaces. Dir Env Jul-17 Sep-17

Technical Advisor was confirmed for

management of confined spaces. Achieved No

34 3

Ensure authorised and competent persons

in place for all high risk activities

(substantive appointments made to all

posts / incorporated into existing job roles)

Dir Env Aug-17 Jul-17 All posts filled by Trust staff Achieved No

35 3

First Estates Steering Group held &

monthly forward plan in place (reports to

Safety & Compliance Committee)

Dir Env Jun-17 Jun-17Regular ETG meetings established, with agreed

term of reference and work plan Achieved No

36 3

Estates and facilities dashboard finalised

with bi-monthly reporting against agreed

metrics (first draft to be issued July 17

after June ESG). System to be fully

implemented by Dec 17

Dir Env Dec-17 Dec-17Dashboard established and presented regularly

to the estates steering groupAchieved No

38 3

Update premises assurance model self-

assessment and develop new action plan

to further strengthen assurance.

Dir Env Dec-17 Mar-18

PAM interim review complete. The findings

were presented to safety and compliance

committee on 9 Aug I7. Continuous

improvement action plan in place. This is an

ongoing exercise / part of environment division

BAU governance.

Achieved No

45 4aImplement formal chief nursing

information officer (CNIO) roleCIO CNO May-17 Apr-17 CNIO appointed and in post. Achieved No

46 4a Board development session CIO Jun-17 Jun-17Updated Board on digital strategy at Board

Development Session in June 2017Achieved No

49 4a CIS capital funding secured CIO May-17 May-17 Funding secured Achieved No

50 4aCancer information system

implementation plan approved by TECCIO Jul-17 Jul-17

The business case was approved by TEC and the

project established. OJEU procurement process

is underway per national framework and

associated timeframes Achieved No

51 5aDevelop and deliver ED workforce

plan/business case for TEC review.DD USC CMO Jul-17 Jun-17

Business case for 3 new Acute physicians, 2

ANPs approved by TEC June 2017 . Achieved No

53 5a Submit bid for GP streaming capital DCEO CFO Apr-17 Apr-17Bid submitted but not successful; other funding

routes to be explored.Achieved No

54 5aDevelop bid for phase one 'do minimum'

improvement works for EDDCEO DD USC May-17 May-17

Bid submitted as a variant bid to wave 2

national ED transformation programme. £1m

capital funding confirmed.

Achieved No

55 5a

ED infrastructure improvements. National

funding contingent on delivery by end Oct

17. Plan in place to deliver this.

DCEO CFO Oct-17 Dec-17

Delays in build programme and scheduling have

resulted in slippage to the completion date for

this project. Now completed with expanded

CDU operational from 27th December 2017

Achieved No

56 5b

Develop an RTT delivery work plan to

address gaps in controls and assurance

and embed new processes implemented in

16/17 (including actions from audit

recommendations)

Dir Perf COO Jun-17 Jul-17

All actions from the audit recommendations are

complete.

A paper taken to CoE on 25/1/18 prior to

review by the Audit Committee. Performance

of RTT continues to be reviewed by TEC

Achieved No

12




(original)

date


Carried

forward

57 5b

Delivery of improved performance against

Breast Symptomatic 2 week wait standard,

develop a joint action plan with HVCCG

Dir Perf COO Jun-17 Jun-17

Draft plan developed for review by Beds and

Herts Cancer Action Group. WHHT sign off by

the TEC in June 2017.

Achieved No

59 7a

Commission external report of cost of back

office function metrics to support more

targeted interventions

CFO May-17 May-17Review commissioned and initial report

provided. Achieved No

61 7a & 7b ITFF application submitted. CFO Jul-17 Jul-17

ITFF application submitted July 2017. Next

steps likely to be an NHSI review of business

cases.

Achieved No

63 7aCommission external review of staffing

levelsCFO Jun-17 Jun-17

GK Transformation commissioned to benchmark

clinical staffing levels. Achieved No

65 7a

Commission third party expertise to

strengthen contractual risk assessment,

mediation and arbitration processes. CFO Jun-17 Jun-17

PWC reviewed 16/17 contract dispute and

drafted mediation statement.

Recommendations to strengthen arrangements

this year made as part of this process. New

mediation cases emerging however.

Achieved No

66 7a

Action plan / implement recommendations

to strengthen contractual risk assessment,

mediation and arbitration processes.

CFO Jul-17 Jul-17PWC recommendations implemented by

contracts team. Achieved No

69 8

Proposed approach to re-boot visible

leadership programme be presented to

TEC for approval.

Dir

CommsMay-17 May-17 Proposed approach agreed at TEC in May-17. Achieved No

79 9

Scope potential opportunities and agree

work plan for partnership work with Royal

Free

DCEO Jul-17 Nov-17 Work plan approved at November Board. Achieved No

80 10

Implement new STP governance

arrangements with strengthened PMO to

support delivery.

CEO STP CEO Jul-17 Aug-17

New STP governance arrangements agreed in

principle. Additional programme support

recruited into PMO to support workstreams.

Recruitment to clinical lead role / clinical

advisory group in progress.

Achieved No

81 10

Ensure visible leadership contribution

from WHHT to STP work streams - agree

WHHT nominees.

CEO STP CEO May-17 May-17Active input from WHHT in STP work streams.

Achieved No

82a 10Develop joint HVCCG and WHHT QIPP

board and increase clinical engagement.CEO HVCCG Jul-17 Jul-17

Joint QIPP Board established. Increased clinical

engagement in place. Achieved No

83 10Complete pilot scheme to discharge to

assess pathway one (discharge home).DIR IC Jul-17 Jul-17

Pilot ended in November 2017 and a six month

evaluation was completed. Patients who would

have gone through this service in month are

being referred to Herts County Council

commissioned Specialist Care at Home service

instead

Achieved No

84 10

Implement discharge to assess pathway

two (further assessment and / or

rehabilitation prior to decision re long

term care) – plan to be developed by July

2017. Implementation milestones TBC

DIR IC Jul-17 Jul-17

Beds are now operational with the Integrated

Discharge team managing the flow into the beds

from WHHT

Achieved No

85 10

Implement discharge to assess pathway

three (patients expected to need a long

term placement). Transition hub to be

developed / implemented by July 2017.

DIR IC Jul-17 Aug-17

Draft SLA is still with HCT for their final

comment and agreement. As now outstanding

this has Director to Director escalation to

resolve. However, invoices are being sent in,

scrutinised and mostly paid in accordance with

the Letter Of Intent from August 2017.

Achieved No

86 7a

In response to a deterioration in financial

plan, develop financial recovery plan and

covering letter to be signed by CEO and

Chair. Secure Board agreement for the

plan.

CFO Oct-17 Oct-17

Recovery plan sent on 16 October 2017.

Progress with the plan will form part of the

trust’s next Quarterly Review meeting with

NHSI.

Achieved No

12




(original)

due date

(revised)Status

Reason for

delay/failure to

deliver as

expected

UpdateCarried

forward

2 1Set trajectory for complaints performance

at Trust and divisional level and embedCNO Jul-17 Jun-18

Partially

achieved

Management

capacity /

operational

pressures

Some improvement in performance

over the year, although not fully

embedded at over 60% against a

trajectory of 85% for year end.

Yes

12 1 90% clinical guidelines in date CMO CNO Mar-18 Sep-18Partially

achieved

Management

capacity /

operational

pressures

As at 07/11/17 the percentage of

clinical guidelines registered with the

Assurance Team and in date is 72%.

Yes

13 1 Audit a sample of guidelines and practice CMO CNO Dec-17 Feb-18 Not rated N/A

As the Trust follows national guidelines,

this action is recommended for closure

as no longer required.

No

16 1Develop metrics for reporting nursing and

medical staff coverDWF CMO Jun-17 Mar-18

Partially

achieved

Management

capacity /

operational

pressures

A form of e-rostering was required to

be in place in order to allow a reporting

metrics to be established, which

required significant time and resource.

However, a medi-rota is now

established to take this action forward.

This requires embedding before it will

provide the required level of reporting

metrics.

Yes

27 2

Relaunch of bullying and harassment

advisors to challenge inappropriate

behaviour

DWF Oct-17 Jun-18Partially

achieved

Milestone too

ambitious

Work is continuing to address this

action. This will be completed as one of

the main activities from the Respect Me

campaign planned for June 2018

Yes

37 3All actions from 2016/17 PAM review

completed.Dir Env Aug-17 Feb-18

Partially

achieved

Milestone too

ambitious

Improvements made across 4 areas

previously deemed inadequate. One

remaining area on car parking. Action

on 2018/19 BAF to reflect the one

outstanding area on car parking. SOC

approved, and minor interim works

currently being costed to improve areas

during interim period.

Yes

39 3Updated 6 facet survey and summary

report Dir Env Sep-17 Feb-18

Partially

achievedExternal

The trust has received the outcome of a

6 facet survey, however it is not happy

with the quality of the report and is

working with the company to address

this.

Yes

40 3 ARCHIBUS full functionality implemented Dir Env Sep-17 Feb-18Partially

achievedExternal

Full functionality cannot be delivered

until 6 facet survey and asset survey

finalised and uploaded.

Yes

41 3Development Control Plans produced for

WGH, SACH and HHGHDir Env Mar-18 Sep-18

Partially

achievedExternal

Programme underway with clinical

teams to determine 'As Is’ and 'To Be'

models for each site. DCP programme

delayed 6 months.

Yes

42 3

Develop action plan to address highest risk

areas - identify priorities for 2018/19

capital programme based on 2017 ^ Facet

& Life Cycle exercise

Dir Env Feb-18 Feb-18Partially

achievedExternal

Initial risk based capital programme

developed for 18/19 based on existing

data re estate performance. Update to

be undertaken once 6 facet survey and

asset survey finalised.

Yes

43 3 Asset Database fully populated. Dir Env Sep-17 Jun-18Partially

achievedExternal

The trust has received the outcome of a

6 facet survey / asset survey, however it

is not happy with the quality of the

report and is working with the company

to address this.

Yes

44 3PPM programme completed - assurance

update report to Safety & complianceDir Env Mar-18 Jun-18

Partially

achievedExternal

System level statutory PPM's

implemented at SACH/HH and WGH

based on existing data - programme will

need to be reviewed and updated once

the 6 facet survey and asset survey has

been completed.

Yes

47 4aFormal Board approval of updated digital

strategy CIO Sep-17 May-18

Partially

achieved

Management

capacity/

operational

pressures

Digital Strategy Framework approved at

FIC in November 2017, with briefing to

Trust Board in December 2017.

Digital Strategy refresh completed and

taken to TEC and FIC in March 2018. To

go to Trust Board for approval in May

2018

Yes

48 4aCompletion of ICT infrastructure

improvement programme CIO Jul-17 Jun-18

Partially

achieved

Management

capacity/

operational

pressures

Plans are in place with robust

programme management and monthly

Exec level review. 90% EUD rollout

completed by the end Sep 2017. The

timeline was moved to reflect delays

due to the trust's response to cyber

risks and high priority incidents.

Yes

BOARD ASSURANCE FRAMEWORK ACTION TRACKER 2017/18

Closure report

Appendix 2

12




(original)

due date

(revised)Status

Reason for

delay/failure to

deliver as

expected

UpdateCarried

forward

52 5a

Recruitment timeline for new posts - target

for appointments to be made by Oct-17

and staff in post by Jan-18.

DD USC CMO Jan-18 Jun-18Partially

achieved

Management

capacity/

operational

pressures

2 new consultants in post. 4 new ANPs

and nurse consultant in post. Additional

locum posts recruited over winter

2017/18. Business case for substantive

changes to establishment and

recruitment to be reviewed at Trust

Board in April 2018.

yes

58 7aDevelop 2 year CIP plan with clear

implementation milestones.CFO CIO Oct-17 Mar-18

Partially

achieved

Management

capacity /

operational

pressures

2 year CIP plan developed. Action plan

in place to produce detailed delivery

programme. Work ongoing.

yes

60 7a

Develop action plans relating to back office

functions to be agreed with relevant

directorates following receipt of report.

CFO Oct-17 Dec-17Partially

achieved

Milestone too

ambitious

Report received and action plan

incorporated into CIPs. Business case

on human resources and financial back

office to be presented to TEC in April

2018

Yes

62 7a

Improve SLR and cost benchmarking and

agree pilot projects for deep dive CFO Jul-17 Nov-17Partially

achieved

Milestone too

ambitious

Working group meeting regularly and

monthly SLR reporting established.

Deep dive areas in progress and findings

incorporated into CIPs.More deep dives

to be undertaken

Yes

64 7a

Report and implementation milestones on

independent review of staffing

establishment levels to respond to

efficiency challenge and NHSI challenge to

trust's high staff costs.

CFO Nov-17 Jan-18Partially

achievedExternal

Report on nursing staff establishment

review scheduled for April 2018. The

trust is still in discussion with NHSI

regarding medical staff review.

Yes

67 7b

Actions to be implemented as agreed from

internal audit of costing, tendering and

control estates capital projectsDir Env Oct-17 Apr-18

Partially

achieved

Milestone too

ambitious

Local actions implemented. Trust

Capital Delivery SOP currently being

written for implementation April 18.

Yes

68 7b

Recruit capital programme manager &

retender call off contract for project

support.

Dir Env Sep-17 May-18Partially

achieved

milestone too

ambitious

Capital Program Manager in post,

procurement in process to establish call

off contract for project support. Target

completion / go live date for call off

contract May 18.

Yes

70 8Finalise stakeholder strategy and action

plan for approval by PSE and Trust Board.

Dir

CommsJul-17 Jun-18

Partially

achieved

Milestone too

ambitious

Draft strategy reviewed by patient and

staff experience committee and

discussion at board development

session. Agreed further work required

around metrics used to measure

progress.

Yes

71 8Stakeholder strategy implementation

milestones

Dir

CommsTBC Not rated N/A

Dependent upon completion of the

action aboveYes

72 8

Comprehensive communications plans for

four major strategic issues (STP, SOC,

Hemel SOC, RFH partnership)

Dir

CommsJun-17 Mar-18

Partially

achieved

Management

capacity /

operational

pressures

Director of Comms is part of STP

comms network which has its own

communications plan. Hemel SOC

clinical engagement workshops held in

September 2017. RFH group model

presented at clinical event in July 2017

and March 18. Timelines reset for SOC

due to internal CQC comms.

Yes

73 8Business case for funding to update the

intranet to be reviewed and updated.

Dir

CommsCIO Oct-17 No date Not achieved

lack of / delay in

capital funding

There has been a delay due to financial

resource issuesYes

74 8Implementation plan for update of the

intranet following confirmation of funding

Dir

CommsCIO

TBC

No date Not achieved N/ADependent upon completion of the

business case and capital funding. Yes

75 8Bi-annual updates on trend analysis of

communications to Trust Board

Dir

CommsOct-17 Jan-18 Not achieved

management

capacity/operation

al pressures

Delayed due to communication team

resource issues. Yes

77 9

Secure approval for acute SOC from

HVCCG, STP, NHSI, DH &Treasury DCEO Oct-17 Mar-18 Not achieved External

SOC submitted to NHS I in September

2017. Delays to review process for

major schemes at a national level.

Senior review meeting scheduled for 1st

May with NHS I and NHS E.

Yes

78 9

Mobilise additional internal programme

team capacity & programme management

structures

DCEO Oct-17 Mar-18 Partially

achievedExternal

Programme Director for Acute

redevelopment and additional service

planner appointed. Remaining posts

approved in principle have been frozen

pending outcome of SOC review

process. Governance structure being

mobilised. First programme Board

meeting held in February 2018.

Yes

82b 10

Develop and implement joint progress

tracker for QIPP programme Board (to be

reviewed via SDB TEC on a regular basis)

CEO HVCCG Oct-17 Feb-18Partially

achievedExternal

Tracker established and reviewed at

joint QIPP programme board. Process

continues to evolve to ensure HVCCG

and Trust views on progress and issues

are fully aligned.

Yes

Partially

achieved

Milestone too

ambitious

Some benefits already being worked up

on basis of initial reports, with the

majority of targeted interventions

expected to have an impact from

2018/19.

Yes87

Action plans to be agreed with relevant

directorates following receipt of a report into

an independent review of clinical divisions

financial metrics,

CFO Nov-17 Mar-187a

12



1

Agenda item: 13/58

Report to: Trust Board

Title of Report: Assurance report from Finance and Investment Committee

Date of meeting: 12 April 2018

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 29 March 2018.

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

Following last month’s FIC and Board recommendations, and subsequent review meeting with NHSI, a change to the Trust’s year end deficit forecast was approved from £35m to £43.2m. It was recognised at the meeting that there was still a material risk to the forecast, dependent upon the final agreement still to be settled with HVCCG on full year revenue.

For assurance that the revised forecast would be achieved, the Committee reviewed the deficit outcome in February compared to forecast, the latest forecast view for March, and the expected outcome from the ongoing discussions with HVCCG on the full year revenue settlement.

The Committee concluded that, excluding the HVCCG discussions, the latest expected outturn was broadly in line with the revised forecast, but there was not sufficient confidence that the outcome of the HVCCG discussions would be successful.

The Committee was therefore not assured that the £43.2m deficit forecast would be met, and recommends that a report on the latest view of the full year deficit is presented to Part 2 of the April Board.

ii. Productivity improvement plans

The Committee reviewed the emerging agenda of the Herts Procurement Shared Service to modernise procurement and supply across the STP. The plan is consistent with the direction of the 2016

13

Tab 13 Assurance report from Finance and investment committee


2

Carter Review on operational productivity, and the aim is to adopt procurement technologies, including electronic ordering and invoicing, based on an interoperable network to enable optimum management of price and demand, and overall improved contract management. Product harmonisation will be a key contributor to deliver Carter estimated total annual savings of between £3m and £5m for acute Trusts similar in size to West Herts.

The expectation is that the plans will develop into a series of discrete business cases across the Trusts in the STP, which will be seeking approval in the first half of 2018/19.

The Committee was supportive of the planned developments and will receive regular updates on progress prior to receiving business cases for review.

iii. Capital Spend/Funding

The Committee was pleased to hear that, finally, the Trust’s application for Capital Spend in the year was approved by NHSI in March, and that of the authorised sum of £13.7m, only £1.4m was for this year, with £6.1m to be spent in 2018/19 and £6.2m in 2019/20.

Together with other funding approved in March of £1.6m, for A&E Primary Care Streaming and Cyber resilience, the authorised capital spend in 2017/18 has increased by £3.0m in March to £9.7m.

Year to date spend at the end of February was £5.9m, which creates a challenge to spend the full £3.8m in March.

The Committee was assured that the spend would continue to be made in line with the priority classifications agreed early in the year, and recommends that the Board approves the DH capital loan of £13.7m, which will be drawn down over a 3 year period.

Financial Plan 2018/19

The Committee reviewed the latest status of the operational and financial plan for 2018/19, which now includes national planning guidance and financial control totals issued after last month’s Committee.

A number of key planning assumptions have yet to be finalised, in particular the reduction in the Trust’s revenues from QIPPs which have yet to be agreed with HVCCG.

The draft plan currently assumes that underlying revenues reduce by £6m year, primarily driven by QIPP reductions. Costs are planned to reduce next year, driven by cost improvements of £14m, 4% of revenues, and the plan is to drive significant operational improvements in patient waiting times for both A&E and elective care.

The draft plan deficit, pre STF funding, currently stands at £40m, £5m better than the equivalent latest forecast for 2017/18. NHSI have set a pre-STF control total of £20m for 2018/19, £20m lower than the Trust’s latest draft, which equates to an additional 6% of CIPs, making an unprecedented 10% in total. After reviewing the

13



3

operational and financial plan the Committee was not assured that the control total could be met.

The Committee fully endorses the need for a very challenging plan, but not one that is set at a level which is not realistically achievable.

The Committee gave its support to the draft plan capital spend of £17m, £12m of which will be funded by a combination of internally generated funds and the £6m of authorised spend carried forward from the current year, with the remaining £5m subject to NHSI approval of the Watford Theatres upgrade Final Business Case which is expected to be submitted by the second quarter of 2018/19.

The Committee also gave its support for the Trust applying for a £20m working capital loan, in addition to the loans to cover capital spend and the final agreed deficit. The loan would make a significant improvement to the liquidity of the Trust, and would enable more up to date payment of suppliers.

The Committee recommends the latest draft plan is presented to part 2 of the April Board.

Corporate risk register (CRR)

The Committee reviewed the 6 IM&T and 5 finance currently on the CRR.

The Committee was assured that the risks and ratings should remain as presented, apart from one ICT & Information risk and one Finance risk which the Committee asked to be revisited prior to presentation to the April Board.

Service Line Reporting

The Committee reviewed a paper on the current progress of SLR reporting in the Trust. This included seeking assurance that the 2017/18 annual national Reference Cost Return due to be submitted in August 2018, would comply with the principles and standards set by NHSI, and is backed by appropriate costing and information capture systems, adequate costing team resource, and procedures in place for a self-assessment quality check prior to submission. The reference costs inform the setting of payment by results (PbR) tariffs in future years and enable benchmarking between Trusts through the reference cost index (RCI).

The Committee noted, and was pleased to hear, that the Trust had volunteered to be an early implementer to complete a national patient level costing return along with the Reference Cost Return, with the same compliance requirements as the Reference Cost return.

Following review the Committee was assured that appropriate compliance with both returns was in place.

13



4

Information and Communications Technology (ICT)

The Committee reviewed the status of those areas of the ICT Transformation Programme, which remain incomplete and many months overdue. These areas include the wide area network, end user device rollout, migration of applications to offsite data centres, and fixed telephony deployment. The actions required by our supplier to complete will be discussed at senior executive level in April, with a report back to next month’s Committee.

Until a completion plan is agreed, with commitments from the supplier, the Committee is not assured that completion will be rapidly implemented.

The Committee was pleased to note that the Trust had been successful in securing £480k funding from NHSE’s Cyber Security Funding Programme. This will be used to replace XP devices and other equipment outside the scope of the Transformation Programme.

The Committee discussed the draft Digital Vision presentation and will feedback recommendations for changes prior to submission to the May Board.

Review of Policies

The Committee received verbal assurance that all IM&T and Finance policies were up to date.

Emergency Medicine Workforce Business Case

The Committee received a report on a Business Case to increase the substantive clinical workforce in ED, to improve capacity, patient experience, quality and performance measures.

The Committee recommended a number of changes be made to the paper before it is presented to Part 2 of the April Board to clarify the associated benefits and risks.

Department of Health & Social Care Bank Pilot Scheme

The Committee reviewed a paper on the tendering consequences of the Herts and Beds consortium, of which the Trust is part, being successful in their application to be one of 12 pilots looking at different shared staff bank arrangements, which are sponsored and funded by DHSC. The aim of the pilots is identify changes to bank arrangements for the benefit of both staff and Trusts, and they will run from April 2018 to January 2019.

The Trust’s current contract with its bank provider expires in March 2019, which would mean running the retendering process

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5

concurrently with the pilot. To enable the results of the pilot to be incorporated in the next round of tendering the TEC recommends extending the current contract by one year to March 2020.

The Committee was assured that this is the optimum course of action for the Trust and endorses the recommendation.

Risks to refer to risk register

See corporate risk register above.

Issues to escalate The Committee recommends the following:

to Part 1 of the April Board for approval:

i. the Department of Health & Social Care capital loan of £13.7m

to Part 2 of the April Board for assurance:

ii. the latest view of achieving the £43.2m deficit forecast.

iii. The latest draft operational and financial plan for 2018/19

to Part 2 of the April Board for review

iv. a paper on the planned resource increase in the Emergency Medicine workforce.

Attendance record

Attended

John Brougham, Non-Executive Director (Chair)

Don Richards, Chief Financial Officer

Mike van der Watt, Medical Director

Phil Townsend, Non-Executive Director

Sally Tucker, Chief Operating Officer

Sean Gilchrist, Director of ICT

Stephen Dunham, Assistant Director of Finance & Commercial Development

Tom Drabble, Patients’ representative

Apologies


Jeremy Livingstone, Divisional Director, Surgery, Anaesthetics & Cancer

Katie Fisher, Chief Executive

Lesley Headland, Chair of Staffside

Lisa Emery, Chief Information Officer

Paddy Hennessy, Director of Environment

Prof. Steve Barnett, WHHT Chair

Clerk

Clare Ransom, Executive Assistant

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1

Agenda item: 14/58


Title of Report: Assurance report from Clinical Outcomes and Effectiveness Committee


Recommendation: For information and assurance

Chairperson: Jonathan Rennison, Chair

Purpose

The report summarises the assurances received, approvals, recommendations and decisions made by the Clinical Outcomes and Effectiveness Committee at its meeting on 30 November 2017

Background The Committee meets bi-monthly and provides assurance to the Board on:

Safe and effective patient care

Prevention, early intervention, recovery and rehabilitation

Ensure that the Trusts responsibility for infection control is effectively fulfilled

Promoting a culture of learning and continuous improvement.

Measure change using clinical outcome measures to monitor the impact of the services provided by the Trust.

Business undertaken

Integrated Performance Report (IPR) The Committee received and reviewed the IPR and was assured that appropriate actions were being taken to maintain and improve performance across a range of measures. In particular, the Committee was informed that there were 6 cases of Clostridium difficile infection (CDI) reported in February. The trust currently has a year to date total of 28 against the full-year target of 23. The rybotyping for each of the 6 cases in February were all individually different. The committee noted that the staffing fill rate remained below target at 91% but with an increase of 0.4% from last month. There are low fill rates in paediatrics, and this area is being reviewed as part of the establishment review covering skill mix and redesign. The complaint response position had deteriorated in month from 76% in January to 44% in February against a target of 85%.

14

Tab 14 Assurance report from the Clinical Outcomes and Effectiveness committee


2

Neonatal peer review 2017 The committee received an update report on the neonatal peer review outcome. Overall the key findings included; evidence of strong clinical leadership, a cohesive team with good collaboration, proactive identification of risks, a successful own education programme, strong links with the network and support for nursing staff to access neonatal specialist nurse training.

There were no immediate risks identified, with two serious concerns noted:-

Restricted space around cots in the IC and HDU areas - it is suggested that a refurbishment of the area is undertaken and a business case for capital funding will be submitted early in 2019.

Entering activity onto the neonatal electronic admissions database to ensure additional workload for staff is captured – a 3-month audit has been undertaken, and the team are now analysing the data.

Two areas of improvement included:-

The number of qualified in speciality (QIS) trained nurses and

the service is to develop a nursing workforce strategy to

achieve compliance towards registered QIS numbers.

A lack of dedicated speech and language therapy service; the

management team and HVCCG are looking at a scoping

exercise to identify the need within the neonatal service

Resources support safe care for full-term babies The committee reviewed an update on the action plans implementing the recommendations from the reducing term admissions report. The committee received an update on actions currently on track for completion within the set timescales and those actions already completed. The committee were also updated on two outstanding actions still in progress. The committee was assured on the progress being made and the mitigations in place to reduce the risk of term admissions to NICU. Learning from deaths 6-monthly report The Committee received an update on the progress that had been made against the actions the trust was taking to implement the recommendations set out in the National Guidance on Learning from Deaths. The committee reviewed the two outstanding actions:-

Ensure that learning from deaths is core to the Trust's quality improvement work – the committee was advised that this was

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3

not yet embedded but continued focus by the trust mortality review group.

Offer a bereavement service for families and carers of people who die while in our care- A bereavement leaflet updated and training programme for PALs and patient affairs in place.

COE Committee risk register to include risks at 15 There are currently no corporate risks aligned to the clinical

outcomes and effectiveness committee. The previous aligned risk

had been closed and re-opened as two individual risk due to the

restructuring of the medicine and emergency medicine divisions.

BAF Action Tracker 2017-18 The Committee reviewed the board assurance framework and was assured that all actions were appropriate and on track. Action 56 to develop an RTT delivery work plan had been completed. Quality Account six monthly review against 2017/18 priorities

The committee received an update on the proposed trust quality

priorities for 2018/19, once finalised will be published as the Quality

account.

The three themes for the 18/19 quality priorities are:-

Sharing a commitment to quality of care and service

Fostering a team working culture

Building an organisation that drives quality

The committee reviewed the priorities and measures of success.

These have been aligned with the corporate objectives for the next

two years and will be signed off by the trust board.

Risks to refer to the risk register

None

Attendance In attendance for specific Items

Jonathan Rennison, Non-Executive Director Ginny Edwards, Non-Executive Director Tracey Carter, Chief Nurse & DIPC Mike van der Watt, Medical Director Martin Keeble, Chief Pharmacist Anna Wood, Associate Medical Director of Clinical Standards and audit Jane Shentall, Director of Performance Leigh Franklin, Assistant trust secretary (minutes) Tracey Payne, Interim Head of Midwifery Elvira Baker, Matron Neonatal services Dr Naaz Merhant, Neonatal consultant Dr Jinadatha, Neonatal Consultant

14



Agenda Item: 15/58


Title of Report:

Patient and Staff Experience Committee Assurance Report to Trust Board

Date of meeting:

12 April 2018

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 22 February 2018..

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

Key Business Undertaken

Training compliance: The committee received a paper regarding steps being taken by the Training team to ensure that mandatory training data is correct. What is being proposed is a ‘bulk upload’ of training data requirements which will ensure that correct data regarding training competencies are in place for all positions within the Trust. The paper adviced that it is likely that in the short term this will impact negatively upon training compliance figures. This work will happen over the next two months with a plan in place to ensure that additional training is put into place to meet any shortfalls in compliance. The Committee recommends this work to the Board.

The Gender Pay Gap Report: The Committee received a paper on the

Publication of WHHT Gender Pay Gap. Whilst the Committee were clearly

concerned by the gaps in pay between our male and female employees and

particularly in relation to CEAs, it was assured by the further analysis which

showed a more positive picture. It was particularly pleasing to see that

women were forming a growing portion of our consultant workforce and

many other gaps between our male and female employees seem to be

narrowing. The Committee recommended the findings of this paper to the

Board.

15

Tab 15 Assurance report from the Patient and staff experience committee


National Staff Survey Results 2017 and next steps: The committee

received a paper presenting the results of the 2017 National Staff survey.

Whilst the Trust saw a small decline in the overall results as compared to

last year’s results it was pleasing to see a significant improvement as

compared to comparator trusts. The full results will be published on 6th

March alongside the publication of national results.

Review of Draft NHS Workforce Strategy: The Committee received a

paper providing an update on the consultation process regarding the

proposed NHS National Workforce strategy. The Committee welcomed the

proposal and were supportive of a number of observations regarding the

proposed strategy, as well as the fact that the trust would be fully involved in

feeding back upon the proposed strategy.

Review of PSEC Terms of Reference and Workplan 2018-19: The committee approved the proposed workplan and Terms of Reference with some minor amendments.

Review of Consultant and SAS Doctor Job Planning 2017/18 The Committee received a paper on the review of consultant and speciality and associate specialist (SAS) doctor job planning. The Committee noted that as at 11 January 2018, 79% of job plans had

been fully signed off. A further 9.5% of plans were not signed off because

they had necessarily been republished mid-year due to ongoing team

reconfiguration. Job plans for 2018/19 were published on 12 January 2018

with a final sign off deadline of 31 March 2018. The Committee welcomed

this update.

Outline of workforce role development Band 4,5 and 6 Nurse activity The Committee received a report to note initiation of an STP workforce

planning project, focussing upon the Band 4, 5 and 6 nursing workforce.

The project will determine whether deployment of current band 5 roles

makes best use of training and skill sets, and whether some duties can best

be undertaken by other qualified and unqualified staff.

Further updating will be provided to the committee once the project has determined options and recommendations for implementation.

Enabling BME Nurse and Midwife Progression into Senior Leadership Positions: The Committee received a paper advising that the Chief Nursing Officer for the NHS Jane Cummings had commissioned an enquiry into gaps in the experiences and opportunities across the NHS between white and BME staff. Senior leaders within the NHS are encouraged to review how they can impact on enabling a culture of diversity and inclusion, to encourage all talent to thrive within health and social care setting. The trust will be fully participating in this work and this will include regular reports to PSEC to ensure good progress with reports to the Board. The Committee recommends this work to the Board.

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The committee were asked to note the following: Update on OHS Service Provision The Committee received a paper for noting which provided details of a

proposal to work with the Royal National Orthopaedic Hospital NHS Trust,

the Royal Free Hospital, Barnet, Enfield and Haringey Mental Health Trust

and North Middlesex Hospital to work together on a new Occupational

Health Service. Update on progress around this work will be provided to

PSEC on an ongoing basis.

Approval to run a Mutually Agreed Resignation Scheme (MARS) The Committee received a paper for noting which provided details of a

proposal that the Trust introduces a Mutually Agreed Resignation Scheme

(MARS) to assist with proposed service reconfigurations during 2018-19.

This paper has also gone to Financial and Investment Committee for

assurance purposes.

Other items reviewed by the Committee:

Patient & Staff Experience Risks/BAF

Patient Experience Performance Report

Review of monthly workforce report

Update on CQC Report Workforce Issues

CQUIN NHS staff health and wellbeing; Indicator 1b Healthy food for NHS staff, visitors and patients

Risks to refer to risk register

.None

Key decisions taken

None

Issues to escalate

The Committee recommended the work being undertaken to improve the accuracy of training data to the Board.

The Committee recommended the Trust’s report into the gender pay gap to the Board for its approval.

The Committee recommended that the Trust be fully involved with

the work being undertaken into enabling BME nurse and midwife

progression into senior leadership positions

Challenges and exceptions

None

Future exceptional items

None

Attendance record

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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

15



Agenda item: 16/58


Title of Report: Charitable Funds Committee Assurance Report to Board


Recommendation: For discussion

Chairperson: Jonathan Rennison, Non-Executive Director Purpose

The report summarises the assurances received, approvals, recommendations and decisions made by the Charitable Funds Committee at its meeting on 15 March 2018.

Background The Committee meets quarterly and provides assurance to the Board:

that robust processes are in place to manage charitable funds and to ensure they are implemented;

that donated funds are utilised in a way that takes into account any stipulations set out by donors and ensure best value is obtained from the funds donated;

that further donations are being encouraged;

that systems comply with regulation and governance of NHS Charities.

Business undertaken

Options report on the future of the charity The committee reviewed and discussed the report on the future status of the charity provided by Kingston Smith. A series of interviews were conducted with representatives of West Herts Hospitals and other NHS trust charities and other charities working in Hertfordshire. From that work 10 options against 13 criteria were outlined in a matrix. The top scoring option recommended was to become an independent charity through merging with the Royal Free Charity. There were two other options which scored similarly highly; to outsource infrastructure services or to move towards independence without merging with another charity. The committee reviewed all the options and agreed that the next step would be to meet with the Royal free charity to gain a better understanding of how this might work. Progress on compliance with general data protection regulations The committee received assurance that the charity is fulfilling its responsibilities in preparing for GDPR and to ensure the trust is complaint by 25 May 2018. Terms of reference and work plan 2018/19 It was agreed that further review of the terms of reference would be required and a meeting would be arranged, circulate to the committee members for review before being taken to the board at its May meeting for final approval.

16Tab 16 Assurance report from the Charitable funds committee


Overview of funds The committee received a report on the charity’s financial position and financial performance as at the end of January 2018. The report included the balance sheet, a statement of financial activity, an investment trend report and a cash flow forecast. The committee was assured that investments were performing well and were being well managed. The committee also received an update on new income, grants and donations. On Site Fundraising The committee received a request to approve a way forward with on-site fundraising for charities or retail where the benefit is unclear. It was agreed that there should be a policy in place to deal with any applications, it was suggested contact with another NHS charity who may already have a similar policy in place.

Escalation to the Corporate Trustee

Update on the options appraisal on the future of the charity

Progress on compliance with GDPR

Terms of reference

Attendance record Jonathan Rennison, Non-Executive Director Ginny Edwards, Non-Executive Director Helen Brown, Deputy Chief Executive Tracey Carter, Chief Nurse Don Richards, Chief Financial Officer Louise Halfpenny, Director of Communications Paul da Gama, Director of Human Resources Jean Hickman, Trust Secretary Leigh Franklin, Assistant Trust Secretary (notes)

16Tab 16 Assurance report from the Charitable funds committee


Page 1 of 2


AGENDA Agenda item: 20/58

03 May 2018 at 9.30am – 12.00noon

Lecture Room, Postgraduate Centre, St Albans 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



02/59 Patient experience presentation

To receive N/A Chief Nurse Presentation

OPENING



04/59 Conflict of interests To note N/A Chair Paper

05/59 Minutes of the meeting held on 12 April 2018

For approval

N/A Chair Paper

06/59 Board action log from 12 April 2018 and previous meetings and decision log

To note N/A Chair Paper


For information

N/A Chair Paper

08/59 Chief Executive’s report For information

N/A Chief Executive

Paper

PERFORMANCE

09/59 Integrated performance report – month 12

For information

and assurance


Chief Operating Officer

Paper

DELIVER A LONG TERM STRATEGY (BAF RISK 9)

14/59 Strategy update For information

and assurance



Paper

GOVERNANCE

15/59 Terms of reference and work plans for board and committees

For approval



Paper

16/59 Bi-monthly report on the corporate risk register

For information

Safety and Compliance Committee

Medical Director Paper

20

Tab 20 Draft agenda for the next board meeting


Page 2 of 2

17/59 Slavery and human trafficking statement 2017

For approval

Safety and Compliance Committee


Paper

COMMITTEE REPORTS

18/59 Assurance report from Finance and Investment Committee

For information

and assurance

Finance and Investment Committee

Committee Chair/ Chief Financial

Officer

Paper

19/59 Assurance report from Clinical Outcomes and Effectiveness Committee

For information

and assurance

Clinical outcomes and effectiveness

committee

Committee Chair/Chief Nurse

Verbal

20/59 Assurance report from the Audit committee

For information

and assurance

Audit Committee Committee Chair/Chief

Financial Officer

Paper

CORPORATE TRUSTEE

16/59 Update on charity general data protection regulations

For information

and assurance

Charitable Funds

Committee

Director of Communications

Paper

ANY OTHER BUSINESS

21/59 Any other business previously notified to the chair

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

25/59 Date of the next board meeting in public: 07 June 2018, Trust Executive Meeting Room, Watford Hospital


20

Tab 20 Draft agenda for the next board meeting


Documents

TRUST BOARD MEETING IN PUBLIC AGENDA effective system of medical workforce planning? 5. An effective system of midwifery workforce planning? 6.Compliance with the Saving Babies' Lives