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TRUST BOARD MEETING TO BE HELD ON WEDNESDAY 25th

JULY 2012IN THE MAIN HALL, THE BENN HALL, NEWBOLD ROAD, RUGBY, CV21 2LN

PUBLIC AGENDA

THE PUBLIC SESSION OF THE TRUST BOARD WILL COMMENCE PROMPTLY AT 1.00PM

P:\Trust Board\Trust Board - Master File\2012\7 - JULY 2012\PUBLIC\Enc 0 - AGENDA JULY 2012 - PUBLIC (Final).doC

Resolution of Items Heard in PrivateIn accordance with the provisions of Section 1(2) of the Public Bodies (Admission to Meetings) Act 1960, and the Public Bodies(Admissions to Meetings) (NHS Trusts) Order 1997, it has been resolved that the representatives of the press and other members of thepublic are excluded from the second part of the Trust Board meeting on the grounds that it would be prejudicial to the public interest due tothe confidential nature of the business transacted. This section of the meeting has been held in private session.

1 General Business Paper Presenter Category1.1. Apologies for Absence Verbal Chairman N/A1.2. Minutes of Meeting held on 27.6.12 Enc 1 Chairman N/A1.3. Actions Enc 2 Chairman N/A1.4. Matters Arising Verbal Chairman N/A1.5. Declarations of Interest Verbal Chairman N/A1.6. Chairman’s Report Verbal Chairman N/A

1.7- Private Trust Board Meeting SessionReport – 27.6.12*

Enc 3 ChairmanN/A

1.8 Chief Executive’s Report Verbal Chief Executive Officer N/A

2Delivering safe, high quality andevidenced patient care

Paper Presenter Category

2.1 QPS Report Enc 4 Mrs M Pandit, Chief Medical OfficerQuality &

Safety

2.2 Serious Incident Group Report Enc 5 Mrs M Pandit, Chief Medical OfficerQuality &

Safety

2.3 Net Promoter Score Enc 6Mrs C Watts, Chief MarketingOfficer

Quality &Safety

2.4Infection Prevention and Control Report(including joint cleaning update with ISSMediclean)

Enc 7Professor M Radford, Chief NursingOfficer

Quality &Saefty

2.5Quality Governance Committee MeetingReport 12.6.12*

Enc 8Mr T Sawdon, Non-ExecutiveDirector

Governance

3Developing excellence in research,innovation and education


No reports Verbal

4Improving the business and serviceframework


4.1 Provider Management Regime Enc 9Mrs S Beamish, Interim ChiefOperating Officer

Governance

4.2 Performance Report Enc 10Mrs S Beamish, Interim ChiefOperating Officer

Governance

4.3 Finance Report Enc 11 Mrs G Nolan, Chief Finance Officer Governance

4.4Audit Committee Meeting Report – 14.5.12& 1.6.12*

Enc 12Mr T Robinson, Non-ExecutiveDirector

Governance

4.5Finance and Performance Meeting Report –28.5.12*

Enc 13Ms S Tubb, Senior IndependentDirector

Governance

5Building a positive reputation andidentity

PresenterCategory

4.1 Foundation Trust Application Update* Enc 14 Mr A Hardy, Chief Executive Officer Strategy

6 Any Other Business

7 Questions from the Public up to 15 minutes

8 Date of Next Meeting:Wednesday 26

thSeptember 2012 starting at 13.00

Please note: asterisked items (*) are for noting and, in general, do not require discussion.

UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST

MINUTES OF THE PUBLIC MEETING OF THE UNIVERSITY HOSPITALS COVENTRYAND WARWICKSHIRE NHS TRUST BOARD HELD ON WEDNESDAY

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JUNE 2012 AT 1.00PM

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AGENDA ITEMDISCUSSION ACTION

HTB 12/285PRESENT

Mrs W Coy, Non-Executive DirectorMr A Hardy, Chief Executive OfficerMrs G Nolan, Chief Finance OfficerMrs M Pandit, Chief Medical OfficerMr T Robinson, Non-Executive DirectorMr T Sawdon, Non-Executive DirectorMr N Stokes, Deputy ChairMr P Townshend, ChairmanMs S Tubb, Senior Independent DirectorMrs C Watts, Chief Marketing Officer

HTB 12/286IN ATTENDANCE

Mrs S Beamish, Interim Chief Operating OfficerMr I Crich, Chief Human Resources OfficerMrs J Gardiner, Trust Board SecretaryDr P Sabapathy, Non-Executive Director (Designate)Mrs Paula Young, Executive Assistant (note taker)

HTB 12/287APOLOGIES

Professor Radford, Chief Nursing OfficerProfessor P. Winstanley, Dean of Medicine, Warwick Medical School

HTB 12/288MINUTE30/05/2012*

Mrs Beamish noted that the records should reflect that she was inattendance as she is a non-voting Executive.

The Trust Board APPROVED the minutes of the meeting held onWednesday 30th May 2012 as a true record of the meeting subject tothe above amendment.

HTB 12/289ACTIONS

The actions completed and actions in progress were NOTED.

HTB 12/290MATTERSARISING

There were no matters arising.

HTB 12/291DECLARATIONSOF INTEREST

There were no declarations of interest.

HTB 12/292CHAIRMAN’SREPORT

The Chairman welcomed Dr Paul Sabapathy; CBE who was invited toattend today’s meeting as Non-Executive Director (designate) and willformally take up post with effect from 1st July 2012. Dr Sabapathy hassubstantial experience both financially and commercially with a strongacademic background; he was previously Chairman and ProChancellor of the University of Central England and Chair of theBirmingham East and North Primary Care Trust. Dr Sabapathy isscheduled to meet with the Chairman on Friday 29th June 2012 as partof his formal Induction process to agree committee membership.

In accordance with the provisions of Section 1(2) of the Public Bodies (Admission to Meetings) Act 1960,and the Public Bodies (Admissions to Meetings) (NHS Trusts) Order 1997, it is resolved that therepresentatives of the press and other members of the public are excluded from the second part of theTrust Board meeting on the grounds that it is prejudicial to the public interest due to the confidential natureof the business about to be transacted. This section of the meeting will be held in private session.



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The Chairman noted that the work arising from the detailed debate anddiscussions held at the Board seminar on Wednesday 13th June 2012is reflected within the agenda of the Board meeting today.

The Chairman noted that he had recently met with the Chair of theArden Cluster, as well as the Chairs of the University and LocalAuthorities as part of the regular framework of discussions within thelocal health economy. He added that it would be beneficial for the Trustto meet with key players as an opportunity to explore additional formsof partnership working; adding that colleagues will be able to take partin future discussions to help meet the challenges within the local healtheconomy.

The Chairman noted that he has an appraisal scheduled with the Chairof the Strategic Health Authority (SHA) in August; following which hewill be conducting annual appraisals for Non-Executive Directors.

HTB 12/293PRIVATE TRUSTBOARD MEETINGSESSIONREPORTS –30.5.12 & 1.6.12

The Chairman advised that the purpose of the report is to advise of theprivate Trust Board session meeting agenda held on 30th April 2012and 1st June 2012 and any key decisions or outcomes made by theTrust Board.

The Board NOTED the contents of the report.

HTB 12/294CHIEFEXECUTIVESREPORT

The Chief Executive Officer announced that Mrs Watts, ChiefMarketing Officer is leaving the Trust at the end of August 2012, formalrecognition of her contribution to the Trust will be made at the TrustBoard in July. The Chief Executive Officer also announced that MrsNolan is confirmed as Deputy Chief Executive Officer.

The Chief Executive Officer reported that he attended the launch of theWarwickshire Healthcare Partnership on 30th May 2012 which provedto be a successful event.

A private Board session was held on 1st June 2012 to formally sign offthe accounts for 2011/12. The Chief Executive Officer demonstratedhis appreciation to Mrs Nolan and her team for their hard work.

The Chief Executive Officer reported that the Care Quality Commissionmade an unannounced visit to the Hospital of St Cross on Tuesday 26th

June 2012. There were no areas of concern highlighted; the verbalfeedback provided on the day was very complimentary, particularly inrelation to the openness and transparency of staff. A formal report willbe available within the next 10 working days and the Trust has 10working days to respond.

The inaugural meeting of the Arden Local Education and TrainingCouncil is to be held on 16th July 2012, of which the Chief ExecutiveOfficer is Chair.

The proposed TFA revised submission date to the Department ofHealth (DH) of 1st June 2013 has verbally been approved by the DH,and is awaiting formal sign off.



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Several members of the Executive Team attended the NHSConfederation National Conference last week which proved veryuseful; key note speakers included the Rt Hon Andrew Lansley, MPand Sir Stuart Hampson, former Chair of the John Lewis Partnership.

The Chief Executive Officer attended the Coventry Health andWellbeing Board on Monday 25th June 2012 at which the StrategicNeeds Assessment was formally signed off. Dr Steve Allen,Accountable Officer for Coventry & Rugby Clinical CommissioningGroup was also in attendance to present the system plan.

The Chief Executive Officer reported that there are now 3 ClinicalCommissioning Groups (CCG) within the Arden Cluster; Coventry &Rugby CCG, NHS Warwickshire North CCG and NHS SouthWarwickshire CCG.

The Chief Executive Officer advised that the DH has asked forexpressions of interest to form Academic Health Science Networks(AHSN’s) by 20th July 2012. A meeting is arranged between the Trustand the Warwick Medical School for 17th July 2012 to formalisearrangements.

The Trust Board NOTED the verbal report provided by the ChiefExecutive Officer.

HTB 12/295SERIOUSINCIDENT GROUPREPORT

The purpose of the report is to provide the Trust Board with aquantitative summary of the significant incidents (SI’s) that wereopened or closed during May 2012 and Trust-wide mortality data. AllSIs are reviewed at the weekly SI Group, which ensure thatinvestigations are undertaken and appropriate actions are put in placeto reduce identified risks.

Mrs Pandit advised that details of SI investigations are also presentedmonthly to the Patient Safety Committee and Quality GovernanceCommittee.

Mrs Pandit reported that since the report presented today was written,there has been a suspected never event and she offered to providefurther details to Board members if required.

Mr Sawdon queried whether details of the never event would bepresented to the Quality Governance Committee. The Chief ExecutiveOfficer advised that further clarification is awaited in respect of thesuspected never event and a formal separate report will be presentedto the Quality Governance Committee. He added that the Trust hadtaken a prudent approach and notified the SHA.

In response to a query from Ms Tubb, Mrs Pandit offered reassurancethat there is no commonality between the cluster of patient falls andunexpected deaths featured within the report. She added that allpatient falls are progressed through the Falls Group overseen byProfessor Mark Radford, Chief Nursing Officer.

Mr Stokes drew the Board’s attention to the high reported mortality



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figures for February 2012 and queried whether these had featuredwithin the Trust Board report presented in May. The Chairmanreassured the Board that the information is closely scrutinised by theQuality Governance Committee. Mrs Pandit AGREED to review themortality data and feedback to Quality Governance Committee.

The Trust Board RECEIVED and APPROVED the report.

Mrs Pandit

HTB 12/296NET PROMOTERSCORE

The purpose of the report is to appraise the Trust Board of the currentNet Promoter Score, with weekly breakdown, information on nextsteps, issues and risks.

Mrs Watts reported that the Trust is achieving in excess of the numberof patients required to complete the survey, which is no mean feat.Better engagement is required from the clinical teams at ward level;this type of methodology will improve the score.

Mr Sawdon queried the cost of undertaking this scheme. Mrs Wattsresponded that the estimated cost is £40k to fund resources whichinclude on-line impressions survey, iPads for data capture, testing andtelemarketing services. As other methodologies become embedded it ishoped that the telemarketing service will cease.

Mr Sawdon noted that appendix 2 of the report details a number ofother patient experience issues that appear in surveys or feedbackacross the Trust which need to be included in all speciality action plansas appropriate, alongside actions for the CQUIN questions. He queriedat what stage these will be included. Mrs Watts advised that specialitieswill report through the Operational Planning and PerformanceMeetings. She added that this is early days; tracking and maintenancewill come through the Patient Engagement and Experience Group whowill review all exceptions both good and bad.

In response to a question from Mr Stokes, Mrs Watts advised that thequality of response differs by methodology; adding that face to faceappears to attract the most positive response followed by texting. Themost negative response is found to be the on-line survey.

Mr Stokes queried what the impact would be of ceasing the on-linesurvey. Mrs Watts suggested that this would not be the mostrepresentative way of gaining opinion. The Trust should approach thisthrough every methodology to help improve the service. She urgedcaution about drawing early conclusions, adding that AddenbrookesHospital, which has won several national awards for patient care, isfeaturing at the bottom of the survey results.

It was noted that in terms of equality and diversity there is exemptioncriteria applied and concerns regarding the over 18 age restriction setby SHA has been noted. Mrs Watts added that the Trust is taking apragmatic and sensible approach to this.

The Chairman thanked Mrs Watts for a very good piece of work whichhe acknowledged to be very challenging.



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The Trust Board:-

APPROVED the report and next steps.

NOTED the current score and ranking and ongoing support forthe focus of the Engagement team on the NPS as the primaryand overarching patient experience performance framework for2012/13.

HTB 12/297QUALITYGOVERNANCECOMMITTEEMEETING REPORT– 8th MAY 2012

The purpose of the report is to advise the Trust Board of the QualityGovernance Committee meeting held on 8th May 2012.

The Trust Board ACCEPTED the contents of the report.

HTB 12/298PROVIDERMANAGEMENTREGIME

The SHA wide Provider Management Regime (PMR) has now beenrolled out nationally, which each Trust is required to complete on amonthly basis.

At the time of writing the report the East and Midlands SHA had notpublished the PMR process for 2012/13. In the absence of this theSHA reissued the 2011/12 template for use in April and May 2012. It isunderstood that the final 2012/13 template is likely to change and mayinclude different indicators within the submission.

Mrs Beamish advised that the risk rating for May remains the same asit did for April; the key issue being A&E. The Patient Steering Group willlead on an action plan to deliver a sustainable solution. However, it isacknowledged that sustainability will take in the region of 12 months toachieve. Modern Matrons, Managers and Senior Leaders are spendinga significant amount of time pushing the system.

Mr Sawdon queried criteria number 11 on page 12 of the PMRdocument ‘100% compliance with WHO surgical checklist’ which isreported as red. Mrs Beamish advised this is directly linked to neverevents; that checklists of people, equipment, markings and consent arein place to minimise the potential for never events. Mrs Pandit addedthat the checklists are used as a brief and debrief before and aftersurgery and it is recommended that similar checklists are used forprocedures. The Chief Executive Officer advised that the Trust’scompliance is reported as red because the target is 100% absolute.The Chairman added that the target threshold has no tolerance onnever events. Mrs Pandit reassured the Board that measures are inplace to ensure that the Trust is as good as it can be.

Mrs Nolan clarified that the financial risk rating forecast for the year enddeclared as 3.0 within the PMR, differs from the in month actualposition reported to the Finance and Performance Committee onMonday 25th June 2012, which was 2.9.

Mrs Nolan requested that the word hopefully be removed from thecomments section for criteria 4 ‘Quality: All cancers 62-day wait for first



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treatment’ on page 3 of the PMR.

It was noted that a further detailed performance report in relation toA&E will be presented in the private session of the Trust Board today.

Dr Sabapathy queried whether there were any common trends in termsof which days experienced a higher volume of patients and whetherthis is related to delayed discharges. He suggested that the issueneeds to be reviewed internally to identify bottlenecks; however, heconceded that whilst work can be done internally, external influenceswill have a significant impact i.e. lack of availability of beds in thecommunity. Ms Tubb advised that Mrs Beamish has undertakenanalytical work in relation to when the A&E target is not being met andsuggested that further expansion of this discussion would be useful inthe private session of the Trust Board today.

The Chairman noted that there is a variable pattern of when patientsare discharged. Common issues within the local health economy factorinto the delayed discharge of patients i.e. aging population,demographics, frail and poorly patients that do not requirehospitalisation occupying hospital beds. He suggested that furtherdiscussion continue in the private session of the Trust Board.

The Chairman noted his gratitude to all Executive colleagues but to MrsBeamish in particular for the work she is undertaking. He added thatthe Trust Board offer support and encouragement to Executivecolleagues to continue with this work, which must demonstrate that thetrajectory is going in the right direction from June onwards.

The Trust Board to APPROVED the Provider Manager Regime returnbased on May 2012 data for onward submission to the SHA. The TrustBoard CONFIRMED its support for Governance Declaration 2 (forinsufficient assurance that all targets are being met) in relation to A&E.

HTB 12/299FINANCE REPORT

The purpose of the report is to update the Trust Board as to thefinancial position of the Trust for the first two months of the 2012/13financial year and the forecast year end position.

The Chairman advised that he did not wish to stifle discussion;however, there will be significant and lengthy discussions held on theprivate session of the Trust Board today due to the sensitivity of thisitem. He added that discussions will feature around the Board’sapproach to Foundation Trust status.

Mrs Nolan advised that the paper presented today is an extract of thepaper presented to the Finance and Performance Committee onMonday 25th June 2012. The month 2 position is a net expendituredeficit position of £2.7m, which is in line with plan. The forecast surplusremains at £2.5m

£2.4m of additional savings over and above the original CIPrequirement are necessary to achieve the £2.5m surplus forecast.£12.7m of QIPP reductions are currently built into the income forecast.Plans for these reductions are not yet finalised by Commissioners. If



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these are realised in future months the associated expenditure needsto be removed from group positions. Plans to remove the expenditurehave not yet been finalised.

Procedural Note: Mrs Coy joined the meeting.HTB 12/299FINANCE REPORT

The Chairman advised that discussions and decisions will be made inthe private session of the Trust Board this afternoon.

The Trust Board APPROVED the content of the report in particular theTrust financial position in Month 2 of 2012/13.

HTB 12/300PEFORMANCEREPORT

The purpose of the report is to update the Trust Board on the currentoperational performance position for the Trust against the national DHand Monitor performance frameworks and the regional Midlands andEast SHA performance framework.

Mrs Beamish noted that there were some anomalies contained withinpage 2 the report. Within the summary of key risks, the targets posing achallenge for 2011/12 should be amended to 2012/13. Within theimplications section it is noted that financial penalties may be appliedby Primary Care Trust’s if 2012/13 CQUIN and Quality Scheduletargets and standards are not achieved. The worst case scenario is2% of the 2012/13 contract value for Quality Schedule targets andstandards and 1.5% of the contract value for not achieving the CQUINtargets. Mrs Beamish noted that it should be amended to 2% of thecontract value for not achieving the CQUIN targets.

It is noted that on pages 6 & 7 of the report there are a significantnumber of areas being delivered. A&E and delayed transfers of careremain the main challenges. The Trust is continuing to workcollaboratively with partners in the local health economy.

Dr Sabapathy drew the Board’s attention to page 10 of the report andthe comment that there were (5 reported cases of MRSA in April and 6in May); however, this contradicted the earlier statement that therewere cumulatively to May 2012 0 MRSA infections. Mrs Beamishconfirmed that this was an error and reassured the Board that therehave been 0 MRSA infections cumulatively to May.

The Trust Board:-

NOTED the changes to the Monitor Compliance framework forsome indicators.

ENDORSED the following key actions being undertaken bymanagement to address the exceptions highlighted in Section3 of the report:

A&E: Maximum waiting time of four hours from arrival toadmission/transfer/discharge: UHCW has developed tworobust action plans: one focusing on front door improvementsand the other discharge planningDelayed transfers of care: The Trust has an internal DischargeAction Plan and there are also specific relevant actions in theArden Cluster work plan



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ENDORSED the actions being undertaken by management toaddress the challenging targets highlighted in Section 4 of thereport.

HTB 12/301RADIATIONPROTECTIONANNUAL REPORT

The Ionising Radiation Regulations 1999 and the Ionising Radiation(Medical Exposure) Regulations 2000 place a number of statutoryduties and responsibilities on the employer. The Radiation ProtectionAdvisor (RPA) provides advice to the employer on compliance withcurrent legislation and good practice

The Radiation Protection Committee (RPC) is responsible foroverseeing the management of radiation protection within the trust; tomonitor activities and incidents; to ensure that RPA advice is followed;and to report to the Patient Safety Committee.

Overall responsibility for compliance lies with the Chief ExecutiveOfficer of the Trust and is a requirement that the annual RPA report isreceived at board level. This report provides an update on patientsafety, staff and visitor safety and environmental impact.

Mr Sawdon queried why a strategy to tackle the issues in relation toadverse events within nuclear medicine would not be ready prior toOctober 2012. Mrs Beamish advised that lead lined rooms takeconsiderable organisation and planning to ensure the correct materialsare used whilst services are maintained during this period.

In response to a question from Mr Robinson, Mrs Beamish advised thatthe Radiation Protection Advisor reviewed the terms of reference inrelation to regulatory requirements and membership.

Dr Sabapathy queried whether other Trusts use similar systems. MrsBeamish confirmed this to be the case and added that incidents arereported nationally and locally to share learning.

Dr Sabapathy queried why MRI’s were not included within section 2.2‘dose reference levels’. Mrs Beamish reassured the Board that allequipment is checked as part of a three yearly dose audit. She addedthat she would be happy to answer any specific questions outside ofthe meeting.

In response to a query from Dr Sabapathy in relation to events reportedon wards 25 and 35, Mrs Beamish confirmed that these relate toseparate events.

Mr Sawdon queried which Committee this reports to; Mrs Panditresponded that she would seek clarification and confirm this with MrSawdon.

In response to a question from Dr Sabapathy in relation item 3.3‘environmental monitoring, Mrs Beamish advised that further planningis required before remedial work can be commenced.

The Trust Board RECEIVED the annual report as part of its assurance

Mrs Pandit



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process.

HTB 12/302FINANCE ANDPERFORMANCECOMMITTEEMEETING REPORT– 23rd APRIL 2012

The purpose of the report is to advise the Trust Board of the Financeand Performance Committee meeting held on 23rd April 2012.

The Trust Board ACCEPTED the contents of the report.

HTB 12/303PATIENT ANDSTAFF STORY

Under the Trust Board’s Patient Story Programme, the Trust is askedto consider the experience of a urology patient at University Hospitalduring February 2012 under the care of Mr Tony Blacker, ConsultantUrologist, Mr Ross Palmer, Modern Matron and staff on Ward 33.

Mrs Watts advised that this was a demonstration of how a patient hadtaken control of their own care. She added that it represents howpatients make informed choices of where they want to have treatmentby undertaking research of procedures, consultants, league tables andcredibility of Trust’s.

Mrs Watts progressed to reading a passage of the patient’s letter to theBoard “Me, I’m frightened of everything in hospitals. But where otherhospitals have promised to help me but invariably failed to deliver,University Hospitals Coventry delivered on everything. Several daysbefore I was admitted for surgery, I was allowed to meet myanaesthetist, my ward manager and the modern matron supervisingthat group of wards. In negotiating with them, I had the sense that theremust be some very good and appropriate management at UniversityHospital Coventry. At every stage, I felt that, subject of course tonecessary safety considerations, they put the patient first and not theirprocedures first. I didn’t feel, as I so often have felt with hospitals, that Iwas dealing with an inflexible bureaucracy. I felt I was being listened to,and procedures were being modified to help me. But I also really liked it– thank you all of you at Coventry – that you were totally straight whereyou disagreed with me. Because I knew you were listening to me, I wasable to listen to you.”

Mr Robinson acknowledged that this was a very passionate andpowerful statement and demonstrates a level of commitment from staffwhich should be commended.

Dr Sabapathy agreed that this was an excellent example of goodpractice; adding that the challenge is sharing this with other areaswithin the Trust.

The Chairman proceeded to read a further passage of the letter “IfTony Blacker, and the anaesthetist, modern matron, ward manager,nurses, radiographers, secretaries, receptionists and urology managerwhom I met at University Hospital Coventry are the future for the NHS,it is, for all its current difficulties, a very bright future.” He added thatthis reflects the personal service offered by staff which merits greatcredit to the people who work in the Trust.

Mrs Coy queried how this good practice will be shared throughout the



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organisation. Mrs Watts advised that ordinarily this would be donethrough the In-touch newsletter, all user message and picked upthrough the modern matron meetings.

The Trust Board:-

ACCEPTED the report and the learning contained in it THANKED the staff praised in the report AUTHORISED its wider dissemination across the Trust for

sharing of good practice

HTB 12/304FOUNDATIONTRUSTAPPLICATION

The purpose of the report is to provide an update on the progress andtimeline for Foundation Trust status application.

UHCW NHS Trust is currently proposing a revised submission date tothe DH of 1st June 2013. It is noted that since the submission of Boardpapers, verbal agreement from the DH has been received.

The Trust Board RECEIVED and ACCEPTED the contents of thereport.

HTB 12/ 305ANY OTHERBUSINESS

There was no other business for discussion.

HTB 12/306QUESTIONS FROMTHE PUBLIC

In response to a question from the public, the Chairman confirmed thathe stated at the previous public meeting of the Trust Board in May that95% of consultants are very dedicated. He added that this was ageneral comment on human nature. It would be naïve to accept thateveryone is perfect. The Chairman emphasised that he does believethat there are remarkable human beings working at every level, whichreaffirms his faith in human nature.

HTB 12/307DATE OF NEXTMEETING

The date of the next meeting is Wednesday 25th July 2012 at 1.00pm inthe Main Hall, The Benn Hall, Newbold Road, Rugby, CV21 2LN.

HTB 12/308APPROVAL OFMINUTES

These minutes are approved subject to any amendments agreed at thenext Trust Board meeting.

SIGNED……………………………………………..

CHAIRMAN

DATE……………………………………………..

UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUSTACTIONS UPDATE: PUBLIC TRUST BOARD MEETINGS

25th

July 2012

NB Items in blue have been completed

- 1 -

AGENDA ITEM ACTION LEAD COMMENTACTIONS IN PROGRESSHTB 12/119 (28.03.12)PERFORMANCEREPORT

The Trust Board RECOMMENDS that theChairman and Chief Executive Officer seek andsecure a meeting with the Chief Executive Officerand Chair of the Arden Cluster Board and thelocal Authorities and agree to the singleownership of patient discharges across theeconomy.

Chairman CEO advised thatChairman is toprogress

HTB 12/295 (27.6.12)SERIOUS INCIDENTGROUP REPORT

Mrs Pandit AGREED to review the mortality dataand feedback to Quality Governance Committee.

Mrs Pandit

HTB 12/301 (27.6.12)RADIATIONPROTECTIONANNUAL REPORT

Mr Sawdon queried which Committee this reportsto; Mrs Pandit responded that she would seekclarification and confirm this with Mr Sawdon.

Mrs Pandit

ACTIONS COMPLETEHTB 12/174 (25.4.12)QPS REPORT

The Chairman requested that efforts are made tofacilitate the production of a detailed report that ispresented in a more timely manner.

Mrs M Pandit Will be addressed aspart of the integratedperformance report.Next report is dueJuly 2012.

HTB 12/237ICT ANNUAL REPORT

The Trust Board acknowledged the draft ICTStrategy for 2012 to 2015 and requested that a fullstrategy be presented to the Trust Board,following approval at the Chief Officers Group.

Mrs Watts Scheduled for July2012 (privatesession)

REPORTS SCHEDULED FOR NEXT MEETING

REPORTS SCHEDULED FOR FUTURE MEETINGSHTB 12/061 (29.2.12)CHIEF EXECUTIVESREPORT

The Chief Executive Officer highlighted to theTrust Board that he had recently attended a ChiefExecutive’s meeting of the Association of UnitedKingdom University Hospitals (AUKUH) and wenton to outline the key benefits of AUKUH. It wasAGREED the he would present a briefing paperon Academic Health Science Networks at a futureTrust Board meeting.

Mr I Crich would present a paper on the future ofmedical education

Mr A Hardy

Mr I Crich

Mr A Hardy topresent paper onAcademic HealthScience Networks.Scheduled forSeptember 2012

February 2013

HTB 12/015 (25.01.12)HIEC

The Trust Board was, however, of the opinion thatthe decision on what role UHCW would play in thedevelopment an Academic Health SciencesNetwork and allocation of resource to leadaccordingly should be REVIEWED at a futureTrust Board.

Mrs C Watts Decision on role ofUHCW to bereviewed at a futureTrust Board. The nextHIEC report isscheduled forOctober 2012

HTB 11/520 (30.11.11)RESEARCH ANDDEVELOPMENTANNUAL REPORT

The Trust Board also AGREED that a Researchand Development strategy be presented at afuture Trust Board meeting to be considered foradoption.

Mrs M Pandit Deferred R&DStrategy to bepresented at futureTrust Board meetingfollowing approval atCOG and StrategyGroup. Scheduled forSeptember 2012.

HTB 12/183 (25.4.12) The Trust Board REQUESTED a progress report Mrs M Pandit Scheduled for

UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUSTACTIONS UPDATE: PUBLIC TRUST BOARD MEETINGS

25th

July 2012

NB Items in blue have been completed

- 2 -

AGENDA ITEM ACTION LEAD COMMENTMEETING THE SHAAMBITION TO MAKEEVERY CONTACTCOUNT (MECC)

to be presented in six months’ time. October 2012.

HTB 12/230 (30.5.12)EDUCATION REPORT

The Trust Board RECEIVED the report andSUPPORTED the work undertaken by Mr Fraser.The Chairman requested that the issue ofeducation be referred to the Training, Educationand Research Committee with a view to exploringmatters of research, development and educationto be brought back to the Trust Board as part ofthe strategic objectives of the Trust, and willfeature as part of the scheduled Education reportin November.

Mrs Pandit Scheduled forNovember 2012

ACTIONS REFERRED TO TRUST BOARD SUB-COMMITTEES


REPORT TO THE TRUST BOARD: PUBLIC

25th

July 2012

Enc 3 - Chairman's report June 2012 I/\trust board\templates\revised header public\Version 2\January 2010

Subject: Trust Board Meeting Session Reports of 27th

June 2012Report By: Philip Townshend, ChairmanAuthor: Jenny Gardiner, Trust Board SecretaryAccountable Executive Director: Philip Townshend, Chairman

GLOSSARY

Abbreviation In FullToR Terms of ReferenceGEH George Eliot Hospital

WRITTEN REPORT (provided in addition to cover sheet)? Yes No

POWERPOINT PRESENTATION? Yes NoNB Presentations need to be submitted for inclusion in Board papers

TitleApprox. Length

PURPOSE OF THE REPORT / PRESENTATION:

To advise the Board of the private Trust Board Session meeting agenda 27th

June 2012, and of any keydecisions/outcomes made by the Trust Board.

SUMMARY OF KEY ISSUES

Chairman’s Report: Mr P Townshend, ChairmanThe Trust Board NOTED the Chairman’s reportA&E Performance: Mrs S Beamish, Interim Chief Operating Officer

The Trust Board:-

ENDORSED the Chairman to take action to facilitate a meeting in July of key players in the local healtheconomy to discuss the 4 hour A&E performance target.

REQUESTED that a survey be performed to provide an account of how and why patients arepresenting to A&E and the findings presented to the Trust Board in July 2012.

ENDORSED the action plan as the agreed way forward.Chief Executive’s Report: Mr A Hardy, Chief Executive OfficerThe Trust Board NOTED the Chief Executive Officer’s report.Risk Register: Mrs M Pandit, Chief Medical OfficerThe Trust Board RECEIVED and ACCEPTED the report detailing the “high” risks as identified on the riskregister.Quality Strategy: Mrs M Pandit, Chief Medical OfficerThe Trust Board APPROVED the quality strategy.Quality Account: Mrs M Pandit, Chief Medical OfficerThe Trust Board APPROVED the 2011-2012 Quality Account, Quality Account Summary, Clinical Audit &CQUIN supplements. The Board ENDORSED the Chairman and Chief Executive Officer to sign the statementof Directors responsibility and the PWC Representation letterWorcestershire Acute Non-Surgical Oncology: Mrs M Pandit, Chief Medical OfficerThe Trust Board APPROVED the progress of partnership working.Consultation Response – Children’s Services at GEH: Mr A Hardy, Chief Executive Officer

The Trust Board;

RECEIVED and ACCEPTED the report



25th

July 2012


AGREED to participate in the consultation by providing a formal consultation response

AGREED to write to the Arden Cluster to formally raise concerns in relation to the late notification ofthe consultation launch and the lack of opportunity for UHCW Trust Board to approve the consultationprior to the launch date.

AGREED to continue discussions with lead clinicians and provide an update on progress at the privatesession of the Trust Board in July 2012.

Preparation for the Olympics: Mrs S Beamish, Interim Chief Operating OfficerThe Trust Board RECEIVED the report and APPROVED the actions being taken to prepare for the OlympicGames.Quality Governance Committee Draft Minutes of the Meeting – 12

thJune 2012: Mr T Sawdon, Non-

Executive DirectorThe Trust Board ACCEPTED the Quality Governance Committee meeting report of 12

thJune 2012.

Update from the Dean: Professor P Winstanley, Dean of Medicine, Warwick Business SchoolThe Trust Board NOTED the verbal update provided by Mrs Coy in the absence of the Dean.Service Review Update: Mrs G Nolan, Chief Finance Officer

The Trust Board:

AGREED to receive a report at the Trust Board in July from the Planning Unit AGREED the principles and process to be adopted as set out in the paper and the delivery framework SUPPORTED the timelines and resource implications to complete the underpinning work to align the

IBP/LTFM AGREED that external opportunities are pursued by the Chief Executive Officer AGREED that a report of the baseline assessment from the PMO diagnostic should be made by the

Chief Finance Officer to Finance and Performance Committee (F&PC) meeting in July 2012. REQUESTED that F&PC advised by Chief Officers Group establish the criteria and performance

measures to define what constitutes strong/weak performance for delivery of the UHCW strategy andto recommend these to the Trust Board for approval.

APPROVED the governance arrangements for this stream of work AGREED that regular feedback on progress with this work is reported by the Chief Finance Officer to

F&PC to address barriers and to keep the exercise on track, with exception reporting to the Board tobe determined by the Chair of F&PC.

Board Seminar Update: Mr I Crich, Chief HR Officer

The Board RECEIVED an update on the discussions held at the Board Seminar held on 13th

June 2012 andAPPROVED the recommendations.Remuneration Committee ToR: Mr P Townshend, ChairmanThe Trust Board APPROVED the revisions to the Terms of ReferenceRemuneration Committee Meeting Report – 7

thJune 2012: Mr P Townshend, Chairman

The Trust Board ACCEPTED the Remuneration Committee meeting report of 7th

June 2012.Draft Audit Committee Meeting Report – 1

stJune 2012: Mr T Robinson, Non-Executive Director

The Trust Board ACCEPTED the Audit Committee meeting report of 1st

June 2012.Draft Finance and Performance Committee Meeting Report – 28

thMay 2012: Ms S Tubb, Senior

Independent DirectorThe Trust Board ACCEPTED the Finance & Performance Committee meeting report of 28

thMay 2012, subject

to amendments.



25th

July 2012


National Staff Attitude and Opinion Survey Results: Mr I Crich, Chief HR Officer

The Trust Board;

AGREED the proposed action plan to address the 2011 National Staff Survey findings. SUPPORTED the recommendation to run the next in house Staff Impressions survey in early

September which will be informed by the 2011 National Staff survey results.

SUMMARY OF KEY RISKS:

No risks were identified.

RECOMMENDATION / DECISION REQUIRED:

For Noting.

IMPLICATIONS:

Financial: N/A

HR / Equality & Diversity: N/A

Governance: N/A

Legal: N/A

REVIEW:

Trust Standing Committee Date Trust Standing Committee DateQuality Governance Committee Remuneration CommitteeFinance and Performance Committee Executive MeetingAudit Committee

DATA QUALITY:

Data/information Source: Reports provided to the private session of the Trust Board held on 27th

June2012

Data Quality Controls:Data Limitations:



JULY 2012

Trust board/templates/header sheet (public) version 4 – July 2011

Subject: QPS Quarterly Trust Board Report – July 2012 Report By: Meghana Pandit – Chief Medical Officer Author: QPS Department Accountable Executive Director: Meghana Pandit – Chief Medical Officer

GLOSSARY

Abbreviation In Full CAE/CAEs Clinical Adverse Event/s CQUIN Commissioning for Quality & Innovation ITU Intensive Therapy Unit HSMR Hospital Standardised Mortality Ratio NHSLA National Health Service Litigation Authority SHMI Summarised Hospital Mortality Index

QPS Quality Patient Safety

WRITTEN REPORT (provided in addition to cover sheet)? Yes No POWERPOINT PRESENTATION? Yes No NB Presentations need to be submitted for inclusion in Board papers Title Approx. Length

PURPOSE OF THE REPORT / PRESENTATION: To appraise the Board of the quality and patient safety issues for quarter 1 January 2012 – 31 March 2012

SUMMARY OF KEY ISSUES:

See pages 2 - 4 of the report

SUMMARY OF KEY RISKS: Summarised above


To receive quarterly QPS report 1 January 2012 – 31 March 2012

IMPLICATIONS:

Financial: HR / Equality & Diversity: Governance: None Legal:



JULY 2012

Trust board/templates/header sheet (public) version 4 – July 2011

REVIEW: Trust Standing Committee Date Trust Standing Committee Date Quality Governance Committee Remuneration Committee Finance and Performance Committee Executive Meeting Audit Committee

DATA QUALITY:

Data/information Source: Datix; Dr Foster Intelligence; Impressions; Quality & Effectiveness Audit Project Database; UHCW E-Library

Data Quality Controls: Internal quality checksData Limitations:

Quality & Patient Safety Report Quarter: 1 January 2012 – 31 March 2012

Prepared for Trust Board July 2012

1 of 19

CONTENTS & KEY POINTS

This quarterly report is based on the latest information available to Quality & Patient Safety (formerly Governance Unit). As there is a time lag with receiving some information (such as clinical adverse events, clinical activity and mortality data), the reporting periods within the report differ between sections. Please refer to the section headings for the data period used within each dashboard report. Where information is presented as quarterly trends the data is capped at the last full quarter so that the analysis is not skewed by missing or incomplete data. For the purposes of this report, quarters are shown according to calendar year.

1.0 PATIENT SAFETY REPORT Prepared by: Yvonne Gatley – Associate Director of Governance Page 5

Quarterly report on Clinical Adverse Events January 2012 – March 2012 • Incident reporting continues to rise month on month, indicating a continuing “open” culture regarding clinical risk management. This equates to approximately 7%

of total in-patient activity (10% being the figure quoted by patient safety expert Charles Vincent as the approximate proportion of inpatient episodes leading to harmful events).

• In our peer group of acute teaching hospitals the most recent National Patient Safety Agency (NPSA) report shows UHCW as being 6th out of 27 Trusts in terms of our reporting rate which the NPSA says indicates an open safety culture that supports improvement. The same report shows that the vast majority of reports are “no harm” incidents and our rate of severe harm and death incidents for the period April – September 2011 is 0.20% compared with our peer average of 0.15%

• Top 5 CAEs: There has been no change in the top 5 reported CAEs since the last quarter.

• Slips, Trips and Falls remains the most frequently occurring patient safety incident. As previously reported, many measures have been implemented to minimise the risk to patients. If serious harm occurs to a patient as a result of a fall, the incident is treated as a serious incident requiring investigation (SIRI) and a root cause analysis is undertaken

• Pressure ulcer reporting continues and is essential for informing the Trust’s target of no avoidable pressure ulcers. Root cause analysis is conducted on all grade 3 or 4 pressure ulcers to ensure any trends are identified and fed back into practice. 206/342 of the reports were for patients admitted with pressure ulcers.

• Medication errors mostly related to administration or supply of a medicine (114), 40 reports were relating to prescription and 32 reports were relating to preparation of medicines. The rest were in other categories of medication incident. Medication incidents continue to be targeted for action as part of the Trust’s Patient Safety First strategy.

• Failure to follow guidelines/procedure/policy The majority of these were reported by Sterile Services regarding non-compliance with theatre checking/documenting of instrument trays. This is an operational management issue and is being dealt with by the management teams.

• Postponed or cancelled surgery The majority of these were reported by Cardiothoracic Surgery and relate mostly to lack of ITU beds.

2.0 MORTALITY REPORT Prepared by: Paul Martin – Director of Governance Page 7

3.0 QUALITY & EFFECTIVENESS REPORT Prepared by: Victoria Brownsword – Quality & Effectiveness Co-ordinator Page 10

Quarterly Dr Foster Mortality Report for 1 January 2012 – 31 March 2012• HSMR for Q4 2012 is 90.4

· Non elective 90.9 • HSMR for the last 12 months is 94.4

· Non elective 94.3 • HSMR shows a continued downward trend • There have been 7 green alerts and 2 red alerts recorded between January and March 2012. The red alerts were for Bariatric Operations and Abdominal Aortic

Aneurysm (AAA) and these are currently being investigated.

2 of 19

3.0 QUALITY & EFFECTIVENESS REPORT Prepared by: Victoria Brownsword – Quality & Effectiveness Co-ordinator Page 9

Clinical Audit: 1 January 2012 – 31 March 2012

• Refer to the Trust Board Report for specific risks highlighted. • The Quality & Effectiveness Facilitators are currently working with audit leads to finalise 2011/12 audits of which only approximately 14% have not yet reached

report writing stage. This percentage includes national audits which we have submitted data to and a national report has not yet been published. • A proposal for a revised process for the Trust wide documentation and consent audit was approved at the March Patient Safety Committee. Specialties will be risk

assessed on a risk versus benefit matrix to specify how frequent an audit should take place. The revisions aim to engage clinical staff and focus on driving improvements. The Quality & Effectiveness Facilitators are currently in the process of finalising the data collection tools and are communicating with specialties to identify data collectors for the audit.

• The Clinical Audit and Effectiveness Forward Programme for 2012/13 was approved at the March Patient Safety Committee. The programme contains two plans – mandatory and local. The mandatory plan is rolling, to reflect the variety of deadlines imposed by National bodies. The team of Quality and Effectiveness Facilitators will be working with audit leads to profile their programme of audit work across the financial year.

Clinical Guidelines

• With the introduction of the new Procedure for the Development and Management of Clinical Guidelines the focus for 2012 is to improve the quality of clinical guidelines stored on elibrary. Authors are offered assistance from CEBIS Specialist/Subject Librarians with literature searching. There is also a more detailed structure to help with the development of clinical guidelines.

• Guidance is reviewed against set criteria to decide if it is a clinical guideline or a clinical operating procedure. Definitions are:- • COP- A set of instructions that describe the method for carrying out tasks or activities to ensure efficiency, consistency and safety. • Clinical guidelines are systematically developed statements designed to help practitioners and patients decide on appropriate healthcare for specific

clinical conditions and/or circumstances • With the introduction of the new Document management system this is the time to review your guidance ensuring only accurate up to date information is saved on

elibrary ready to be transferred to the new system.

4.0 COMPLAINTS REPORT Prepared by: Sharon Wyman - Complaints Manager Page 12

Quarterly report on Complaints received: Jan 2012 – Mar 2012

• For the quarter Jan 2012 – Mar 2012 we experienced a decrease in the number of complaints against the previous quarter. • 10% of complaints did not receive a formal response within our internal standard of 25 working days - due to complexity or lack of a timely response on 16 cases. • Details on those requiring further local resolution and complaints referred to PHSO.

5.0 IMPRESSIONS REPORT Prepared by: Julia Flay - PPI Facilitator Page 15

• Quarter April 2012 – 31 June 2012 for all respondents • Due to the management restructure, Impressions data for the period April – June 2012 won’t be available until mid July. Please contact Julia Flay, Patient

Involvement Facilitator, on extension 25186 should your require further details.

3 of 19

6.0 NON-CLINICAL RISK REPORT Prepared by: Dipak Chauhan - Head of Safety and Non Clinical Risk Page 16 • This report summarises incident data trends and patterns for the quarter 1 January 2012 – 31 March 2012 • The report is primarily for information and highlights some key themes and issues in regard to Non Clinical Risk management (Occupational Safety, and Health,

Security and Fire)

7.0 LEGAL CLAIMS REPORT Prepared by: Julie Midgley – Trust Solicitor Page 19 Quarterly report on Claims received: 1 January 2012 – 31 March 2012 • The Trust currently has 349 cases. The NHSLA’s contingent financial provision in respect of Clinical Negligence claims is currently £32 million. • In the last 12 months the Legal Department has received 112 new claims with 29 being received in the period of January to March 2012. • The 3 highest risk specialties are Obstetrics, Accident and Emergency and Orthopaedics. • The level of damages paid during the period January to March 2012 was £ 2,538,965 (to include Periodical Payments to patient for life).

4 of 19

1.0 PATIENT SAFETY (All reports based on Clinical Adverse Event (CAE) incident dates) – January 2012 – March 2012

1.1 CAEs reported by month – 12 months trend (Apr 11 – Mar 12)

Total number of CAEs reported - 11567

984

782

946

933914

10021060980

992

1034

994

946

0

100

200

300

400

500

600

700

800

900

1000

1100

1200

Apr 11 May 11 Jun 11 Jul 11 Aug 11 Sep 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12

No

of C

AEs

1.2 CAEs reported by Grade – last 12 months

0

100

200

300

400

500

600


High - Red

Low - Amber

Moderate - Blue

Very low - Green

Performance Indicator: Results of a UK pilot study of adverse events in hospitalised patients Proportion of inpatient episodes leading to harmful events

10% (around half preventable)

Source: Vincent C. A. (2000). Presentation at BMJ Conference ‘Reducing Error in Medicine’. London. In DH (2000). An Organisation with a memory: Report of an expert group on learning from adverse events in the NHS chaired by the Chief Medical Officer.

FCE's Jan 12 – Mar 12 (These figures are fasttrack)

Total In-Patient Activity No of CAEs reported during

quarter CAEs as % of in-patient

activity

41282 2956 7.16%

5 of 19

1.4 Top 5 Types of CAEs – Trend over 12 months

0

20

40

60

80

100

120

140

160

180

200

220

240

260

280


All Medicationincidents

Postponed orcancelled surgery

Slips, trips, falls andcollisions

Failure to followguidelines/procedures/policy

All Pressure Ulcers

1.3 Top 5 Types of CAEs – (Jan 12 – Mar 12)

Slips, trips, falls and collisions 771

Pressure sore / decubitus 342

Medication 212

Failure to follow guidelines/procedures/policy 160

Postponed or cancelled surgery 58

6 of 19

DR FOSTER MORTALITY REPORT TRUST BOARD – July 2012

SUMMARY FOR DR FOSTER DATA – 30th April 2012 (2 Month Time Lag)

Month All HSMR Non-Elective HSMR All Procedures Peer Group (12) April 2012 103.2 100.3 105.4 88.1 May 2011 – Apr 2012 94.3 94.3 89.8 95 Month Red Alerts Green Alerts High Relative Risk April 2012 0 5 0

All HSMR Trend: May 2011 – Apr 2012

0

20

40

R

60

80

100

120

May

-11

Jun-

11

Jul-1

1

Aug-

11

Sep-

11

Oct

-11

Nov

-11

Dec

-11

Jan-

12

Feb-

12

Mar

-12

Apr-

12

elat

ive

risk

Relative risk National bench mark

Peer Group (12) HSMR Trend: May 2011 – Apr 2012

0

20

40

60

80

100

120

Uni

vers

ity H

ospi

tals

Of L

eice

ster

NH

STr

ust

Not

tingh

am U

nive

rsity

Hos

pita

ls N

HS

Trus

t

Hea

rt O

f Eng

land

NH

S Fo

unda

tion

Trus

t

Oxf

ord

Uni

vers

ity H

ospi

tals

NH

S Tr

ust

Uni

vers

ity H

ospi

tal O

f Nor

thSt

affo

rdsh

ire N

HS

Trus

t

Cam

brid

ge U

nive

rsity

Hos

pita

ls N

HS

Foun

datio

n Tr

ust

Uni

vers

ity H

ospi

tals

Cov

entry

and

War

wic

kshi

re N

HS

Trus

t

Uni

vers

ity H

ospi

tals

Bris

tol N

HS

Foun

datio

n Tr

ust

Sand

wel

l and

Wes

t Birm

ingh

amH

ospi

tals

NH

S Tr

ust

Wor

cest

ersh

ire A

cute

Hos

pita

ls N

HS

Trus

t

Uni

vers

ity C

olle

ge L

ondo

n H

ospi

tals

NH

S Fo

unda

tion

Trus

t

Uni

vers

ity H

ospi

tals

Birm

ingh

am N

HS

Foun

datio

n Tr

ust

Roy

al L

iver

pool

and

Bro

adgr

een

Uni

vers

ity H

ospi

tals

NH

S Tr

ust

Rel

ativ

e Ri

sk

National bench mark Relative Risk

7 of 19

++ Peer Group (12): Cambridge UH NHS FT, Heart of England NHS FT, Nottingham UH NHS Trust, Oxford Radcliffe Hospitals NHS Trust, Royal Liverpool & Broadgreen UH NHS Trust, Sandwell & W.Bham Hospitals NHS Trust, University College Hospitals NHS FT, University Hospital Bham NHS FT, UH North Staffordshire NHS Trust, UH Bristol NHS FT, UH Leicester NHS Trust, Worcester, Acute Hospitals NHS Trust

8 of 19

3.0 QUALITY & EFFECTIVENESS REPORT - TRUST BOARD JULY 2012

This report includes all clinical audits within the approved Clinical Audit & Effectiveness Programme for 2012/13.

Completion' is defined as those audits completed in this financial year (where that is appropriate) the findings have been presented or

where action plans have been developed and the benefit measured from completing the audit.

3.1 Summary of Progress

The bar illustrates progress against the forward plan including Local and Mandatory audits:

Actual Completion 3%

Target Completion Rate/Quarter 0% 10% 40% 50%Not

initiated 41%

Q1 Q2 Q3 Q4 Data Collection 12%

Report Writing 3%

Completed 3%

3.2 Progress by Specialty Group

The table illustrates the number of stage 1 and stage 2 completed audits as at 25th June 2012

against the plan for each specialty group (excluding those audits abandoned):

No of Audits

Cardiac and Respiratory 11 0%

Renal 5 0%

ED 6 0%

Head & Neck 3 0%

Neurosciences 10 0%QIA/Non-

Participation 0%

Oncology/haematology 1 0% Abandoned 2%

Surgery 12 8% On Hold 1%

Trauma & Orthopaedics 6 0%

Women & Children's 28 0%

Imaging 1 0%

Anaesthetics 31 3%

Care of the elderly and Acute

medicine 15 0%

Theatres 11 0%

Ambulatory services 21 0%

Hospital of St Cross 0 0%

Other (Resuscitation, Palliative

Care, Dietetics, Infection Control,

Pharmacy, Nursing) 32 6%

46

Risk / Issues Identified

1

8

3.3 Continuous Data Collection Audits

0

1

1

7

24

14

0

15

8

1

Completed

0

Progress against the plan excludes continuous data collections audits, as they are ongoing and do not result

in a completed status.

Monitoring of these audits is performed in preparation for reporting in the Quality Accounts and through

the Patient Safety Committee.

2

Total number of Continuous data collection audits (including Local and Mandatory audits)

Quality & Effectiveness Department not informed of any risks to data

data submission

25th June 2012

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Not initiated Data Collection Report Writing Completed

Status of Audit

% o

f A

ud

its

0

0

0

0

0

1

0

0

1

0

0

3.4 Status of the 2012/13 Clinical Audit & Effectiveness Programme as at 25th June 2012

(excluding continuous data collection audits)

0

0

0

0

2

0%

2%

1%

QIA/Non-Participation Abandoned On Hold

Status of Audits

% o

f A

ud

its

3.5 Reason for Non-completion of 2012/13 audits as at 25th June 2012

9 of 19

3.6 Risks/Issues

Risk Description Consequence Likelihood Current Risk

20916284410102760

3.8 Outstanding Action Plans as at 25th June 2012

The following information presents the number of 2012/13 audits that have reached the second stage of completion and the action planning phase has commenced.

11100

3.9 Benefit Realisation from Clinical Audits as at 25th June 2012

The Quality and Effectiveness Department developed a process to capture the benefits realised from implementing recommendations from action plans.

The redesigned process commenced November 2011 and the results to date are captured and reported below for action plans for 2012/13.

Category of Benefit Change Required to Realise Benefit

No of audits

No of

audits

Patient and staff experience 1 People changes 1

Improved levels of safety 0 Process changes 1

Effectiveness of care 0 Technology changes 0

Links to performance 0 Other changes 0

Examples of Quantifiable Benefit

Audit Title

1444 - To Examine GP adherence to Best Practice

guidelines when referring patients with breast pain to

UHCW breast service

Description

Patients will be referred to the specialist unit

for appropriate reasons. Increased

education of primary care members of staff

Category of Benefit

Patient and staff experience

Specialty

Surgery - Breast

1. Potentially avoidable incidents

occurring due to failure to address

the recommendations from the

three successive National Falls

Audit reports.

Cardiac and Respiratory

3.7 Number of outstanding action plans by Specialty Group pre 2012/13:

18

Action proposed/ in place to

Renal EDHead & NeckNeurosciencesOncology/haematologySurgery

No change required

A lead has been identified to

address the

recommendations from the

audit reports.

Revised system for action

planning and capturing

realised benefits will support

improved evidence of

compliance but old reports

will remain a risk.

QaED is continuing to

support the Resuscitation

Team and ascertain

obstacles in preventing the

Trust from participating in

the audit.

3

2 2 4

Action plan implemented

9

3 4 12

3

Gap analysis for national audit

2. Adverse publicity and financial

penalties associated with non

compliance with NHSLA (Level 2

standard 5, criteria 1 & 9) due to

insufficient evidence of audit

recommendations being acted

upon for making improvements.

3. Failure to submit data to

ICNARC for National Cardiac

Arrest Audit (NCAA) due to inability

to accurately collect the real time

cardiac arrest data and outcome

data.

Trauma & OrthopaedicsWomen & Children'sImagingAnaesthetics & TheatresCare of the elderly and Acute medicineBloodAmbulatory services

Action plan approved and in progressAction plan to be developed

Hospital of St Cross

Other (Resuscitation, Palliative Care, Dietetics,

Infection Control, Pharmacy, Nursing)

1

0 0 0

Patient and staff

experience

Improved levels of

safety

Effectiveness of care Links to performance

1 1

0 0

People changes Process changes Technology

changes

Other changes

10 of 19

3.10 elibrary status report Trust Report Month: July 2012

Current Under Review Expired Total

All Directories 1876 78% 186 8% 330 14% 2392

Corporate Business Records 106 75% 11 8% 24 17% 141

Clinical Guidelines 572 60% 124 13% 258 27% 954

Patient Information Leaflets 1198 92% 51 4% 48 4% 1297

* Duplicates have been removed before calculating the data

11 of 19

4.0 COMPLAINTS TRUST BOARD REPORT (First Received Jan 12 – Mar 12)

4.3 Types of Complaints based on primary issue – (Jan 12 – Mar 12) Types of Complaints received Total Admissions, discharge and transfer arrangements 6 Appointments, delay/cancellation (out-patient) 1 Appointments, delay/cancellation (in-patient) 4 Attitude of staff 9 All aspects of clinical treatment 77 Communication/information to patients (written and oral) 17 Consent to treatment 1 Patients' privacy and dignity 1 Personal records (including medical and/or complaints) 1 Failure to follow agreed procedure 5 Totals: 122

4.1 Complaints received by month – Trend over 12 months

32

42

40

4243 43

54

44

37

41

44

35

20

30

40

50

60

Apr 11 May 11 Jun 11 Jul 11 Aug 11 Sept 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12

No

ofC

ompl

aint

s

4.2 Complaints received by Division – Trend over 12 months

0

5

10

15

20

25

Apr 11(32)

May 11(42)

Jun 11(40)

Jul 11(42)

Aug 11(43)

Sept 11(43)

Oct 11(54)

Nov 11(44)

Dec 11(35)

Jan 12(37)

Feb 12(41)

Mar 12(44)

Hotel & Core Services Division

Diagnostics & Service Division

Medicine & Emergency Division

Coventry & Warw ickshirePathology Services

Specialised Networks Division

Surgical Services Division

Women & Children's Division

4.4 Complaints received by Profession – (Jan 12 – Mar 12)

Jan 12 Feb 12 Mar 12 Total

Medical (including surgical) 21 28 25 74 Professions supplementary to medicine 1 1 0 2 Nursing, midwifery and health visiting 10 9 11 30 Scientific, technical and professional 0 2 0 2 Trust administrative staff/members 5 1 8 14 Totals: 37 41 44 122

12 of 19

4.5 No of Patients received in Trust – (Jan 12 – Mar 12)

No of Complaints for

patient activity during the Financial year

Complaints as % of patient activity

Division Action type Jan-12 Feb-12 Mar-12 Grand Total

Diagnostic & Service Daycase 149 155 177 481

Elective 38 33 29 100

Non Elective 97 105 97 299

Outpatient 372 345 409 1126

Diagnostic & Service Total 656 638 712 2006** 13 0.64%

Medicine & Emergency Daycase 808 865 1030 2703

Elective 41 36 50 127

Non Elective 3475 3374 3687 10536

Outpatient 9178 8803 8766 26747

A&E Emergency Assessment 7673 7365 7987 23025

Rugby A&E 0

Medicine & Emergency Total 21175 20443 21520 63138 45 0.07%

Specialised Networks Daycase 1502 1510 1697 4709

Elective 303 300 338 941

Non Elective 709 740 789 2238

Outpatient 10778 10517 10921 32216

Specialised Networks Total 13292 13067 13745 40104 10 0.02%

Surgery Daycase 1856 1892 2012 5760

Elective 847 960 1060 2867

Non Elective 946 923 985 2854

Outpatient 21670 20654 22407 64731

A&E Eye Unit 1200 1115 1247 3562

Surgery Total 26519 25544 27711 79774 32 0.04%

Womens and Childrens Daycase 243 318 307 868

Elective 130 140 133 403

Non Elective 2151 1945 2298 6394

Outpatient 7926 7552 7954 23432

A&E Childrens Emergency 2571 2535 2999 8105

A&E Gynae Short Stay 435 364 393 1192

Womens and Childrens Total 13456 12854 14084 40394 21 0.05%

Grand Total 75098 72546 77772 225416 121 0.05% Total complaints excluding Coventry & Warwickshire Pathology Services (1 complaint) ** reflects data captured on PAS only 13 of 19

Complaints Performance Summary by Division (Jan 12 – Mar 12)No of complaints completed within 25 working days – Trust target (performance shown as traffic light indicator)

Division Received Re-opened Acknowledged Acknowledged Replied Replied to Replied to Open for _ in 3 Days in 25 Days over 25 Days 25 Days _ Count Count Count % Count % Count % Count % Count % Count % Anaesthetics 1 0 1 100% 1 100% 1 100% 1 100% 0 0% 0 0% Diagnostics & Service Division 12 0 12 100% 12 100% 12 100% 11 92% 1 8% 0 0% Emergency Department 1 0 1 100% 1 100% 1 100% 1 100% 0 0% 0 0% Medicine & Emergency & Rugby Divisi 44 0 44 100% 44 100% 43 98% 38 86% 5 11% 1 2% Coventry &Warwickshire Pathology Se 1 0 1 100% 1 100% 1 100% 1 100% 0 0% 0 0% Specialised Networks Division 10 0 10 100% 10 100% 10 100% 9 90% 1 10% 0 0% Surgery 31 0 31 100% 31 100% 30 97% 29 94% 1 3% 1 3% Trauma and Orthopaedics 1 0 1 100% 1 100% 1 100% 1 100% 0 0% 0 0% Women & Children's 21 0 21 100% 21 100% 21 100% 17 81% 4 19% 0 0% TOTALS 122 0 122 100% 122 100% 120 98% 108 89% 12 10% 2 2%

4.6 Further contact following response under Local Resolution Between January 2012 and March 2012 there were 47 contacts made by complainants having received the outcome to their complaint and of these, 35 required a further response. The number of contacts the previous quarter was 40.

4.7 Complaints Referred to Parliamentary & Health Service Ombudsman (PHSO) Between January 2012 and March 2012 there were 3 complaint files requested by the PHSO, compared to 4 the previous quarter. 2 complaints were returned in this period which required further local resolution by the Trust.

14 of 19

5.0 IMPRESSIONS REPORT FOR TRUST BOARD April - June 2012

5.1 Due to the management restructure, Impressions data for the period April – June 2012 won’t be available until mid July.

15 of 19

6.0 Non-Clinical Risk: Trust Board Report for 01/04/12 to 31/03/12

6.1 Non-Clinical Incidents – Trend over 12 months

6.1 Incident Trend over 12 months A total of 1708 incidents were reported for the period 01/01/2011 to 31/12/11. The reporting trend shows a decrease in reporting for the 12 month period compared to the previous year (total number of incidents for 2010 was 2197).

6.2 Incident By Person Type or Property Affected

This bar chart shows the breakdown of incidents for Q4 for 2011 and 2012. As can be seen the majority of reported incidents relate to Staff. As with other incidents the general trend appears to be a downward reporting for 2012.

6.2 Non-Clinical Incidents by Division

16 of 19

Top 10 Incidents over 12

months Rolling Period Total Incidents by Detail and Incident

date Quarter 4 (1/4/12 to 31/3/12) Q4 Total

1 Abuse Staff by pat 421 1 Abuse Staff by Pat 56 2 Needle‐sharp 208 2 Needle‐sharp 45 3 Acc_Other 197 3 STF_collision 38 4 STF_collision 193 4 Acc_Other 38 5 Security Premises, Land or Real

Estate 168 5

Security personal Prop 26

6 Security personal Prop 153 6 Abuse ‐ other 22 7 Exposure to electricity,

hazardous substance, infection etc. 115

7 Exposure to electricity, hazardous substance, infection etc.

15 8 Abuse ‐ other 101 8 Lifting accidents 11 9 Lifting accidents 84 9 Security ‐ other 11 10

Security ‐ other 60

10 Security incident related to Premises, Land or Real Estate 10

6.3 Top 10 types of incidents reported (01/04/11 to 31/03/12)

The table shows that there is not much movement when compared with the top 10 incident type reported over Q4 or those relating to a 12 Month rolling period. The 1st two items are the same with STF and Accident Others respective 4 and 5 or vice a versa for the following year.


17 of 19

6.4 Non-Clinical Incidents by Person Type or Property Affected


The trend for the top five incidents identified in the Q4 figures on the whole show no significant trends accept for the Abuse of staff by patients.

18 of 19

7.0 CLAIMS TRUST BOARD REPORT (All reports based on date First Received) January 2012 – March 2012 7.1 Claims received by month – Trend over 12 months

7.2 Claims received by Division – Trend over 12 months

0

1

2

3

4

5

6

7

Apr 11 May 11 Jun 11 Jul 11 Aug 11 Sep11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12

DIAGSV

MEDEM

SPECNW

SURG

WOMEN

7.3 Types of Claims received – (January 12 – March 12)

Other 1

Fail/ Delay Treatment 8

Lack of pre-operative evaluation 1

Failure to diagnose/delay in diagnosis 8

Wrong diagnosis made 1

Intra-operative problems 5

Failure to warn (informed consent) 1

Inappropriate Treatment 2

Lack Of Assistance/Care 1

Foreign Body Left in Situ 1

Totals: 29

19 of 19



25th

July 2012

Trust board/templates/header sheet (public) version 6 – August 2011

Subject: Significant Incident & Mortality ReportReport By: Meghana Pandit, Chief Medical OfficerAuthor: Yvonne Gatley, Associate Director of Governance (Patient Safety)Accountable Executive Director: Meghana Pandit, Chief Medical Officer

GLOSSARY

Abbreviation In FullSI Significant incident



TitleApprox. Length


To provide the Trust Board with a quantitative summary of the significant incidents that were opened or closedduring June 2012 and Trustwide mortality data.

All SIs are reviewed at the weekly SI Group, who ensure that investigations are undertaken and appropriateactions are put in place to reduce identified risks.

Details of SI investigations are also presented monthly to the Patient Safety Committee and QualityGovernance Committee


SIs:See report 15 new SIs opened during June 2012: see report for details of types of incident 2 SI investigations completed during the month 13 ongoing investigations 1 potential Never Event (? Retained foreign body post-operatively)

Mortality:See report(April 2012)Red alerts: 0Green alerts: 2High relative risk: 4


Never events – the Trust has conducted a gap-analysis and continues to put in measures to minimise therisk of further never events. Compliance with the surgical safety checklist is monitored monthly.

Serious Falls – the Falls Group is putting additional measures into practice to mitigate the risks.



25th

July 2012



The Trust Board are asked to RECEIVE and ACCEPT the report.

IMPLICATIONS:

Financial:

HR / Equality & Diversity:

Governance: Patient Safety

Legal:

REVIEW:


DATA QUALITY:

Data/information Source: DATIX Risk Management SystemDr Foster RTMI

Data Quality Controls: Internal quality checksData Limitations:

SI/MORTALITY REPORT TO TRUST BOARD JULY 2012

- 1 -

Summary of SIs for June 2012

New this month (June): 15 Ongoing investigations: 13

Completed this month: 2 Never Events reported this month: 1

New SIs by Specialty and Type of Adverse Event

Acu

teP

hys

icia

ns

Car

dia

c/

Tho

raci

c

Surg

ery

Gas

tro

en

tero

logy

Ge

ne

ralS

urg

ery

Gyn

aeco

logy

Ge

ron

tolo

gy

Ne

on

ato

logy

Ne

uro

surg

ery

Ob

ste

tric

s

The

atre

s

Tota

l

Delay in obtaining medical device/ equipment 0 0 0 0 0 0 0 0 1 0 1

Equipment user error 0 0 0 0 0 0 0 0 1 0 1

Fall from a height, bed or chair 1 0 0 0 0 0 0 1 0 0 2

Missing equipment / device 0 0 0 1 0 0 0 0 0 0 1

Other - Infection control incident 0 0 0 0 0 0 1 0 0 0 1

Retainedneedle/swab/instrument 0 0 0 0 0 0 0 0 0 1 1

Fall on level ground 0 0 1 0 0 1 0 1 0 0 3

Unplanned admission / transferto specialist care unit 0 0 0 0 0 0 0 0 1 0 1

Unexpected deteriorationfollowing treatment/procedure 0 1 0 0 0 0 0 0 0 0 1

Delay or failure to monitor 1 0 0 1 0 0 0 0 0 0 2

Failure to act on adversesymptoms 0 0 0 0 1 0 0 0 0 0 1

Totals: 2 1 1 2 1 1 1 2 3 1 15

SI/MORTALITY REPORT TO TRUST BOARD JULY 2012

- 2 -

Completed SIs by Specialty and Type of Adverse Event

ObstetricsRespiratory

medicineTotal

Unintended injury in the course of an operation or clinicaltask 0 1 1

Failure/delay to order correct tests, image etc 1 0 1

Totals: 1 1 2

- 3 -

MORTALITY REVIEW GROUP - DR FOSTER MORTALITY REPORT – JULY 2012

SUMMARY FOR DR FOSTER DATA – APRIL 2012(2 Month Time Lag)

Month All All HSMR Non-Elective HSMR Elective HSMR All Procedures

April 2012 94.0 103.1 100.3 227.3 105

May 2011 – April 2012 92.2 94.3 94.3 93.3 89.8

Time period SHMI

Jul 2010 to Jun 2011 107.3

Oct 10 to Sept 11 105.25

All HSMR Trend: May 2011 - Apr 2012 Non-Elective HSMR Trend: May 2011 - Apr 2012

- 4 -

NEW RED MORTALITY ALERTS (Expected outcome at least twice as high as National benchmark, triggering negative cusum alert)

No new red mortality alerts for April 2012.

NEW GREEN MORTALITY ALERTS (Expected outcome at least twice as low as National benchmark, triggering positive cusum alert)

DateReceived

MonthAlerted

DatixNo

Green /Red

Diagnosis/Procedure

GroupDescription Action Description Trust Lead Status

02.07.12 April2012

292 Green Liver Disease,Alcohol Related

1 death v 3.2 expected For information only Dr Eaden Open

02.07.12 April2012

293 Green Septicaemia (exceptin Labour)

5 deaths v 11.4 expected For information only TBC Open

HIGH RELATIVE RISK (Relative Risk is significant worse than benchmark)

DateReceived

MonthAlerted

DatixNo

Green /Red

Diagnosis/Procedure


02.07.12 April2012

294 High RR Alcohol related mentaldisorders

3 deaths v 0.5 expectedMay 11 to April 12

Notes review TBC Open

02.07.12 April2012

295 High RR Intracranial injury Nov 2011 to Apr 201224 deaths v 14.3

expected

Notes review Mr Dardis Open

02.07.12 April2012

296 High RR Craniotomy for trauma Dec 2011 to Apr2012 – 8deaths vs 4.1 expected.

Previously alertedNovember 2011.

Notes review Mr Dardis Open

02.07.12 April2012

297 High RR Urinary Tract Infection Jan – Apr 201238 deaths v 27.9

expected

Notes review TBC Open

- 5 -

ALERT INVESTIGATIONS

DateReceived

MonthAlerted

DatixNo

Green/Red

Diagnosis/Procedure


01/02/2012 Nov 2011 278 Red TherapeuticTransluminalOperations on IliacArtery

One year: 4 deaths v 0.4expected

Coding and clinical reviewcomplete.Reported to MRG in May 2012.Actions in progress.

Miss Marshall Open

01/05/12 Feb 2012 285 Red Bariatric Operations 1 death v. 0 expectedOne year: 1 death v. 0expected

Coding review complete.A mortality review e-form hasbeen completed for the patientconcerned by Dr Venkatesh.Mr Menon to present at JulyMRG.

Mr Menon Open

01/05/12 Feb 2012 286 Red Repair of AbdominalAortic Aneurysm(AAA)

3 deaths v. 1.7 expectedOne Year: 11 deaths v.6.3 expected

Coding review completed22.05.12.Report to MRG in July 2012.

Miss Marshall Open

++ Peer Group (12): Cambridge UH NHS FT, Heart of England NHS FT, Nottingham UH NHS Trust, Oxford University Hospitals NHS Trust, Sandwell & W.Bham Hospitals NHS Trust,University College Hospitals NHS FT, University Hospital Bham NHS FT, UH North Staffordshire NHS Trust, UH Bristol NHS FT, UH Leicester NHS Trust, Worcester, Acute Hospitals NHSTrust

Dr Foster RTMl is a clinical benchmarking tool which allows UHCW to monitor mortality and highlight potential areas of variation or concern when clinical outcomes differ from the nationalpicture. Alerts are based on primary diagnosis and primary procedure in the first episode of care during a patient's admission. If an alert occurs, the relevant MD/CD is informed andinvestigates in order to ensure that there are no areas of concern in relation to patient care and this process is monitored by the Mortality Review Group (MRG)



25th

July 2012


Subject: Patient Engagement and Experience ReportReport By: Christine Watts, Chief Marketing OfficerAuthor: Janet White, Director of Engagement & Foundation Trust Project

DirectorAccountable Executive Director: Christine Watts, Chief Marketing Officer

GLOSSARY

Abbreviation In FullCQUIN Commissioning for Quality and InnovationKPI Key Performance IndicatorNICE National Institute for Health and Clinical ExcellenceNPS Net Promoter ScorePEEG Patient Engagement and Experience GroupSHA Strategic Health AuthorityUHCW University Hospital Coventry & Warwickshire



TitleApprox. Length


To report to the Trust Board the current Net Promoter Score, with weekly breakdown, information onnext steps, issues and risks


Action planning progress


Ongoing costs and resource requirements Possible future changes to NPS requirements UHCW’s ranking against other Trusts Implementation in A&E and of 10% of all footfall


For Trust Board approval of the report and next steps, noting of the current score and ranking andongoing support for the focus of the Engagement team on the NPS as the primary and overarchingpatient experience performance framework for 2012/13



25th

July 2012


IMPLICATIONS:Financial: CQUIN income

Cost implications of ongoing maintenance and future expansion to meetrequirements (as yet unclear)

HR / Equality & Diversity: Exemption criteria being applied (Deputy Chief Nurse has advised andwe are collecting Equality & Diversity information as part of interviewingso can monitor) but have concerns over age 18 restriction set by SHA

Pressure on staff and future sustainable resourcingGovernance: Ranking

Legal:

REVIEW:Trust Standing Committee Date Trust Standing Committee DateQuality Governance Committee Remuneration CommitteeFinance and Performance Committee Executive MeetingAudit Committee

DATA QUALITY:Data/information Source:Data Quality Controls:Data Limitations:

Patient Engagement and ExperienceA Patient Revolution: Net Promoter Score (NPS) Report to Trust Board

July 2012

Background

Below is the NPS and associated information for June. Also presented is the breakdownby specialty for May as well as June, as outlined and explained in last months NPSreport.

Monthly performance summary

For June 2012 performance is as follows:

% response rate 13.10%

NPS +44.2 (April baseline was +44.4)

As the SHA round up/down the score to the nearest whole figure, both the score will be

reported as +44.

Copy of Report to Commissioners for onward submission to SHA was submitted by duedate is available as appendix 1.

During the first quarter of 2012/13 the Trust is only required to submit monthly data, butwe do have a weekly breakdown available (see table below) and we will continuereporting this to the Trust Board going forward.

Week Detractor Passive PromoterGrandTotal

NPSScore

no ofdischarges

%surveyed

9 38 65 129 232 39.2 1708 13.6

10 28 47 121 196 47.4 1436 13.6

11 21 58 127 206 51.5 1681 12.3

12 38 58 135 231 42.0 1761 13.1

13 41 45 133 219 42.0 1714 12.8

GrandTotal

166 273 645 1084 44.2 8300 13.1

During June we received the organisational ranking against other Trusts across the SHA.

UHCW remained in the bottom quartile in this SHA ranking table.

Specialty Breakdown (May)

Specialty Detractor Passive PromoterGrandTotal Score

A&E 7 5 12 24 20.8

Accident & Emergency 7 15 27 49 40.8

Age Related Medicine 2 5 6 13 30.8

Anaesthetics 1 1 100.0

Breast Surgery 1 3 4 75.0

Cardiology 3 15 18 36 41.7

Cardiothoracic 2 1 3 33.3

Cardiothoracic Surgery 3 7 20 30 56.7

Clinical Haematology 1 4 5 60.0

Clinical Oncology 1 3 11 15 66.7

Clinical Pharmacology 2 2 100.0

Colorectal Surgery 1 1 2 50.0

Critical Care Medicine 1 4 5 80.0

Dermatology 1 1 0.0

Diabetes/Endocrine 1 1 3 5 40.0

Diabetic Medicine 1 2 3 33.3

Endocrinology 1 3 2 6 16.7

ENT 1 7 14 22 59.1

Gastroenterology 3 5 9 17 35.3

General Medicine 11 24 34 69 33.3

General Surgery 16 28 52 96 37.5

Geriatric Medicine 3 6 9 18 33.3

Gynaecology 4 7 10 21 28.6

Haematology 4 4 100.0

Histopathology 1 1 100.0

Infectious Diseases 1 2 3 66.7

Maxillo-Facial Surgery 2 5 7 71.4

Medicine 2 5 7 14 35.7

Mixed Specialties 2 2 100.0

Neonates 3 5 8 25.0

Neonatology 3 5 8 16 31.3

Nephrology 1 3 4 75.0

Neuro Rehabilitation 1 1 2 -50.0

Neurology 1 7 7 15 40.0

Neurosurgery 5 7 19 31 45.2

Obs & Gynae 7 12 14 33 21.2

Obstetrics 9 15 27 51 35.3

Oncology 3 3 100.0

Ophthalmology 1 3 13 17 70.6

Orthopaedics 3 7 10 40.0

Paediatrics 9 5 14 28 17.9

Plastic Surgery 1 3 5 9 44.4

Radiology 1 1 100.0

Rehabilitation 1 9 4 14 21.4

Renal Medicine 2 1 5 8 37.5

Respiratory Medicine 7 5 25 37 48.6

Rheumatology 8 5 18 31 32.3

Trauma & Orthopaedics 5 19 96 120 75.8

Unknown 19 24 43 86 27.9

Urology 3 8 20 31 54.8

Vascular Surgery 2 2 100.0

Transplantation Surgery 2 2 100.0

Plastics 1 1 100.0

Audiology 2 2 -100.0

Clinical Genetics 1 1 100.0

Transient Ischaemic Attack 1 1 100.0

Hepatology 1 1 0.0

Orthodontics 1 1 100.0

NULL 1 1 100.0

Grand Total 157 276 612 1045 43.5

Specialty Breakdown (June)

Specialty Detractor Passive PromoterGrandTotal Score

A&E 5 5 5 15 0.0

Accident & Emergency 17 14 32 63 23.8

Age Related Medicine 3 1 5 9 22.2

Breast Surgery 1 1 5 7 57.1

Cardiology 4 9 28 41 58.5

Cardiothoracic 1 1 100.0

Cardiothoracic Surgery 1 2 15 18 77.8

Clinical Haematology 3 3 3 9 0.0

Clinical Oncology 1 3 10 14 64.3

Clinical Pharmacology 1 1 -100.0

Colorectal Surgery 1 1 4 6 50.0

Critical Care Medicine 2 2 100.0

Diabetes/Endocrine 2 2 100.0

Diabetic Medicine 1 4 2 7 14.3

Endocrinology 1 5 6 83.3

Ent 4 9 17 30 43.3

Gastroenterology 8 6 15 29 24.1

General Medicine 18 27 63 108 41.7

General Surgery 24 15 66 105 40.0

Geriatric Medicine 2 7 10 19 42.1

Gynaecological Oncology 1 1 0.0

Gynaecology 9 9 16 34 20.6

Infectious Diseases 1 1 2 50.0

Maxillo-Facial Surgery 1 4 11 16 62.5

Medicine 6 6 12 50.0

Mixed Specialties 1 1 -100.0

Neonates 2 2 100.0

Neonatology 1 4 5 80.0

Nephrology 1 6 10 17 52.9

Neuro Rehabilitation 1 1 2 0.0

Neurology 5 11 16 32 34.4

Neurosurgery 6 5 24 35 51.4

Obs & Gynae 3 9 7 19 21.1

Obstetrics 5 15 33 53 52.8

Oncology 1 3 3 7 28.6

Ophthalmology 1 7 8 87.5

Oral Surgery 1 1 100.0

Orthopaedics 8 5 13 38.5

Paediatrics 1 4 2 7 14.3

Pain Management 1 1 0.0

Plastic Surgery 6 8 14 57.1

Radiology 3 3 100.0

Rehabilitation 1 4 6 11 45.5

Renal Medicine 1 1 2 0.0

Respiratory Medicine 1 8 19 28 64.3

Rheumatology 2 1 9 12 58.3

Trauma & Orthopaedics 16 25 103 144 60.4

Unknown 9 19 27 55 32.7Upper GastrointestinalSurgery 2 2 100.0

Urology 7 14 15 36 22.2

Vascular Surgery 3 8 11 72.7

Transplantation Surgery 2 2 100.0

Hepatology 1 1 100.0

Orthodontics 1 1 100.0

NULL 1 1 100.0

Paediatric Surgery 1 1 -100.0

Grand Total 166 273 645 1084 44.2

Next steps/actions

We have increased the volume of text message responses we collect by implementingautomated text messaging. This is reducing the cost of asking the NPS question withinthe SHA requirements.

We will be completing work with our Impressions software supplier and with appropriatestaff at UHCW to reflect the new organisational structure and move from the oldDivisions to the new Speciality Groups for data collection and reporting purposes. It isanticipated that this will be completed during July.

By the end of June, we had all the requirements for CQUIN indicators 3a, 3b and 3c fullyin place.

Implementation team continues to meet fortnightly to plan and progress work towardsmeeting the requirements, recently announced nationally, to include A&E by April 2013and towards SHA’s declared, though not yet detailed, requirement for coverage of 10%of all footfall from April 2013.

Work has progressed towards action plans for 10 point increase in score (must score+54.44 or above in March 2013), including:

Executive Management Group briefed on our Net Promoter Score and NationalPatient Survey results at a meeting in June. This will included initial thoughtsabout action planning for both the NPS and Patient Survey results (including the5 CQUIN questions) improvements and inclusion of work to fill the gaps identifiedin our gap analysis against the recently published NICE patient experiencestandards. The proposals for the action planning approach was approved.

Action planning template approved by Patient Engagement & Experience Group. Meeting with specialties us to help them understand the patient experience

evidence available to them (Impressions returns, patient’s verbatim comments,complaints, surveys etc.) and to commence their action plans for improvement.

Specialty Group NPS (RAG rated) and Complaints numbers and type (RAGrated) included in Specialty Group Performance management review meetings.

Patient experience team members attending any specialty or group meetings tohelp support patient experience improvement action planning.

NPS to be included in Specialty/ Specialty Group KPIs to embed it in day to dayperformance management.

Verbatim comments/reasons for giving an NPS are available to front-line teamsthrough Impressions and these are being used with front-line staff to driveimprovements

Issues/risks

Ongoing costs – being minimised by actions previously described to reduce use oftelephony service1.

Cost and risks of inclusion of A&E – paper prepared for sharing with SHA to help informthem of the issues and influence national implementation.

Cost of implementing 10% response rate across all footfall, especially if CQUIN valueremains the same or is less in real terms – will look to minimise costs.

Awaiting results of SHA survey to facilitate analysis of effects of different datacollection/interview methods on results and may well have to report on numbers ofresponses by collection methodology – at UHCW this requires a further development tothe Impressions software, as this was not in the original SHA guidance2.

Possible application of weighting factors going forward (SHA indicate that might be apossibility depending on initial NPS results and outcome of collection method survey)and effect on UHCW’s score going forward – we assume SHA will re-baselineorganisations’ scores.

Conclusion

The Trust Board is asked to approve the report and note:

the UHCW current score of +44.2 the achievement of a response rate above the required 10% that UHCW is already in a strong position to achieve the CQUIN indicators the risks and issues and especially the resource consequences of ongoing

maintenance and extension into A&E or 10% of all footfall the action planning actions and proposals the need to acknowledge that UHCW needs to improve our NPS and reputation

for delivering high quality across all specialties as there is wide variation acrossservices

the need now for frontline staff to become more engaged in the process andusing the action planning tool and NICE standards going forwards and to knowtheir score and how patients perceive their service

The Board is asked to recognise and continue to support the focus of the Engagementteam on the NPS as the primary and overarching patient experience performanceframework for 2012/13.

1Just for in-patient coverage, as costs will necessarily rise as we move towards 10% of all footfall e.g. use

of telephone interviews for A&E patients

2Depends on actual SHA requirements

Appendix 1

ITEMS in YELLOW: please select from drop down

ITEMS in BLUE: please type value

ITEMS in GRAY: will auto populate

1.0 Submission descriptors

(select from list)

(select from list)

(select from list)

(populates automatically, please review)

(please detail the data collection route)

2.0 Submission confirmations

(survey within 48 hours of discharge)

3.0 Organisational NPS ResponseWeek 1 Week 2 Week 3 Week 4 Week 5

27/05/2012 03/06/2012 10/06/2012 17/06/2012 24/06/201202/06/2012 09/06/2012 16/06/2012 23/06/2012 30/06/2012

(number of defined DISCHARGES within the period)

(number of NPS responses from cohort in 3.1)

4.0 Net Promoter ScoreWeek 1 Week 2 Week 3 Week 4 Week 5

(automatically populates from data entered above)

(automatically populates from data entered above)

645

166

2.3 Confirmation of weekly reportingNO(if you are submitting combined monthly data please insert all figures in

the week 1 column)

START DATEEND DATE

8300

44.18819188 #DIV/0! #DIV/0! #DIV/0!

4.2 Organisation Monthly44.18819188

3.1 Total number of inpatients in period

3.2 Total number of responses in period

3.3 Number of promoters

3.4 Number of passives

3.5 Number of detractors

4.1 Organisation NPS - weekly#DIV/0!

1084

273

Impressions survey (paper based, face to face interviews and hand held) ,

Impressions "lite" NPS (telephone interviews, face to face interviews- hand held and face to face

YES

YES

1.4 Provider procode

1.5 NPS tool

2.1 Confirmation of survey timeliness

2.2 Confirmation of internal reporting(monthly reporting to board at organisational, speciality and ward

level, including plans for improvement)

University Hospitals Coventry and Warwickshire NHS Trust

RKB

JUN

Friends and Family Submission Proforma

1.1 PCT cluster nameArden PCT Cluster

1.2 Time period - month

1.3 Provider name



25th

July 2012


Subject: Infection Prevention & Control and Cleaning Report – April to June 2012Report By: Dr M Weinbren, Director and Kate Prevc, Modern Matron (Infection

Prevention & Control Team)Authors: Dr M Weinbren, Director and Kate Prevc, Modern Matron (Infection

Prevention & Control Team)Mark Gough, ISS Mediclean

Accountable Executive Director: Professor Mark Radford, Chief Nursing Officer

GLOSSARY

Abbreviation In FullICNA Infection Control Nurses AssociationMRSA Meticillin Resistant Staphylococcus AureusDH Department of HealthRCA Root cause analysisHPA Health Protection AgencyIPC Infection Prevention & Control



TitleApprox. Length


To receive the Infection Prevention & Control and Cleaning report for April to June 2012.


Infection Prevention and Control No MRSA bacteraemia since May 2011. Clostridium difficile; 19 cases, with end of year trajectory of 70. Para influenza 3 outbreak in Neonatal Unit

Cleaning Rotational enhanced cleaning of the Emergency Department commenced Other high risk areas to be identified Trust wide review of cleaning standards using ICNA tool


Potential patient safety and reputational issues



25th

July 2012



Trust Board asked to accept and note the report.

IMPLICATIONS:

Financial: Potential commissioner penalties for not achieving targets

HR / Equality & Diversity: -

Governance: Patient safety

Legal: -

REVIEW:


DATA QUALITY:

Data/information Source:Data Quality Controls:Data Limitations:

12.7.12. 1


INFECTION PREVENTION & CONTROL andCLEANING REPORT

April to June 2012

1. Introduction

The purpose of this report is to brief the Trust Board on;

The progress of the Trust for the first quarter of the year in relation to the Infection Preventionand Control Team’s “Annual Plan” of work 2012/13 and

To present the Cleaning report for the same quarter.

A. INFECTION PREVENTION AND CONTROL

2. Progress against National Performance Targets (Criterion 1)

2.1 MRSA

MRSA Bacteraemia Comparative Chart by Quarter and Year (Post 48 hours from admission only)

Quarter 2008/09 2009/10 2010/11 2011/12 2012/13

1st Quarter 3 3 1 1 0

2nd Quarter 10 2 1 0

3rd Quarter 2 2 1 0

4th Quarter 2 1 1 0

The upper level trajectory set for the Trust for 2012/13 is 2 MRSA bacteraemia. The Trust has nothad any bacteraemia since May 2011.

Elective and Emergency MRSA Screening

The Trust continues to screen all elective patients undergoing surgery for MRSA and is meetingthe Department of Health’s guidance in this area.

2.2 Clostridium difficile

To date the Trust has acquired 19 Clostridium difficile cases which is 1 above trajectory for thecurrent period of time (18). The end of year trajectory is 70. The Infection Prevention and ControlTeam will now start to undertake root cause analysis (RCA) on each case acquired within theTrust.

C. Diff cases Comparative Chart by Quarter and Year

(apportioned cases only)

0

10

20

30

40

50

60

1st Quarter 2nd Quarter 3rd Quarter 4th Quarter

Quarter

Noofcases

2008/09

2009/10

2010/11

2011/12

2012/13

12.7.12. 2

All Matrons have been asked by the Chief Nursing Officer to undertake an infection controlnursing association (ICNA) audit within their areas and were given a two week period for this tooccur. The average mark for this quarter for ICNA environmental audits was 78%. The previousquarter’s score was 76%. The pass mark nationally for the ICNA environmental audit is 85 %

2.3 E Coli bacteraemia

Data collection for E coli bacteraemia began on 1st June 2011 in line with DH mandatoryrequirements. There were 87 bacteraemias reported during the first quarter. E Coli is theorganism that is most commonly the cause of bacteraemia. There is no target attached to thiselement yet but we are within confidence limits when set against other Trusts in the WestMidlands.

2.4 Glycopeptide Resistant Enterococci (VRE)

Quarter one 2012 Quarter two 2012 Quarter three 2012 Quarter four 20121

Quarter 0ne 2011 Quarter Two 2011 Quarter Three 2011 Quarter four 20122 2 1 1

Quarter one 2010 Quarter two 2010 Quarter three 2010 Quarter four 20101 4 2 0

2.5 Meticillin Sensitive Staphylococcus Aureus (MSSA) bacteraemias

The Trust has a robust programme for RCAs following MSSA bacteraemia. The Trust had 17 forthis quarter. Themes pulled from the RCAs are:

Probable Source - RCA outcome

Peripheral Cannula, 6

Tunnelled line, 3

Dialysis line, 1

Skin/soft tissue, 6Pneumonia, 1

Contaminant, 3

other, 3

Sepsis not

recognised initially, 4

Not known, 2

2.6 Reporting of data

The Trust is fully compliant with set targets with all data reporting and targets.

12.7.12. 3

3. Outbreaks/incidents of Infection

3.1 MSSA Outbreak on Neonatal Unit

There have been no further cases of the outbreak strain but the Unit continues to actively screen.

3.2 Pertussis

There were two cases of pertussis during this quarter, one involved a senior member of staff whoreturned from holiday with what was self diagnosed as a chest infection which did not respond totreatment. Once blood serum confirmed pertussis a look back exercise was undertaken and nofurther cases were identified. All patients concerned were spoken to and reassured. The HealthProtection Agency (HPA) were involved.

3.3 Other incidents that required contact tracing and action

Pertussis ( whooping cough) 2 Meningitis 1

MRAB 1 TB 6

Scabies 1 Para influenza 1

Chicken Pox 3 Decontamination issues 1

Influenza 3 Shingles 1

3.4 Para influenza 3

Three babies on the Special Care Baby Unit were reported as having Para influenza 3. As thebabies had initially been together but moved to different areas during the incubation period(between 2-8 days) and we were still within the incubation period which starts when the lastpatient is isolated, this meant potentially all babies had the potential to develop Para influenza.3

The unit was full and there was no capacity so the decision was taken to declare the Unit closeduntil we could reasonably assess whether we thought there had been further spread. It is notunusual for hospitals within the network to be full and ask other hospitals to take high riskpatients. This process was used to inform other areas. We ensured that we had capacity tostabilise and keep safe any babies who became acutely unwell so the service remained safe. Thedifficult decision to stop visiting to all but parents was taken as HPA had reported increased rateswithin the community and young children are often vectors in this transmission.

The Unit was able to take new patients into HDU and part of the SCBU three days into theincident and was fully open as normal eleven days since the onset. This was due to high Infectioncontrol standards by the staff as there were no further cases of spread. This was initially reportedas highly unusual in the neonatal setting and papers were suggesting a minimum closure of 4-6weeks and in one case 3 months. However subsequent discussion with Birmingham Children’sHospital reveals that they have also seen incidents of Para influenza 3.

4. Water Quality - Legionella (Criterion 5)

4.1 Legionella at University Hospital

A number of positive samples were detected in the FM building. Meetings have been held and aseries of remedial works undertaken. The contamination was at a low level and no cases haveoccurred. Further water samples are about to be repeated and if negative the incident will beclosed.

4.2 Legionella at Rugby

The measures to control the contamination on the Rugby site are near completion. There havebeen no cases of hospital acquired legionella to date.

12.7.12. 4

4.3 Legionella at Stratford

The Trust manages a satellite renal unit at this site. A meeting was held on the 5th

January and itwould appear that all the corrective measures have been taken. Results of repeat testing areawaited. The HSE inspector is expecting a report from each Chief Executive who has patients onthis site detailing any lessons learnt.

To date there have been no cases of human legionella associated with the water system. TheHSE is fully involved with the situation with one of their senior inspectors regularly attendingmeetings.

4.4 Pseudomonas and water safety management group.

A group is being developed in response to the DH guidance around pseudomonas following theneonatal deaths in Belfast. This group will undertake a gap analysis and risk assessments onhigh risk units and will then monitor safe practice to ensure that we are correctly managingpseudomonas in line with the guidance. Initial work has identified good practice in line with thisguidance but we need to develop audit pathways and a line of accountability. This will be WaterSafety Group to report to the Water Management Group and then to the Infection Prevention andControl Committee and upward to Trust Board.

5. Audit programme

The following audits have been carried out in the quarter using the Infection Control NursesAssociation (INCA) Analysis:

Audits 2011 2012

MRSA compliance audit 79% 83%

Clostridium difficile compliance audit 95% 91%

Hand hygiene audit 88% 87%

Sharps Audit 87% Q2

Environmental ICNA 76% 78%

Clostridium difficile compliance against the quick action guide remains consistently high reflectingthe high level of recognition and prompt action to isolate amongst staff. The drop in compliancereflects the adoption of PCR testing and equivocal results which are causing some confusion assome patients are symptomatic so not being placed on treatment. The audit form has beenaltered to take this into consideration. We await microbiology’s decision as to whether this testremains part of our testing armoury.

6. Training (Criterion 9)

The Infection Prevention and Control (IPC) Team have undertaken training of ISS staff toengender an understanding of organisms and the impact of the spread of these on patients. TheIPC team wanted ISS staff to understand the importance of their role in limiting the spread oforganisms and the importance of cleaning, particularly in the healthcare environment whenpatients are vulnerable. The IPC Team will be providing some evening sessions to capture latestaff and will also provide a similar service to portering staff to explain the importance of goodhand hygiene.

Collaboration with a local schools media studies group has been highly successful. CardinalNewman School media studies group have developed a hand hygiene video and they haveproduced a very watchable video with their own backing track. This will be put onto the intranetsite and will be played for visitors on the screens. This is also being used by the team as ateaching aid and it has proved to be very popular. The group are very keen and are now lookingat a series of posters or photographs to assist us in getting the hand hygiene message across.

12.7.12. 5

B. CLEANING REPORT

1. Work to Date

During this quarter ISS conducted a total of 283 audits, of these 99% were verified by ModernMatrons. The audits include all aspects of the ward areas including patient areas, day rooms andoffices. All aspects of cleanliness are monitored and reported. The average score for thequarter was 98.1%, being broadly consistent to last quarter’s average of 97.79%. The areasidentified as “very high risk” continue to be audited on a weekly basis and the results show anaverage of 98.42% compared with previous quarter’s average of 98.28%.

All audit reports are forwarded to the Modern Matrons and identify any rectifications required.These are followed through by the Healthcare Cleaning Management Team who ensure thatappropriate action is taken in a timely manner.

In the period April to June 2012, ISS have carried out a total of 3,194 terminal cleans that can bebroken down as follows:

Single Rooms for Pre-Fogging – 52 Terminal Cleans for 4 -4 6 Bed Bays – 131 Terminal Cleans for Single Rooms – 3011

ISS have requested the Trust jointly review and agree the terminology for terminal cleans andwhether it is appropriate to request a terminal clean in all instances.

2. Monitoring

The Trust continues to rely solely on the ICNA audits to monitor the standards delivered by ISS.This tool is not compliant with National Standards of Cleanliness. ISS are more than happy to usethis audit to enhance the monitoring of cleanliness, however, the joint Maximiser audits shouldalso be formally recognised, as they are compliant with National Standards.

ISS recognise that there has been an increase in C-Diff and we will continue to work with theTrust to reduce cases. As part of this work ISS have agreed to steam clean all nurses equipmentto ensure it is cleaned to an acceptable standard. This equipment will be handed back to theTrust on completion of works.

3. People and Equipment

ISS have purchased new digital radios to further enhance communications.

We have also provided additional helpdesk machines to cleaning management team to assistwith the monitoring of tasks logged through the helpdesk and provide a faster response torequests for ad hoc tasks.

The initial delivery of Infection Control training has gone well and we look forward to working inpartnership with the Infection Control and Prevention Team to ensure all healthcare cleaningoperatives are fully compliant with Trust policy and guidelines.

4. Working in Partnership

ISS continue to work very closely with the Trust’s Chief Nursing Officer and his direct reports.This ever developing relationship and the appreciation of the need to maintain effective lines ofcommunication ensures that we can respond to the needs of the Trust and provide support inareas as required to assist the Trust to meet its objectives and targets. We very much lookforward to the continuation of this relationship and would confirm the commitment of ISS and themanagement team in actively supporting the Trust to achieve its long term goals.

12.7.12. 6

With regards cleaning of Patientline equipment, and following submission of options for cleaning,the Trust have requested that ISS clean this equipment on a once a week basis only. This servicewill sit outside of the PMS.

C. RECOMMENDATION

The Trust Board asked to note the Infection Prevention & Control and Cleaning report for April toJune 2012.

UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUSTREPORT TO THE TRUST BOARD: PUBLIC

25th

July 2012


Subject: Quality Governance CommitteeReport By: Tim Sawdon, Non-Executive DirectorAuthor: Paul Martin, Director of Clinical GovernanceAccountable Executive Director: Meghana Pandit, Chief Medical Officer

GLOSSARY

Abbreviation In FullHR Human ResourcesOD Organisational DevelopmentIT Information TechnologyCQC Care Quality CommissionQRP Quality Risk ProfileIG Information Governance



TitleApprox. Length


To advise Trust Board of the details of the Quality Governance Committee meeting on 12 June 2012


Minutes, actions, and matters arising from June 2012 all agreed.

HR Quality & Diversity – Report presented and accepted. Mandatory training discussed. Patient Experience Committee – Report presented and accepted. Diminishing numbers of

wheelchairs was highlighted. Signage Group to be contacted regarding congestion in revolving mainentrance doors.

Patient Safety Committee – Report presented and agreed. Delay in receiving current figures regardingDr Foster information was highlighted. Situation regarding training and working with junior doctors wasalso discussed.

Information and IT Committee - Report presented and agreed. Options for Electronic Patient Recordsto be explored.

Risk Committee – Report presented and accepted. Difficulties regarding A&E targets were explainedand it was felt that in order to gain some recognition of the difficulties, the issue should be raised withother relevant bodies and maybe make representation to the Chairman. Format of the Risk Registerwas discussed.

Ad Hoc Reports -o CQC report presented and agreedo Internal audit report presented, but conclusion questioned. It was decided to return it to Audit

Committee for response and report back. AOB – letter regarding Committee members and attendance was highlighted.


Identified within individual reports

UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUSTREPORT TO THE TRUST BOARD: PUBLIC

25th

July 2012



For consideration by the Board

IMPLICATIONS:

Financial: None Highlighted

HR / Equality & Diversity: None highlighted

Governance: Potential risk to compliance with CQC Registration outcomes re QRP

Legal: None

REVIEW:


DATA QUALITY:



REPORT TO TRUST BOARD: PUBLIC

25th

JULY 2012

Subject: Provider Management RegimeReport By: Sharon Beamish, Interim Chief Operating OfficerAuthor: Simon Reed, Head of Performance ManagementAccountable Executive Director: Sharon Beamish, Interim Chief Operating Officer

GLOSSARYAbbreviation In FullDH Department of HealthUHCW University Hospitals Coventry and WarwickshireSHAs Strategic Health AuthoritiesPCTs Primary Care Trusts



TitleApprox. Length

PURPOSE OF THE REPORT / PRESENTATION:The SHA wide Provider Management Regime (PMR) has now been rolled out which each Trust is required tocomplete on a monthly basis.

The PMR was introduced in shadow form for East Midlands and West Midlands Trusts during the periodJanuary to February 2012. The return from Trusts for March 2012 was reported at the SHA’s public boardmeeting in May 2012. The PMR process has been fully operational from April 2012 onwards. This regime wasintroduced to support Trusts, by working with the SHA in a “Monitor like” way, to help prepare Trusts for theirDH and Monitor Foundation Trust assessment and subsequent monitoring post authorisation under the MonitorCompliance Framework.

The regime provides an opportunity for providers to earn autonomy from the SHA. Providers who candemonstrate consistent performance of governance, finance, quality and contract management will make lessfrequent PMR returns and meet with the SHA less often than those Trusts that face issues. There is also aclear escalation process for Trusts with persistently poor ratings or other issues. The detailed processes andrules by which a Trust can gain autonomy or might face escalation are outlined within separate SHA guidance.

The first return of the Provider Management Regime templates to the SHA was on the last working day ofJanuary (31 January 2012); and is required on the last working date of every month thereafter. Latesubmissions are automatically given a red governance risk rating. The expectation is that the monthly templatereturns are signed off by the Trust Board.

At the time of writing this report the East and Midlands SHA have not published the PMR process for 2012/13.In the absence of this the SHA have reissued the 2011/12 template so that it can be used for April, May andJune 2012. It is understood that the final 2012/13 template is likely to change and will include differentindicators in the Governance Risk Rating Section of the submission.

SUMMARY OF KEY ISSUES:Based on the data provided by the relevant leads the Trust risk ratings are as detailed below:

PERIODGovernanceRisk Rating

FinancialRisk Rating

ContractualPosition

APR-12 Amber/Green(1.0)

Green (3.0) Amber

MAY-12 Amber/Green(1.0)

Green (3.0) Amber

JUN-12 Amber/Red(2.0)

Green (3.0) Amber



25th

JULY 2012

Appendix A is UHCW’s proposed submission to the SHA at the end of July 2012.

Specified areas of insufficient assurance are:

C-diff A&E – total time in A&E


The governance risk rating is showing as Amber/Red and the contractual position is showing as Amber


Trust Board to approve the Provider Manager Regime return based on June 2012 data for onwardsubmission to the SHA.

Trust Board to confirm its support for Governance Declaration 2 (for insufficient assurance that all targetsare being met) in relation to C-diff and A&E.

IMPLICATIONS:Financial: N/A

HR / Equality & Diversity: N/A

Governance: Performance against the PMR submission will impact on the trusts ability tomove forward with its Foundation Trust application

Legal: N/A


DATA QUALITY:


SELF-CERTIFICATION RETURNS

Organisation Name:


Monitoring Period:

June 2012

NHS Midlands & EastProvider Management Regime

2012/13

Returns [email protected] by

the last working day of each month

1 Cover Sheet Page 1 of 21 Enc 9.1 - PMR June 2012

2012/13 In-Year Reporting

Name of Organisation: Period: June 2012

Organisational risk rating

* Please type in R, A or G

Governance Declarations

Supporting detail is required where compliance cannot be confirmed.

Governance declaration 1

Signed by: Print Name:

on behalf of the Trust Board Acting in capacity as:

Signed by: Print Name:


Governance declaration 2

Signed by : Print Name :


Signed by : Print Name :


If Declaration 2 has been signed:

Target/Standard:

The Issue :

Action :

Target/Standard:

The Issue :

Action :

University Hospitals Coventry and Warwickshire

NHS Trust

The Board is satisfied that plans in place are sufficient to ensure continuing compliance with all existing targets (after the application of thresholds), and with all

known targets going forward. The board is satisfied that plans in place are sufficient to ensure ongoing compliance with the Code of Practice for the Preventionand Control of Healthcare Associated Infections (including the Hygiene Code) and CQC Essential standards. The board also confirms that there are no material

contractual disputes.

NHS Trust Governance Declarations :

NHS Midlands and East organisations, subject to the Provider Management Regime, must ensure that plans in place are sufficient to ensure compliance inrelation to all national targets and including ongoing compliance with the Code of Practice for the Prevention and Control of Healthcare Associated Infections,

CQC Essential standards and declare any contractual issues.

Each organisation is required to calculate their risk score and RAG rate their current performance as per the 2011/12 Provider Management Regime, in additionto providing comment with regard to any contractual issues and compliance with CQC essential standards:

Contractual Position (RAG as per NHS Midlands and East PMR guidance)

Key Area for rating / comment by Provider

3.0

Amber

Governance Risk Rating (RAG as per NHS Midlands and East PMR guidance)

Financial Risk Rating (Assign number as per NHS Midlands and East PMR guidance)

Andrew Hardy

Chairman

Score / RAG rating*

2.0 (Amber/Red)

For one or some of the following declarations Governance, Finance, Service Provision, Quality and Safety, CQC essential standards or the Code of Practice forthe Prevention and Control of Healthcare Associated Infections the Board cannot make Declaration 1 and has provided relevant details below.

Please complete sign one of the two declarations below. If you sign declaration 2, provide supporting detail using the form below. Signature may be either hand

written or electronic, you are required to print your name.

Chief Executive Officer

Please identify which targets have led to the Board being unable to sign declaration 1. For each area such as Governance, Finance, Contractual, CQC EssentialStandards, where the board is declaring insufficient assurance please state the reason for being unable to sign the declaration, and explain briefly what steps arebeing taken to resolve the issue. Please provide an appropriate level of detail.

The board is suggesting that at the current time there is insufficient assurance available to ensure continuing compliance with all existing targets (after the

application of thresholds) and/or that it may have material contractual disputes.

Philip Townshend

C-diff

UHCW has developed two robust action plans: one focusing on front door improvements and the other

discharge planning

The Trust is above the trajectory for June 2012

The Trust is delivering a range of actions including initiating deep clean program, increased inspections

and the development and launch of 100 days free campaign

A&E: total time in A&E

Increased volume and acuity of A&E activity

2 Gov Dec Page 2 of 21 Enc 9.1 - PMR June 2012

Ref Area Indicator Sub SectionsThresh-

old

Weight-

ingApr-12 May-12 Jun-12

Comments where target

not achieved in month?

1 Safety Clostridium DifficileAre you below the ceiling for your

monthly trajectoryContractwith PCT

1.0 YES YES NO

For Jun we had 8 Cdiff against a target of 6. Our ytd position is19 against at target of 18

ACTIONS:

Actions taken include:

o Deep clean program initiated in high risk areas (Starting ED –

June)

o Trust wide ICNA environment scoring and compliancechecking of cleaning standards

o Increased unannounced environment audit inspections on

wards and departments

o Communication to clinical staff reinforcing C Diff management

guidanceo Escalation meetings with specialities with C Diff cases, with

RCA actions in Performance framework meetings

o Development and launch of 100 days free campaign for CDiff,

including hand hygiene compliance training, antibiotic training

and awareness as well as ICNA/Maximiser compliance trackingat bi-monthly operational cleaning performance meeting chaired

by CNO. Mar

2 Safety MRSAAre you below the ceiling for your

monthly trajectoryContractwith PCT

1.0 YES YES YES

Surgery 94%Anti cancer drug treatments 98%

Radiotherapy 94%

From urgent GP RTT 85%

From consultant screening servicereferral

90%

5aPatient

ExperienceRTT waiting times – admitted 95th percentile 23 wks 1.0 YES YES YES

5bPatient

ExperienceRTT waiting times – non-admitted 95th percentile 18.3 wks 1.0 YES YES YES

6 QualityAll Cancers: 31-day wait from diagnosis tofirst treatment

96% 0.5 YES YES YES

all cancers 93%for symptomatic breast patients

(cancer not initially suspected)93%

8a Quality A&E: Total time in A&ETotal time in A&E

(95%)≤ 4 hrs 1.0 NO NO NO

the minimum target of 95%.

ACTIONS:

In response to the current front door 95% performance UHCW

has developed two robust action plans: one focusing on frontdoor improvements and the other discharge planning. These

plans focus on the following areas:

• Capacity and control functions• Required developments aimed at supporting and improving

current processes• Speeding up of assessment

• Improved discharge planning

These are monitored and performance managed through a seriesof project groups which feed through to the newly established

patient flow steering group.

In addition Newton have been appointed to review processes in

ED with the view to replicating the success they had in driving up

performance in Gloucester by driving out the waits in thepathway

Daily capacity planning has been introduced with all wardsrequired to identify their daily discharges to meet their expectedadmissions (based on 6 weeks rolling activity data)

The aim of this action plan is to support improved performanceagainst the 95% target in a sustainable fashion, in readiness for winter pressures.

The action plan was agreed by the Strategic Health Authority and the PCT In May 2012

Total time in A&E(95th percentile)

≤4 hrs

0.5 YES YESYES7

A&E:

QualityCancer: 2 week wait from referral to datefirst seen, comprising either:

YES YES

University Hospitals Coventry

and Warwickshire NHS Trust

3

4

1.0

ACUTE

GOVERNANCE RISK RATINGS 2011/12

QualityAll cancers: 31-day wait for second or

subsequent treatment, comprising either:

All cancers: 62-day wait for first treatment,

comprising either:Quality 1.0

Insert YES (target met in month), NO (not met in month) or N/A (as appropriate)

See separate rule for A&E

YES YES YES

The position reported for May at the end of June was Amber.

This was based on fast-track data and therefore a best

prediction. Following validation of activity for May this was

reported as 84.9%. However, this target is performance

managed on a quarterly basis because it is recognised activity isattributed to months as patients progress along their care

pathway. In relation to May, two further patients have been

identified in July corresponding to May activity. This now means

UHCW has delivered the required performance for May. It is

expected UHCW will achieve the target for June and Quarter 1

YES

Total Wait: 95th percentile target of <=240 mins. June3 GRR Acute Page 3 of 21 Enc 9.1 - PMR June 2012


old

Weight-



not achieved in month?Time to initial assessment

(95th percentile)≤15 mins

Time to treatment decision(median)

≤60 mins

Unplanned re-attendance rate ≤5%Left without being seen ≤5%

17Patient

experience

Certification against compliance with

requirements regarding access to

healthcare for people with a learningdisability

N/A 0.5 YES YES YES

CQC Registration

A Safety CQC RegistrationAre there any complianceconditions on registration

outstanding.0 1.0 NO NO NO

B Safety CQC RegistrationAre there any restrictive

compliance conditions onregistration outstanding.

0 2.0 NO NO NO

C SafetyModerate CQC concerns regarding thesafety of healthcare provision

0 1.0 NO NO NO

D SafetyMajor CQC concerns regarding the safetyof healthcare provision

0 2.0 NO NO NO

E SafetyFormal CQC Regulatory Action resulting in

Compliance Action0 2.0 NO NO NO

F SafetyFormal CQC Regulatory Action resulting in

Enforcement Action0 4.0 NO NO NO

G Safety

NHS Litigation Authority – Failure to

maintain, or certify a minimum published

CNST level of 1.0 or have in placeappropriate alternative arrangements

0 2.0 NO NO NO

TOTAL 1.0 1.0 2.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0RAG RATING :

8b

A&E:

NB Please record the areas not being met

in the comments sheet

Quality

RED = Score Over 4

AMBER / RED = Score between 2 and 3.9

2

GREEN = Score Less than 1

No

weighting

AMBER/GREEN = Score between 1 and 1.9

2 3

Total Wait: 95th percentile target of <=240 mins. June

performance was 258 minsTime to initial assessment: 95th percentile target of <= 15 mins.

June performance was 28 minsTime to treatment: Median target of <=60 mins. Juneperformance was 61 mins.

3 GRR Acute Page 4 of 21 Enc 9.1 - PMR June 2012


old

Weight-


Mar



Receiving F/U contact within 7

days of discharge95%

Having formal review

within 12 months95%

11 QualityMinimising mental health delayed transfers

of care≤7.5% 1.0

12 QualityAdmissions to inpatients services had

access to crisis resolution home treatment

teams

90% 1.0

13 QualityMeeting commitment to serve new

psychosis cases by early intervention teams95th percentile

Contract

with PCT0.5

14 Effectiveness Data completeness: identifiers 99% 0.5

15 EffectivenessData completeness: outcomes for patients

on CPA50% 0.5

17Patient

experience



healthcare for people with a learning

disability

N/A 0.5

CQC Registration

A Safety CQC RegistrationCompliance condition's on

registration0 1.0

B Safety CQC RegistrationRestrictive compliance conditions

on registration0 2.0

C SafetyModerate CQC concerns regarding the

safety of healthcare provision0 1.0

D SafetyMajor CQC concerns regarding the safety of

healthcare provision0 2.0


Compliance Action0 2.0


Enforcement Action0 4.0

G Safety



CNST level of 1.0 or have in place

appropriate alternative arrangements

0 2.0

TOTAL 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

MENTAL HEALTH



and Warwickshire NHS TrustInsert YES (target met in month), NO (not met in month) or N/A (as appropriate)

10 QualityCare Programme Approach (CPA) patients,

comprising either:1.0

3 GRR MH Page 5 of 21 Enc 9.1 - PMR June 2012


old

Weight-


Mar



16a QualityCategory A call –emergency response

within 8 minutesLife Threatening 75% 1.0

16b QualityCategory A call – ambulance vehicle arrives

within 19 minutes95% 1.0

17Patient

experience



healthcare for people with a learning

disability

N/A 0.5

CQC Registration

A Safety CQC RegistrationCompliance condition's on

registration0 1.0

B Safety CQC RegistrationRestrictive compliance conditions

on registration0 2.0

C SafetyModerate CQC concerns regarding the

safety of healthcare provision0 1.0

D SafetyMajor CQC concerns regarding the safety of

healthcare provision0 2.0


Compliance Action0 2.0


Enforcement Action0 4.0

G Safety



CNST level of 1.0 or have in place

appropriate alternative arrangements

0 2.0

TOTAL 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Insert YES (target met in month), NO (not met in month) or N/A (as appropriate)AMBULANCE



and Warwickshire NHS Trust

3 GRR Amb Page 6 of 21 Enc 9.1 - PMR June 2012


old

Weight-


Mar



1 Saf ety Clostridium Dif f icileAre you below the ceiling for your monthly

trajectory

Contract with

PCT1.0

2 Saf ety MRSAAre you below the ceiling for your monthly

trajectory

Contract with

PCT1.0

18 Quality Delay ed Transf ers of CareAre you below the ceiling for your monthly

trajectory

Contract with

PCT0.5

19Patient

ExperienceGUM Access - within 48 hours 95th percentile ≤ 48 hrs 0.5

20 Ef f ectiv eness Chlamy dia ScreeningContract with

PCT0.5

21 Ef f ectiv eness Smoking quittersContract with

PCT0.5

8a Quality Minor Injuries Unit / A&E (Q1):Total time

(95th percentile)≤ 4 hrs 1.0

Total time

(95th percentile)≤4 hrs

Time to initial assessment

(95th percentile)≤15 mins

Time to treatment decision (median) ≤60 mins

Unplanned re-attendance rate ≤5%

Left without being seen ≤5%

22Patient

Experience6 week wait f or diagnostic 100% ≤ 6 wks 0.5

23 Saf ety New birth v isitsContract with

PCT0.5

24 Ef f ectiv eness HPV (Human Papillomav irus) UptakeContract with

PCT0.5

25Patient

Experience

Community equipment store response

within sev en day s100% ≤ 7 day s 0.5

26a Saf etyUrgent District Nurse response within 24

hours100% ≤ 24 hrs 0.5

26bPatient

Experience

Non-urgent District Nurse response within

48 hours100% ≤ 48 hrs 0.5

17Patient

experience

Certif ication against compliance with


healthcare f or people with a learning

disability

N/A 0.5

CQC Registration

A Saf ety CQC RegistrationAre there anycompliance conditions on

registration outstanding.0 1.0

B Saf ety CQC RegistrationAre there anyrestrictive compliance conditions

on registration outstanding.0 2.0

C Saf etyModerate CQC concerns regarding the

saf ety of healthcare prov ision0 1.0

D Saf etyMajor CQC concerns regarding the saf ety

of healthcare prov ision0 2.0

E Saf etyFormal CQC Regulatory Action resulting

in Compliance Action0 2.0

F Saf etyFormal CQC Regulatory Action resulting

in Enf orcement Action0 4.0

G Saf ety


maintain, or certif y a minimum published

CNST lev el of 1.0 or hav e in place

appropriate alternativ e arrangements

0 2.0

TOTAL 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

COMMUNITY TRUST


University Hospitals Coventry and

Warwickshire NHS TrustInsert YES (target met in month), NO (not met in month) or N/A (as appropriate)

See separate rule for MIU/A&E

8b Quality

MIU / A&E/ WiC (f rom Q2):

NB Please record the areas not being met

in the comments column

No

weighting

3 GRR Comm Page 7 of 21 Enc 9.1 - PMR June 2012

FINANCIAL RISK RATING 2012/13

Criteria Indicator Weight 5 4 3 2 1

Annual

Plan

2011/12

Apr-12 May-12 Jun-12

Mar

Comments on Performance in Month

Underlying

performanceEBITDA margin % 25% 11 9 5 1 <1 5 4 4

Forecast performance is 10.7% for 2012/13

Achievement

of planEBITDA achieved % 10% 100 85 70 50 <50 4 4 4

Return on assets % 20% 6 5 3 -2 <-2 3 3 3This is the score for Net Return after Financingas calculated under the new Monitor ComplianceFramework

I&E surplus margin % 20% 3 2 1 -2 <-2 2 2 2 12/13 Plan shows a 0.5% surplus

Liquidity Liquid ratio days 25% 60 25 15 10 <10 2 2 2Improvement necessitates ongoing increases inliquidity

Average Weighted Average 100% 0.0 3.2 2.9 2.9 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Overriding

rulesOverriding rules

Overall

ratingFinal Overall rating 0.0 3.0 3.0 3.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Weighted average adjsuted to reflect overallfinancial efficiency score

Overriding Rules :

Max Rating

3322312 Two Financial Criteria at "2"

Plan not submitted complete and correctPDC divident not paid in full

Insert the Score (1-5) Achieved for each Criteria Per Month

One Financial Crieterion at "1"One Financial Crieterion at "2"

Plan not submitted on time

Two Financial Criteria at "1"

Financial

efficiency

Risk Ratings

University Hospitals Coventry and Warwickshire NHSTrust

Rule

4 FRR Page 8 of 21 Enc 9.1 - PMR June 2012

FINANCIAL RISK TRIGGERS 2012/13

Criteria Apr-12 May-12 Jun-12 Mar Comments on Performance in Month

1Unplanned decrease in EBITDA margin in twoconsecutive quarters

No No Yes

Based on Q4 performance for 2011/12 & Q1 for 2012/13. Q4performance last financial year was below planned levels by0.3%. EBITDA margin for Q1 2012/13 is currently 0.5%behind plan.

Q3 11/12 performance was above planne levels which causedthe previous months indicators to be green

2Quarterly self-certification by trust that the financial riskrating (FRR) may be less than 3 in the next 12 months

No No NoForecast outturn for 2012/13 remains at 3 - under the newcompliance frameowrk

3 FRR 2 for any one quarter Yes Yes YesThe Month 3 in-year performance is an FRR of 2 - althoughthe forecast for 2012/13 delivery remains at 3

4Working capital facility (WCF) agreement includes defaultclause

n/a n/a n/aCurrently we do not have a WCF

5Debtors > 90 days past due account for more than 5% oftotal debtor balances

Yes Yes YesAction - Increased focus on debt recovery

6Creditors > 90 days past due account for more than 5% oftotal creditor balances

Yes Yes YesIssues around large intra-NHS balances

7Two or more changes in Finance Director in a twelvemonth period

No No No

8Interim Finance Director in place over more than onequarter end

No No NoSubstantive Chief Finance Officer appointed. Commenced inpost 1st January 2012.

9Quarter end cash balance <10 days of operatingexpenses

Yes Yes YesImprovement necessitates ongoing increases in liquidity - M32012/13 position also <10 days of operating expenditure

10 Capital expenditure < 75% of plan for the year to date No No NoCapital expenditure < 75% of plan for Month 3

TOTAL 4 4 5 0 0 0 0 0 0 0 0 0

NB Scoring: An answer of "YES" = 1.0

RAG RATING :

GREEN = Score between 0 and 1

AMBER = Score between 2 and 4

RED = Score over 5


Insert "Yes" / "No" Assessment for the Month

5 Fin Risk Triggers Page 9 of 21 Enc 9.1 - PMR June 2012

CONTRACTUAL RISK RATINGS2012/13

Criteria RAG Apr-12 May-12 Jun-12 Comments on Performance in Month

All key contracts are agreed and signed.Both the NHS Trust and commissioner arefulfilling the terms of the contract.There are no disputes or performance notices inplace.

G

The NHS Trust and commissioner are in disputeover the terms of the contract.Performance notices have been issued by one orboth parties.

A A A A

Full sign-off of the 2012/13 contract.However, there is still a contract querywhich has not been closed down from 11/12relating to the performance against the 95thpercentile total time spent by patients in theA&E department clinical quality indicator

One or more key contract is not signed by thestart of the period covered by the contract.There is a dispute over the terms of the contractwhich might, or will, necessitate SHA interventionor arbitration.The parties are already in arbitration.

R

University Hospitals Coventry and WarwickshireNHS Trust

Insert R, A or G into appropriate row for the Month

6 CRR Page 10 of 21 Enc 9.1 - PMR June 2012

Unit Apr-12 May-12 Jun-12 Mar Comments on Performance in Month

1 SHMI - latest data Ratio 105.3 105.3 105.3The SHMI is produced and published quarterly by the NHSIC. 105.3 relates to published data in April.

2Venous Thromboembolism(VTE) Screening

% 93.4 93.3 92.3

3a Elective MRSA Screening % 137.96 125.52 136.361740 tests were undertaken on patients needing screeningout of the 1276 total number of admissions.

3bNon Elective MRSAScreening

% 65.28 69.99 69.9

4Single Sex AccommodationBreaches

Number 0 0 0

5Open Serious IncidentsRequiring Investigation (SIRI)

Number16

7

16

1

22

2

Open SIRIsNumber that were over the 45 day target on the last day ofthe month

6 "Never Events" in month Number 0 0 1 Never event - ?retained swab post-operatively

7CQC Conditions or WarningNotices

Number 0 0 0

8Open Central Alert System(CAS) Alerts

Number 12 13 13

9RED rated areas on yourmaternity dashboard?

Number 2 2 11. Caesarean section rate 29.47% but this includes Caesarean sections performed

on patients outside of Coventry postcodes.

10Falls resulting in severeinjury or death

Number 0 2 3interpreted as those falls incidents graded as 'major' or'catastrophic'

11 Grade 3 or 4 pressure ulcers Number 2 1 4 Hospital Acquired - avoidable

12100% compliance with WHOsurgical checklist

Y/N N N N Apr 97.7%, May 98.4%, June 98.9%

13 Formal complaints received Number 41 44 29

14Agency and bank spend as a% of turnover

% 2.9 3.4 3.06

15 Sickness absence rate % 4.59 4.69 4.73


Insert Performance in Month

QUALITY

Criteria

7 Quality Page 11 of 21 Enc 9.1 - PMR June 2012

For each statement, the Board is asked to confirm the following:

For CLINICAL QUALITY, that: Response

1

If the Trust Board is unable to make the above statement, the Board must:

2

3

4

5

For SERVICE PERFORMANCE, that: Response

6 For RISK MANAGEMENT PROCESSES, that: Response

7

8 9

10

11 Response

12 Response

13 14 15 16 17

Signed on behalf of the Trust: Print name Date

CEO Andrew Hardy

Philip Townshend

Chair Philip Townshend

The management structure in place is adequate to deliver the annual plan objectives for the next three years.

The Board is satisfied that all directors are appropriately qualified to discharge their functions effectively, includingsetting strategy, monitoring and managing performance, and ensuring management capacity and capability

The selection process and training programmes in place ensure that the non-executive directors have appropriateexperience and skills


A Statement of Internal Control (“SIC”) is in place, and the trust is compliant with the risk management and assuranceframework requirements that support the SIC pursuant to the most up to date guidance from HM Treasury (seehttp://www.hm-treasury.gov.uk)

For BOARD, ROLES, STRUCTURES AND CAPACITY, that:

The Board is satisfied that, to the best of its knowledge and using its own processes and having had regard to the SHA'sProvider Management Regime (supported by Care Quality Commission information, its own information on seriousincidents, patterns of complaints, and including any further metrics it chooses to adopt), its NHS trust has, and will keepin place, effective arrangements for the purpose of monitoring and continually improving the quality of healthcareprovided to its patients.

Be satisfied that, to the best of its knowledge and using its own processes (supported by CQC information and includingany further metrics it chooses to adopt), its Trust has, and will keep in place, effective arrangements for the purpose ofmonitoring and continually improving the quality of healthcare provided to its patients.

Be satisfied that, to the best of its knowledge and using its own processes, plans in place are sufficient to ensureongoing compliance with the CQC's registration requirements

Certify it is satisfied that processes and procedures are in place to ensure that all medical practitioners providing careon behalf of the NHS foundation trust have met the relevant registration and revalidation requirements.

June 2012Board Statements

Issues and concerns raised by external audit and external assessment groups (including reports for NHS LitigationAuthority assessments) have been addressed and resolved. Where any issues or concerns are outstanding, the boardis confident that there are appropriate action plans in place to address the issues in a timely manner

All recommendations to the board from the audit committee are implemented in a timely and robust manner and to thesatisfaction of the body concerned

Be satisfied that the Trust is embedding patient experience into the service design, improvement and delivery cycle.

The board is satisfied that plans in place are sufficient to ensure ongoing compliance with all existing targets (after theapplication of thresholds), and compliance with all targets due to come into effect during 2011/12.

The necessary planning, performance management and risk management processes are in place to deliver the annualplan

The management team have the capability and experience necessary to deliver the annual plan

For COMPLIANCE WITH THE NHS CONSTITUTION, that:

The Board maintains its register of interests, and can specifically confirm that there are no material conflicts of interestin the Board

The trust has achieved a minimum of Level 2 performance against the key requirements of the Department of Health’sInformation Governance Toolkit

The Board is assured that the trust will, at all times, have regard to the NHS constitution

8 Bd Statements Page 12 of 21 Enc 9.1 - PMR June 2012

NHS Midlands and East Provider Management Regime

Area Details

1 C.Diff Performance against contract with main commissioner

2 MRSA

MRSA objective: those trusts which are not in the best performing quartile for MRSA should deliver performance that is at least in line with theMRSA objective target figures calculated for them by DH. The SHA expects those NHS trusts without a centrally calculated MRSA objective toagree an MRSA target for 2011/12 that at least maintains existing performance.

Where a trust has an annual MRSA objective of six cases or fewer and has reported six cases or fewer in the year to date, the MRSAobjective will not apply for the purposes of the SHA's Provider Management Regime

If a trust with an annual objective of six cases or fewer declares a risk of exceeding the de minimis level and its annual MRSA objective in-year, but has not yet done so, it will be required to [provide, and then] report monthly against, an MRSA action plan until the risk has beensatisfactorily addressed.

3Cancer:31 day wait

31-day wait: measured from cancer treatment period start date to treatment start date. Failure against any threshold represents a failureagainst the overall target. The target will not apply to trusts having five cases or less in a quarter.

4Cancer:62 day wait

62-day wait: measured from day of receipt of referral to treatment start date. This includes referrals from screening service and otherconsultants, including consultant upgrades. Failure against either threshold represents a failure against the overall target. The target will notapply to trusts having five cases or less in a quarter.

For patients referred from one provider to another, breaches of this target are automatically shared and treated on a 50:50 basis. Thesebreaches may be reallocated in full back to the referring organisation(s) provided there is written agreement to do so between the relevantproviders (signed by both Chief Executives) in place at the time the trust makes its monthly declaration to the SHA.

RTTWhile performance is measured on an aggregate basis, NHS trusts are required to meet the threshold on a monthly basis – consequentlyfailure in any month represents failure for the quarter and should be reported via the exception reporting process.

6 Cancer Measured from decision to treat to first definitive treatment. The target will not apply to trusts having five cases or fewer in a quarter.

7 CancerMeasured from day of receipt of referral – existing standard (includes referrals from general dental practitioners and any primary careprofessional). Failure against either threshold represents a failure against the overall target. The target will not apply to trusts having fivecases or fewer in a quarter.Specific guidance and documentation concerning cancer waiting targets can be found at:http://nww.connectingforhealth.nhs.uk/nhais/cancerwaiting/documentation

8a A&E (Q1) In Quarter one - 95th percentile waits for 4 hours or less to be used

8b A&E (Q2) From Quarter two:• 95th percentile waits for 4 hours or less to be used• Time to initial assessment: for ambulance arrivals. Initial assessment to include a pain score and early warning score.• Time to treatment decision: time from arrival to see a decision-making clinician (defining management plan and may potentially discharge• Unplanned reattendance rate: within 7 days of original attendance. Includes patients referred back by another health professional. The SHAwill not score this for paediatric specialist NHS trusts.• Left without being seenThe SHA will keep these measures under review during 2011/12 and may change its implementation in line with national policy.

9 Stroke The SHA will consider its introduction during 2011/12 following publication of DH's technical guidance.

10 Mental 7-day follow up:Health:CPA

Numerator:The number of people under adult mental illness specialties on Care Programme Approach who were followed up (either by face-to-facecontact or by phone discussion) within seven days of discharge from psychiatric inpatient care.Denominator:the total number of people under adult mental illness specialties on Care Programme Approach who were discharged from psychiatricContact can include face-to-face or telephone contact. Guidance on what should and should not be counted when calculating theachievement of this target can be found on Unify2.For 12 month review (from Mental Health Minimum Data Set):

Numerator:The number of adults in the denominator who have had at least one formal review in the last 12 months. Date last seen by care coordinatorwill be used as a proxy for formal Care Programme Approach review during 2011/12.Denominator:The total number of adults who have received secondary mental health services and who were on the Care Programme Approach at anypoint during the reporting period.For full details of the changes to the Care Programme Approach process, please see the implementation guidance, Refocusing the CareProgramme Approach on the Department of Health’s website.All patients discharged to their place of residence, care home, residential accommodation, or to non-psychiatric care must be followed upwithin seven days of discharge. Where a patient has been transferred to prison, contact should be made via the prison in-reach team.Exemptions from both the numerator and the denominator of the indicator include:

• patients who die within seven days of discharge;• where legal precedence has forced the removal of a patient from the country; or• patients discharged to another NHS psychiatric inpatient ward.

11 Mental Health: Numerator:The number of non-acute patients (aged 18 and over) whose transfer of care was delayed averaged over the quarter.

DTOC Denominator:Number of non-acute patients (aged 18 and over) admitted to the trust, summed across the quarter. Delayed transfers of care attributable tosocial care are excluded.

12 Mental This indicator applies only to admissions to the NHS trust’s mental health psychiatric inpatient care. The following cases can be excluded:

Health: • admissions to psychiatric intensive care units;I/P and • internal transfers of service users between wards in a trust and transfers from other trusts;CRHT • patients recalled on Community Treatment Orders; or

• patients on leave under Section 17 of the Mental Health Act 1983.An admission has been gate-kept by a crisis resolution team if they have assessed the service user before admission and if they wereinvolved in the decision-making process, which resulted in admission.For full details of the features of gate-keeping, please see Guidance Statement on Fidelity and Best Practice for Crisis Services on theDepartment of Health’s website.As set out in Guidance Statement on Fidelity and Best Practice for Crisis Services the crisis resolution home treatment team should:

a) provide a mobile 24 hour, seven day a week response to requests for assessments;b) be actively involved in all requests for admission: for the avoidance of doubt, ‘actively involved’ requires face to face contact unless it can be

demonstrated that face-to-face contact was not appropriate or possible. For each case where face-to-face contact is deemed inappropriate,a declaration that the face-to-face contact was not the most appropriate action from a clinical perspective will be required;

c) be notified of all pending Mental Health Act assessments;d) be assessing all these cases before admission happens; and

The SHA will not utilise a general rounding principle when considering compliance with these targets and standards, e.g. a performance of 94.5% will be considered as failing to

achieve a 95% target. However, exceptional cases may be considered on an individual basis, taking into account issues such as low activity or thresholds that have little or no

tolerance against the target, e.g. those set between 99-100%.

Ref

5a&b

Thresh-

olds

Notes Page 13 of 21 Enc 9.1 - PMR June 2012

NHS Midlands and East Provider Management Regime

Area DetailsRef

e) be central to the decision making process in conjunction with the rest of the multidisciplinary team

13 Mental HealthMonthly performance against commissioner contract. Threshold represents a minimum level of performance against contract performance,rounded down.

14 Mental Patient identity data completeness metrics (from Mental Health Minimum Data Set) to consist of:Health: • NHS number;MDS • Date of birth;

• Postcode (normal residence);• Current gender;• Registered General Medical;• Practice organisation code; and• Commissioner organisation code.

Numerator: count of valid entries for each data item above.NB For details of how data items are classified as VALID please visit the data quality constructions available on the Information Centre’s website:

www.ic.nhs.uk/services/mhmds/dqDenominator: total number of entries.

15 Mental Outcomes for patients on Care Programme Approach:Health: • Employment status:CPA Numerator:

The number of adults in the denominator in paid employment (i.e. those recorded as ‘employed’) at the time of their most recent assessment,formal review or other multi-disciplinary care planning meeting, in a financial year. Include only those whose assessments or reviews werecarried out during the reference period. The reference period is the last 12 months working back from the end of the reported quarter.

Denominator:The total number of adults (aged 18-69) who have received secondary mental health services and who were on the Care ProgrammeApproach at any point during the reported quarter.

• In settled accommodation:Numerator:The number of adults in the denominator who were in settled accommodation at the time of their most recent assessment, formal review orother multi-disciplinary care planning meeting. Include only those whose assessments or reviews were carried out during the referenceperiod. The reference period is the last 12 months working back from the end of the reported quarter.Denominator:The total number of adults (aged 18-69) who have received secondary mental health services and who were on the Care ProgrammeApproach at any point during the reported quarter.

• Having an HoNOS assessment in the past 12 months:Numerator:The number of adults in the denominator who have had at least one HoNOS assessment in the past 12 months. NOTE: When implementedMHMDS v4 will allow services to report all HoNOS variants, including those for young people and people in secure services. Until this timetrusts should report standard HoNOS inclusive of all ages and ward types.Denominator:The total number of adults who have received secondary mental health services and who were on the Care Programme Approach during thereference period.

AmbulanceCat A

Life threatening

17 Learning Meeting the six criteria for meeting the needs of people with a learning disability, based on recommendations set out in Healthcare for All(2008):a) Disabilities:

AccessDoes the NHS trust have a mechanism in place to identify and flag patients with learning disabilities and protocols that ensure that pathwaysof care are reasonably adjusted to meet the health needs of these patients?

b) to healthcare Does the NHS trust provide readily available and comprehensible information to patients with learning disabilities about the following criteria?:• treatment options;• complaints procedures; and• appointments.

c) Does the NHS trust have protocols in place to provide suitable support for family carers who support patients with learning disabilities?d) Does the NHS trust have protocols in place to routinely include training on providing healthcare to patients with learning disabilities for all

staff?e) Does the NHS trust have protocols in place to encourage representation of people with learning disabilities and their family carers?f) Does the NHS trust have protocols in place to regularly audit its practices for patients with learning disabilities and to demonstrate the findings

in routine public reports?Note: Boards are required to certify that their trusts meet requirements a to f above at the annual plan and in each quarter. Failure to do sowill result in the application of the service performance score for this indicator.

18 DTCs Performance against contract with main commissioner

19 GUM Access to GUM within 48hours against a target of 95% compliance.Access

20 Chlamydia Performance against contract with main commissionerScreening

21 Smoking Performance against contract with main commissionerQuitters

22 6 Wk Wait Access to diagnostics against a target of 100% complianceDiagnostics

23 New birth Performance against contract with main commissionervisits

24 HPV Human Papillomavirus (HPV) uptakePerformance against contract with main commissioner

25 Comm'ty Responses within 7 daysEquip Store

26 a Urgent DN Response by a DN within 24 hours of receiving an urgent request / referral

26 b Non-Urgent DN Response by a DN within 48 hours of receiving a non-urgent request / referral

16a

Notes Page 14 of 21 Enc 9.1 - PMR June 2012



25th

July 2012

1

Subject: UHCW Operational Performance ReportReport By: Sharon Beamish, Interim Chief Operating OfficerAuthor: Simon Reed, Head of Performance ManagementAccountable Executive Director: Sharon Beamish, Interim Chief Operating Officer

GLOSSARY

Abbreviation In FullDH Department of HealthUHCW University Hospitals Coventry and WarwickshireSHAs Strategic Health AuthoritiesPCTs Primary Care Trusts



TitleApprox. Length


To update the board on the current operational performance position for the Trust against the nationalDH and Monitor performance frameworks and the regional East and Midlands SHA performanceframework


Performance against the Monitor Compliance Framework:

PERIOD April 2012 May 2012 June 2012 QUARTERONE

RATING Amber/Green Amber/Green Amber/Red Amber/Red

Performance against the NHS Performance Framework

Performance Against the East and Midlands SHA Provider Management Regime



ContractualPosition


Green (3.0) Amber


Green (3.0) Amber


Green (3.0) Amber

PERIOD April 2012 May 2012 June 2012 QUARTERONE

RATING Performing PerformingPerformanceUnder Review

PerformanceUnder Review



25th

July 2012

2


TARGETS IN EXCEPTION

Performance against the C-diff target Performance against the total time in A&E – 95% of patients should be seen within four hours target Performance against the Delayed transfers of care target

TARGETS POSING A CHALLENGE FOR 2012/13

Performance against the MRSA target Maximum time of 18 weeks from point of referral to treatment in aggregate – admitted Maximum time of 18 weeks from point of referral to treatment in aggregate – non-admitted Maximum time of 18 weeks from point of referral to treatment in aggregate – patients on an

incomplete pathway RTT delivery in all specialties


Trust Board are asked to endorse the following key actions being undertaken by management to addressthe exceptions highlighted in Section 3 of the report:

o C-diff: The Trust is delivering a range of actions including initiating deep clean program, increasedinspections and the development and launch of 100 days free campaign

o A&E: Maximum waiting time of four hours from arrival to admission/transfer/discharge: UHCW hasdeveloped two robust action plans: one focusing on front door improvements and the otherdischarge planning

o Delayed transfers of care: The Trust has an internal Discharge Action Plan and there are alsospecific relevant actions in the Arden Cluster work plan

Trust Board are asked to endorse actions being undertaken by management to address the challengingtargets highlighted in Section 4 of the report

IMPLICATIONS:

Financial: Financial penalties may be applied by PCTs if 2012/13 CQUIN and QualitySchedule targets and standards are not achieved. The worst case scenario is2% of the 2012/13 contract value for Quality Schedule targets and standardsand 2.5% of 2012/13 out-turn for not achieving the CQUIN targets.

HR / Equality & Diversity: None identified

Governance: Performance against the Monitor Compliance Framework rating and PMRsubmission will impact on the trusts ability to move forward with its FoundationTrust application.

Performance against the DH Performance Framework rating has significantconsequences for the Trust Board, if UHCW is rated as ‘Underperforming’ forthree consecutive quarters.

Legal:



25th

July 2012

3

REVIEW:

Trust Standing Committee Date Trust Standing Committee DateQuality Governance Committee Remuneration CommitteeFinance and Performance Committee 23/07/2012 Executive MeetingAudit Committee

DATA QUALITY:



REPORT TO TRUST BOARD MEMBERS – JULY 2012

4

PERFORMANCE REPORT FOR JUNE 2012

1. EXECUTIVE SUMMARY OF PERFORMANCE

This Executive version of the 2012/13 Performance Report is presented toTrust Board on a monthly basis and a more detailed version of the report ispresented to the Finance & Performance (F&P) Committee (which is a sub-committee of the Trust Board) on a monthly basis. This Executive version ofthe Performance Report highlights performance against the two Nationalperformance frameworks and the regional performance framework managedby the East and Midlands Strategic Health Authority:

2012/13 Monitor Compliance Framework (national) 2012/13 Department of Health NHS Performance Framework (national) 2012/13 Provider Management Regime (regional)

The Performance Report highlights targets in exception against requiredthresholds (section 3) and targets which will pose the University Hospitals ofCoventry and Warwickshire a challenge to deliver in 2012/13 (section 4).

The more detailed version of the report, to the F&P Sub Committee includesappendices on the above frameworks and an appendix which showsperformance against contract targets, including progress on CQUIN schemes.

1.1. Monitor Compliance Framework Rating

Table 1 shows monitoring by UHCW for the period 1 April to 30 June 2012against the Monitor Compliance Framework Indicators. The Table belowprovides the Trust’s assessment for the Monitor Compliance Frameworkrating, based on the current level of performance.

Table 1

PERIOD April 2012 May 2012 June 2012 QUARTER ONERATING Amber/Green Amber/Green Amber/Red Amber/Red

If a target in the Monitor Compliance Framework is failed by a Trust aweighted penalty is levied by Monitor. The risk ratings above are based onthe sum of the penalties against the thresholds in Table 2 below (a lowpenalty score is good)

Table 2

Rating ScoreGreen < 1.0Amber-Green ≥ 1.0 and < 2.0 Amber-Red ≥ 2.0 and < 4.0 Red ≥ 4.0

Detailed performance monitoring by month against the Monitor ComplianceFramework is undertaken and is presented monthly to the Finance andPerformance Committee.



5

1.2. Department of Health NHS Performance Framework Rating

The NHS Performance Framework Implementation Guidance sets out theDepartment of Health’s (DH) approach to supporting Strategic HealthAuthorities (SHAs) and Primary Care Trusts (PCTs) to identify and tacklepoor performance of NHS providers (non Foundation Trusts).

Organisations will be measured against a series of indicators, categorisedunder the two key domains below:

Finance Quality of Services

The lowest score across these domains will determine the overallorganisations performance category, which is based on a three pointscale of: Performing, Performance under Review or Underperforming, andthe subsequent level of intervention and escalation.

Under the escalation process organisations with a rating ofUnderperforming for three consecutive quarters could be deemed aschallenged.

Performance of Acute Trusts is communicated in the DH publication TheQuarter.

Table 3 below provides the Trust’s assessment for the NHS PerformanceFramework quality of services rating, based on the current level ofperformance.

Table 3

PERIOD April 2012 May 2012 June 2012QUARTER

ONE

RATING Performing PerformingPerformanceUnder Review

PerformanceUnder Review

The DH applies a score of 3 if a Trust achieves the “Performing” thresholdspecified for each target, a score of 2 if a Trust fails against the “Performing”threshold but achieves the “Underperforming” threshold and 0 for failing atarget. The ratings above are based on a weighted average of these scoresagainst the thresholds in Table 4 below (a high score is good).

Table 4

Rating ScorePerforming ≥ 2.4 Performance under review ≥ 2.1 and < 2.4Underperforming < 2.1

Detailed performance monitoring by month against the DH PerformanceFramework is undertaken and is presented monthly to the Finance andPerformance Committee



6

1.3. East and Midlands SHA Provider Management Regime

The SHA wide Provider Management Regime (PMR) has now been rolled out whicheach Trust is required to complete on a monthly basis.

Based on the data provided by the relevant leads the Trust risk ratings are asdetailed in Table 5;

Table 5



ContractualPosition


Green (3.0) Amber


Green (3.0) Amber


Green (3.0) Amber

2. CURRENT PERFORMANCE (Table 6)

No TARGET 2012_13

Mo

nit

or

Co

mp

lian

ce

Fra

mew

ork

2012_13

NH

SP

erf

orm

an

ce

Fra

mew

ork

THRESHOLD Jun12Trend

(2)Risk(3) RAG

E1Clostridium Difficile –meeting the ClostridiumDifficile objective

<=70 19 High R

C2

Methicillin-resistantStaphylococcus aureus(MRSA) bacteraemia –meeting the MRSA objective

<=2 0.00 High G

3

All cancers: 31-day wait forsecond or subsequenttreatment, comprising –surgery (1)

>=94% 100% Low G

4

All cancers: 31-day wait forsecond or subsequenttreatment, comprising - anticancer drug treatments (1)

>=98% 100% Low G

5

All cancers: 31-day wait forsecond or subsequenttreatment, comprising –radiotherapy (1)

>=94% 97.95% Low G



7

No TARGET 2012_13

Mo

nit

or

Co

mp

lian

ce

Fra

mew

ork

2012_13

NH

SP

erf

orm

an

ce

Fra

mew

ork


(2)Risk(3) RAG

6

All cancers: 62-day wait forfirst treatment - from urgentGP referral for suspectedcancer (1)

>=85% 85.14% Low G

7

All cancers: 62-day wait forfirst treatment - from NHSCancer Screening Servicereferral (1)

>=90% 100% Low G

C8

Maximum time of 18 weeksfrom point of referral totreatment in aggregate –admitted (1)

>=90% 94.19% High G

C9

Maximum time of 18 weeksfrom point of referral totreatment in aggregate –non-admitted (1)

>=95% 97.33% High G

C10

Maximum time of 18 weeksfrom point of referral totreatment in aggregate –patients on an incompletepathway (1)

>=92% 96.87% High G

C11RTT delivery in allspecialties (1)

0 2 High G

12Diagnostic Test WaitingTimes (1)

<1% 0.03% Low G

13All cancers: 31-day waitfrom diagnosis to firsttreatment (1)

>=96% 99.70% Low G

14

Cancer: two week wait fromreferral to date first seen,comprising - all urgentreferrals (cancer suspected)(1)

>=93% 94.95% Low G

15

Cancer: two week wait fromreferral to date first seen,comprising - for symptomaticbreast patients (cancer notinitially suspected) (1)

>=93% 97.03% Low G

E16A&E: maximum waiting timeof four hours from arrival toadmission/transfer/discharge

>=95% 93.91% High R



8

No TARGET 2012_13

Mo

nit

or

Co

mp

lian

ce

Fra

mew

ork

2012_13

NH

SP

erf

orm

an

ce

Fra

mew

ork


(2)Risk(3) RAG

17

Certification againstcompliance with req accessto healthcare for people withlearning disability

Compliance G Low G

E18 Delayed transfers of care <=3.5% 5.21% High R

19Mixed sex accomodationbreaches

0.00% 0.00 Low G

20 VTE Risk Assessment >=90% 93.35 Low G

(1)Due to validation processes undertaken against this target the data for May is included inthis report. The data for June 2012 will be included in next month’s report.

(2)Trend Key:

Improving performancePerformance remaining the sameDeteriorating performance

(3)Risk Key:

HighDelivery of target assessed as high risk through regular performance managementmeetings

MediumDelivery of target assessed as medium risk through regular performancemanagement meetings

LowDelivery of target assessed as low risk through regular performance managementmeetings

3. EXCEPTION REPORTS

The following indicators have been assessed as red across one or both of thetwo national performance frameworks.

E1: CLOSTRIDIUM DIFFICILE – MEETINGTHE CLOSTRIDIUM DIFFICILE OBJECTIVE

KEY ACTIONS/COMMENTS:

This indicator is in exception (RED) in the followingperformance frameworks:

o 2012/13 Monitor Compliance Frameworko 2012/13 NHS Performance Framework

In June 2012 there were 8 c-diff infections inUHCW. This is 2 (33.3%) above the maximumtarget of 6 for June 2012. Cumulatively for theperiod April to June 2012 there were 19 c-diffinfections in UHCW. This is 1 (5.6%) above thecumulative target of 18.

ACTIONS:



9

TRUST LEVEL - NUMBER OF C-DIFF INFECTIONS

0

50

100

Apr-

12

May-1

2

Jun-1

2

Jul-12

Aug-1

2

Sep-1

2

Oct-

12

Dec-1

2

Dec-1

2

Jan-1

3

Feb-1

3

Mar-

13

Number of monthly C-Diff

Infections

Number of cumulative C-Dif f

Infections

TRUST CUMULATIVE TARGET

(Denominator)

Actions taken include:o Deep clean program initiated in high risk

areas (Starting ED – June)o Trust wide ICNA environment scoring and

compliance checking of cleaning standardso Increased unannounced environment audit

inspections on wards and departmentso Communication to clinical staff reinforcing C

Diff management guidanceo Escalation meetings with specialities with C

Diff cases, with RCA actions in Performanceframework meetings

o Development and launch of 100 days freecampaign for CDiff, including hand hygienecompliance training, antibiotic training andawareness as well as ICNA/Maximisercompliance tracking at bi-monthlyoperational cleaning performance meetingchaired by CNO.

E16: A&E: MAXIMUM WAITING TIME OFFOUR HOURS FROM ARRIVAL TOADMISSION/TRANSFER/DISCHARGE


This indicator is in exception (RED) in the followingperformance framework:o 2012/13 Monitor Compliance Frameworko 2012/13 NHS Performance Framework

During June 2012, 814 patients out of 14,062attendances at A&E were seen outside of 4 hours.This means that UHCW’s performance was at94.21% or 0.79% below the minimum target of95%. Cumulatively for the period April to June2012, 2,711 patients out of 44,541 attendances atA&E were seen outside of 4 hours. This meansthat UHCW’s cumulative performance was at93.91% or 1.09% below the target.

ACTIONS:

UHCW TRUST - PERCENTAGE OF A&E PATIENTS SEEN WITHIN 4 HOURS FROM ARRIVAL TO

ADMISSION, TRANSFER OR DISCHARGE

90.00

91.00

92.00

93.00

94.00

95.00

96.00

97.00

98.00

99.00

100.00

Ap

r-1

2

Ma

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2

Ju

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2

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%

UHCWCumulative % Target >=95% UHCWMonth%

In response to the current front door 95% performanceUHCW has developed two robust action plans: onefocusing on front door improvements and the otherdischarge planning. These plans focus on the followingareas:

Capacity and control functions Required developments aimed at supporting and

improving current processes Speeding up of assessment Improved discharge planning

These are monitored and performance managedthrough a series of project groups which feed throughto the newly established patient flow steering group.



10

In addition Newton have been appointed to reviewprocesses in ED with the view to replicating thesuccess they had in driving up performance inGloucester by driving out the waits in the pathway

Daily capacity planning has been introduced with allwards required to identify their daily discharges to meettheir expected admissions (based on 6 weeks rollingactivity data)

The aim of this action plan is to support improvedperformance against the 95% target in a sustainablefashion, in readiness for winter pressures.

The action plan was agreed by the Strategic HealthAuthority and the PCT In May 2012

E18: DELAYED TRANSFERS OF CARE KEY ACTIONS/COMMENTS:

This indicator is in exception (RED) in the followingperformance framework:

o 2012/13 NHS Performance Framework This measures as the denominator, the total

number of beds as at the end of the month against,as the numerator, the number of acute patients(aged 18 and over) whose transfer of care wasdelayed each week. In June 2012 there were 60 or5.55% delays from 1,081 occupied beds. This is2.05% above the maximum target of 3.5%.Cumulatively for the period April to June 2012,there have been 167 or 5.21% delays from 3,208occupied beds. This is 1.71% above the target.

ACTIONS:

TRUST LEVEL - DELAYED TRANSFERS OF CARE AS A PERCENTAGE OF OCCUPIED BEDS

0.00

1.00

2.00

3.00

4.00

5.00

6.00

Ap

r-1

2

Ma

y-1

2

Ju

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%

%Month %Cumulative TRUST TARGET % The Trust recognises the position with regard toDelayed Transfers of Care and over the last six monthshas been working proactively to improve the situationand implement fundamental changes to dischargeplanning. It must however be recognised that this is ahealth economy wide responsibility, including UHCW.The Trust has good relationships with its partnerorganisations to work towards these improvements.The Trust has an internal Discharge Action Plan andthere are also specific relevant actions in the ArdenCluster work plan. The Trust has appointed aDischarge Director and a Lead Nurse for Patient CareStandards and Discharge, to drive the implementationand roll out of the action plans, with full roll out plannedby 31.7.12. The situation is strictly monitored internallyalongside twice weekly formal meetings with partnerorganisations.



11

The UHCW discharge action plan will address anumber of operational issues as well as implementing anumber of clinical actions across inpatient wards in theTrust such as daily board rounds, weeklyMultidisciplinary Team Meetings (MDT’s) to agreepathways for the more difficult to discharge patients.Many of the actions aim to improve UHCW internalprocesses and decision making with regard to patientflow and discharge. This will lead to a reduction ofinternal waits and the setting of more challengingtimescales with regard to discharge. A major risk of thisinternal improvement alone is that the pressure onexternal agencies will increase, leading to a potentialincrease in Delayed Transfers of Care, unless a healtheconomy approach is followed. The target of DelayedTransfers of Care must, therefore, not be considered asa target solely for one organisation, as improvement inperformance in this area requires engagement andcooperation from all agencies.

A key issue with driving down the DTOC is theavailability of Home Support (HSSTS) for patients.Despite the Partnership Trust increasing the hours ofthis service to over 1000 hours per week and usingexternal companies it cannot meet the demand and atany one time there are 20-30 patients awaiting support.This has been formally escalated to the commissionersin the last 7 days

In April this year the Trust was set a target by thecommissioners of 120 unsupported discharges eachday and the external agencies (Social services,Continuing Health, Intermediate Care etc) were set atarget of 20 supported discharges daily. UHCW has hitit’s target every day without fail but the number ofsupported discharges has rarely been achieved. Ifadditional capacity were to be found by the externalagencies for home support they too would then achievethe targets set them by the commissioners.

The SHA met with the Arden cluster during June todiscuss it’s concerns regarding the high levels of DTOCacross all 3 of the acute Trusts (West Midlands ishighlighted as an outlier nationally and Coventry ishighlighted as an outlier in the West Midlands) It wasmade very clear at the meeting that this was an healtheconomy target and the commissioners had a veryclear role to play in driving down the DTOC in Arden

The expectation is that the internal improvementswithin UHCW will be completed by the end of July2012.. The expectation is that these discussions willlead to a reduction in Delayed Transfers of Care by theend of Quarter 2 2012.



12

4. CHALLENGES (Not included in Section 3)

The following targets are considered to pose a challenge for UHCW to deliverduring 2012/13 and have been risk assessed as high in Table 5 (Section 2) ofthis report.

C2: METHICILLIN-RESISTANTSTAPHYLOCOCCUS AUREUS (MRSA)BACTERAEMIA – MEETING THE MRSAOBJECTIVE


During June there have been no MRSAinfections in UHCW. Cumulatively for the periodApril to June 2012 there have been no MRSAinfections. This target is considered to be achallenge because the target for the whole of2012/13 is only 2 MRSA cases.

ACTIONS:

TRUST LEVEL - NUMBER OF MRSA BACTERAEMIA

0

2

4

6

8

10

Ap

r-1

2

Ma

y-1

2

Ju

n-1

2

Ju

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Au

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Se

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De

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3

Number of monthly MRSA bacteraemias Infections

Number of cumulative MRSA bacteraemias Infections

TRUST CUMULATIVE TARGET (Denominator)

Delivery against this target is being closelymonitored by the Infection Control Team andSpecialty Groups

C8: MAXIMUM TIME OF 18 WEEKS FROMPOINT OF REFERRAL TO TREATMENT INAGGREGATE – ADMITTED


During May 2012, out of the 3,755 patientsadmitted for first definitive treatment, 3,537patients were treated within 18-weeks. This isequivalent to 94.19%, which is 4.19% above thetarget of 90% (218 patients were not treatedwithin 18 weeks)

ACTIONS:

Trust Level - percentage of Admitted patients seen within 18 weeks

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ap

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2

Ma

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Admitted adjusted

Target

Note: Validated data for this target is not availablefor June 2012 at the time of writing this report.

Fast track unvalidated data for June 2012 shows thatthis target continues to be achieved.

C9: MAXIMUM TIME OF 18 WEEKS FROMPOINT OF REFERRAL TO TREATMENT INAGGREGATE – NON-ADMITTED

KEY ACTIONS/COMMENTS



13

During May 2012, out of the 6,509 patientstreated through a non-admitted pathway for firstdefinitive treatment, 6,335 patients were treatedwithin 18 weeks. This is equivalent to 97.33%which is 2.33% above the target of 95% (174patients were not treated within 18 weeks)

ACTIONS:

Trust Level - percentage of Non Admitted patients seen within 18 weeks

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ap

r-1

2

Ma

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No

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Non Admitted

Target



C10: MAXIMUM TIME OF 18 WEEKS FROMPOINT OF REFERRAL TO TREATMENT INAGGREGATE – PATIENTS ON ANINCOMPLETE PATHWAY


At the end of May there were 17,140 patientswaiting for a first definitive treatment. Out ofthese, 16,603 had been waiting less than 18-weeks. This is equivalent to 96.87% which is4.87% above the target of 92% (537 patientswere waiting greater than 18 weeks)

ACTIONS:

Trust Level - percentage of Incomplete pathways within 18 weeks

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ap

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Incomplete

Target



C11: RTT DELIVERY IN ALL SPECIALTIES KEY ACTIONS/COMMENTS:

At the end of May there were 2 specialties wherethe three 18-week targets were not met(admitted, non-admitted and incomplete).Specialties failing the targets were:

o Trauma & orthopaedics (failed admittedand non-admitted and therefore T&O iscounted twice by the DH)

ACTIONS:

Trust Level - Total number of specialties not achieving RTT performance

0

1

2

3

4

5

6

7

8

9

10

Ap

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Oct

-12

No

v-1

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r-1

3


Fast track unvalidated data for June 2012 shows thatthe targets were achieved in every specialty exceptTrauma and Orthopaedics.



25th

July 2012

Subject: UHCW Finance Report for the Period to 30th

June 2012

Report By: Mrs G Nolan - Chief Finance Officer

Author: Miss S Oakley - Senior Finance ManagerMr A Hobbs - Associate Director of Finance – OperationsMrs S Rollason – Associate Director of Finance – Commissioning &InformationMr A Jones – Associate Director of Finance – Corporate Services

Accountable Executive Director: Mrs G Nolan - Chief Finance Officer

GLOSSARY

Abbreviation In FullBPPC Better Payments Practice CodeCIP Cost Improvement ProgrammeCLRN Comprehensive Local Research NetworkCQUIN Commissioning for Quality and InnovationCRL Capital Resource LimitDH Department of HealthEBITDA Earnings before Interest, Depreciation and AmortisationEFL External Financing LimitENT Ear, Nose and ThroatET&R Education, Training and ResearchGP General PractitionerHPC Healthcare Purchasing ConsortiumHR Human ResourcesI&E Income and ExpenditureICT Information and Communications TechnologyIFRS International Financial Reporting StandardsPDC Public Dividend CapitalPFI Private Finance InitiativeROA Return on AssetsUHCW University Hospitals Coventry and Warwickshire NHS TrustVAT Value Added TaxWTE Whole Time EquivalentYTD Year to DateRAG Red, Amber, Green (Risk rating scoring system)



TitleApprox. Length


• To update the Board as to the financial position of the Trust for the first three months of the 2012/13financial year and the forecast year end position.


• The month 3 position is a net expenditure deficit position of £4.4m which is in line with plan.

• The forecast surplus remains at £2.5m

• Escalation issues have been pursued through the Finance & Performance Committee



25th

July 2012


• £2.6m of additional savings over and above the original CIP requirement are necessary to achieve the£2.5m surplus forecast

• £10.1m of QIPP reductions are currently built into the income forecast. Plans for these reductions are notyet finalised (by commissioners). If these are realised in future months the associated expenditure isassumed removed from group positions. Plans to remove the expenditure have not yet been finalised.


The Trust Board is asked to:

• Note the content of the report in particular the Trust financial position in Month 3 of 2012/13

IMPLICATIONS:

Financial: Achieve statutory break-even duty and remain within CRL and EFL

HR / Equality & Diversity: None identified

Governance: None identified

Legal: None identified

REVIEW:


DATA QUALITY:


TRUST BOARD

Integrated Finance Report – as at Month 3 – 2012/13

Contents Page

Statement of Comprehensive Income 2

Statement of Financial Position 3

Cash-Flow 4

Capital Expenditure 5-6

Glossary 7

2

Statement of Comprehensive

IncomePlan

Forecast

OutturnVariance Plan Actual Variance Plan Actual Variance

£000 £000 £000 £000 £000 £000 £000 £000 £000

Income

Income from Activities 404,081 405,849 1,768 101,473 102,620 1,147 33,693 34,474 781Other Operating Income 68,999 70,982 1,983 17,479 17,893 414 5,642 5,630 (12)

Corporate Workstreams 269 269 0 0 0 0 0 0 0

Total Income 473,349 477,100 3,751 118,952 120,513 1,561 39,335 40,104 769

Operating Expenses

Pay (265,425) (277,451) (12,026) (67,731) (69,560) (1,829) (22,558) (23,392) (834)Non Pay (159,018) (171,627) (12,609) (40,516) (43,382) (2,866) (13,500) (14,347) (847)

Corporate Workstreams 11,582 5,992 (5,590) 29 0 (29) 29 0 (29)

CIP gap to target delivery 0 11,415 11,415 0 0Additional savings required 0 2,550 2,550 0 0 0 0 0 0

Reserves (12,696) (1,084) 11,612 (2,832) 138 2,970 (971) (63) 908QIPP 5,253 4,176 (1,077) 301 0 (301) 103 0 (103)

Total Operating Expenses (420,304) (426,029) (5,725) (110,749) (112,804) (2,055) (36,897) (37,802) (905)

EBITDA 53,045 51,071 (1,974) 8,203 7,709 (494) 2,438 2,302 (136)EBITDA Margin % 11.2% 10.7% 6.9% 6.4% 6.2% 5.7%

Non Operating Items

Profit / loss on asset disposals 0 0 0Fixed Asset Impairments 0 0 0Depreciation (23,096) (21,241) 1,855 (5,774) (5,310) 464 (1,925) (1,770) 155

Interest Receivable 96 85 (11) 24 21 (3) 8 6 (2)Interest Charges (462) (393) 69 (116) (98) 18 (39) (26) 13Financing Costs (23,213) (23,152) 61 (5,803) (5,788) 15 (1,934) (1,929) 5PDC Dividend (3,870) (3,870) 0 (968) (968) 0 (323) (323) 0

Total Non Operating Items (50,545) (48,571) 1,974 (12,637) (12,143) 494 (4,213) (4,042) 171

Net Surplus 2,500 2,500 0 (4,434) (4,434) 0 (1,775) (1,740) 35

Net Surplus Margin % 0.5% 0.5% -3.7% -3.7% -4.5% -4.3%

2012/13 Year To Date Month

Finance Report – as at Month 3 – 2012/13Statement of Comprehensive Income – Primary Statement

Year to DateSurplus Position

o The Trust is currently reporting a netexpenditure position on plan for Month 3

Incomeo Income from activities is over-performing by

£1.1m at Month 3 due to significant over-performance on activity at Month 2. Thishas been confirmed as part of the monthlymonitoring processes.

o Other income reflects timing differences inET&R between income and expenditure

Operating Expenditureo CIPs are under-delivering by £0.3mo Pressures in the system amount to £1.8mo Non-Operating expenditure is £0.5m below

budget

ForecastSurplus Position

o The Trust continues to forecast delivery of a£2.5m surplus for 2012/13 with a financialrisk rating of 3

QIPP Assumptionso The income forecast currently assumes

£10.1m of QIPP savings are deliveredo This is matched by a reduction in

expenditure of £4.2m (currently held inreserves) – these reductions inincome/expenditure have not yet beenidentified

Underlying Issueso The gap over and above the planned CIP

that is necessary to deliver the £2.5msurplus is £2.6m (Month 2 - £2.4m)

o This is a combination of:

Pressures in the system (includingactivity) amount to £4.6m

A benefit from non-operating expenditureof £2.0m

Actions/Mitigationso Continuation of financial controlso OPPM management of group efficiency

deliveryo Board led identification and targeting of

further savingso Project & Performance Management Office

to co-ordinate delivery going forward

3

Prior Year

OutturnStatement of Financial Position Plan

Forecast


£000 £000 £000 £000 £000 £000 £000 £000 £000 £000

Non-current assets

379,857 Property, plant and equipment 386,922 388,835 1,913 379,601 378,679 (922) 91 (704) (795)0 Intangible assets 0 0 0 0 0 0 0 0 0

3,511 Investment Property 3,511 3,511 0 3,511 3,511 0 0 0 032,066 Trade and other receivables 34,333 34,311 (22) 31,672 31,921 249 (1,071) (1,127) (56)

415,434 Total non-current assets 424,766 426,657 1,891 414,784 414,111 (673) (980) (1,831) (851)Current assets

10,217 Inventories 10,821 10,717 (104) 10,321 10,146 (175) 0 (83) (83)18,158 Trade and other receivables 17,909 19,313 1,404 19,702 17,778 (1,924) (3,492) (6,337) (2,845)7,459 Cash and cash equivalents 1,764 1,693 (71) 2,582 8,107 5,525 (3,155) (1,622) 1,533

35,834 30,494 31,723 1,229 32,605 36,031 3,426 (6,647) (8,042) (1,395)

124 Non-current assets held for sale 0 0 0 124 124 0 0 0 035,958 Total current assets 30,494 31,723 1,229 32,729 36,155 3,426 (6,647) (8,042) (1,395)

451,392 Total assets 455,260 458,380 3,120 447,513 450,266 2,753 (7,627) (9,873) (2,246)Current liabilities

(38,174) Trade and other payables (29,620) (32,814) (3,194) (40,851) (42,231) (1,381) 5,823 8,240 2,418

(2,862) Borrowings (6,246) (6,246) 0 (3,531) (3,556) (25) 0 0 0(2,000) DH Working Capital Loan 0 0 0 (2,000) (2,000) 0 0 0 0(1,500) DH Capital loan (3,120) (3,120) 0 (1,500) (1,500) 0 0 0 0(1,982) Provisions (427) (427) 0 (577) (1,982) (1,405) 0 0 0

(10,560) Net current assets/(liabilities) (8,919) (10,884) (1,965) (15,730) (15,114) 616 (825) 198 1,023404,874 Total assets less current liabilities 415,847 415,773 (74) 399,055 398,997 (58) (1,805) (1,633) 172

Non-current liabilities:

Trade and other payables 0 0(284,216) Borrowings (278,778) (278,778) 0 (282,667) (282,643) 24 29 29 0

0 DH Working Capital Loan 0 0 0 0 0 0 0 0 0(9,750) DH Capital loan (14,730) (14,730) 0 (9,750) (9,750) 0 0 0 0(2,247) Provisions (1,956) (1,956) 0 (2,334) (2,377) (43) 0 (130) (130)108,661 Total assets employed 120,383 120,309 (74) 104,304 104,227 (77) (1,776) (1,734) 42

Financed by taxpayers' equity:

24,124 Public dividend capital 24,124 24,124 0 24,124 24,124 0 0 0 032,445 Retained earnings 35,019 34,945 (74) 28,088 28,011 (77) (1,776) (1,734) 4252,092 Revaluation reserve 61,240 61,240 0 52,092 52,092 0 0 0 0

108,661 Total Taxpayers' Equity 120,383 120,309 (74) 104,304 104,227 (77) (1,776) (1,734) 42


Finance Report – as at Month 3 – 2012/13Statement of Financial Position

The main statement of financial position year to date variances against the plan are an increase in cash balance of £5.5m, which is a result of: i) reduced current trade andreceivables levels of £1.9m, following an improvement in the Trust's collection of outstanding debt over that originally planned; ii) a total increase in trade payables and currentprovisions of £2.8m and iii) a reduction in balance of property, plant and equipment of £0.9m compared to the original plan, which is mainly due to slippage in the year to datecapital additions.

The variances in forecast outturn to plan reflect the final presentation adjustments that were made to the Trust's 2011/12 yearend accounts. The deprecation charge forecastfor 2012/13 has also been reduced from plan by £1.8m to take account of the year-end revaluation exercise.

4

Mar-12 Cash Flow Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13£000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000

46,883 EBITDA 2,509 2,903 2,297 4,975 5,989 4,818 5,503 4,655 4,167 5,803 3,168 4,285

(78) Donated assets received credited to revenue but non-cash 0 0 0 0 (300) (300) (200) 0 0 0 0 0(22,601) Interest paid (1,978) (1,964) (1,944) (1,962) (1,962) (1,962) (1,962) (1,962) (1,962) (1,963) (1,963) (1,961)(4,185) Dividends paid (991) (1,935)1,700 Increase/(Decrease) in provisions 0 0 130 (44) 0 0 (44) 0 0 (45) 0 (1,843)

21,719 Operating cash flows before movements in working capital 531 939 483 2,969 3,727 1,565 3,297 2,693 2,205 3,795 1,205 (1,454)

(17,950) Movements in Working Capital (1,881) 6,606 (959) (4,022) (2,178) (1,100) 602 (1,529) (780) (704) (359) (3,900)

3,769 Net cash inflow/(outflow) from operating activities (1,350) 7,545 (476) (1,053) 1,549 465 3,899 1,164 1,425 3,091 846 (5,354)

(10,165) Capex spend (1,896) (1,170) (1,123) (1,502) (276) (574) (3,088) (1,372) (1,472) (2,177) (974) (3,840)75 Interest received 9 7 6 7 7 7 7 7 7 7 7 6

1,135 Cash receipt from asset sales 181(8,955) Net cash inflow/(outflow) from investing activities (1,887) (1,163) (1,117) (1,495) (269) (567) (3,081) (1,365) (1,465) (2,170) (967) (3,653)

(5,186) CF before Financing (3,237) 6,382 (1,593) (2,548) 1,280 (102) 818 (201) (40) 921 (121) (9,007)

0 Public Dividend Capital received0 Public Dividend Capital repaid

(3,500) DH loans repaid 0 0 0 0 0 (1,750) 0 0 0 0 0 (1,750)(1,691) Capital Element of payments in respect of finance leases and PFI (606) (33) (29) (574) (41) (41) (597) (41) (41) (597) (41) (41)

0 Drawdown of loans 0 0 0 0 0 0 0 0 0 0 0 8,100

(5,191) Net cash inflow/(outflow) from financing (606) (33) (29) (574) (41) (1,791) (597) (41) (41) (597) (41) 6,309

(10,377) Net cash outflow/inflow (3,843) 6,349 (1,622) (3,122) 1,239 (1,893) 221 (242) (81) 324 (162) (2,698)

17,600 Opening Cash Balance 7,223 3,380 9,729 8,107 4,985 6,224 4,331 4,552 4,310 4,229 4,553 4,3917,223 Closing Cash Balance 3,380 9,729 8,107 4,985 6,224 4,331 4,552 4,310 4,229 4,553 4,391 1,693

Monthly cash balances (actuals to June 12 & forecasts from July

12)

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

Apr-

11

May-1

1

Jun-1

1

Jul-11

Aug-1

1

Sep-1

1

Oct-11

Nov-1

1

Dec-1

1

Jan-1

2

Feb-1

2

Mar-

12

Apr-

12

May-1

2

Jun-1

2

Jul-12

Aug-1

2

Sep-1

2

Oct-12

Nov-1

2

Dec-1

2

Jan-1

3

Feb-1

3

Mar-

13

Apr-

13

May-1

3

Jun-1

3

month

£'0

00

Finance Report – as at Month 3 – 2012/13Cash Flow

The cash position continues to plan for capital borrowing of £8.1m inMarch 2013 to finance this years programme

5

PlanForecast


£000 £000 £000 £000 £000 £000 £000 £000 £000

Confirmed CRL 2,098 2,098 0

Forecast CRL Adjustments 17,796 18,049 253

Total Forecast CRL 19,894 20,147 253 5,381 4,189 (1,192) 2,016 1,123 (893)

PlanForecast


£000 £000 £000 £000 £000 £000 £000 £000 £000

Major Schemes

PFI lifecycle 9,696 9,949 253 3,211 3,211 0 1,071 1,071 0

New staff car park on land formerly for staff 2,000 2,000 0 0 0 0 0 0 0

Lifecycle of Radiotherapy including Linacs 1,200 1,200 0 949 576 (373) 0 (43) (43)

PACS Replacement Project 1,350 1,350 0 10 0 (10) 10 0 (10)

Neurosurgical Inst For CJD 1,000 1,000 0 0 0 0 0 0 0

0 0

Aggregated Other Schemes 5,629 5,629 0 1,211 402 (809) 935 95 (840)

Total Capital Expenditure 20,875 21,128 253 5,381 4,189 (1,192) 2,016 1,123 (893)

Less: Donated/granted Asset Purchases 800 800 0 0 0

Less: Book value of assets disposed of: 181 181 0 0 0

Net Charge against CRL 19,894 20,147 253 5,381 4,189 (1,192) 2,016 1,123 (893)

Under/(Over)Commitment against CRL (total) 0 0 0 1,192 893

Capital Expenditure Programme


Capital Resource Limit (CRL)


Finance Report – as at Month 3 – 2012/13Capital Expenditure

The year to date slippage in the capital programme primarily relates to three schemes: bowel cancer screening mailing equipment; breast screening mobilepacs and imaging equipment; and lifecycle of the linear accelerator. All these schemes are however progressing and will be completed during quarter 2.Whilst there is £1.192m year to date slippage on the capital programme, the year to date capital spend equates to 78% of the year to date plan, whichremains above the PMR financial risk indicator of 75%

6

Capital Cash Funding Sources2012/13

£'000Notes

Internally Generated FundsDepreciation 23,096 Potential reduction re revaluation exerciseSurplus 1,700 Surplus excludes donations * (shown separately)

Proceeds of Asset Disposals 57 Bowel Screening Equipment

External FundsNew Finance Leases (Net) 864Donations * 800 re Arden Cancer Centre

Other Capital Contributions Received 700 re Staff Car ParkNew Public Dividend Capital 0New Capital Investment Loans 8,100

ApplicationsWorking Capital Loan Repayment (2,000)Capital Investment Loan Repayment (1,500)New Capital Investment Loan Repayment 0PFI Finance Lease Creditor (2,226)

Other Finance Lease Repayments (451)

PFI LifecyclingLifecycle Payments in Unitary Payment (12,249)

Net Cash Generated 16,891

Cash (Applied)/Released to Address LiquidityMovement in Loan Repayments (< 1 year) 2,000 } Cash released or applied in order to ensure

Movement in New Loan Repayments (< 1 year) (1,620) } liquidity is unaffected by balance sheetMovement in PFI Finance Lease Principal Repayments (< 1 year) (3,620) } movementsAdjustmentLiquidity (Improvement)/Reduction (1,700) All revenue surpluses applied to improving liquidity

Net Cash Available for Capital Expenditure 11,951

Finance Report – as at Month 3 – 2012/13Capital Financing

7

EBITDA Earnings before Interest, Calculated as Income less Operating ExpenditureTax, Depreciation & i.e. a measure of operating profitAmortisation

FRR Financial Risk Rating Scoring method used by Monitor to assess financial risk – compound measure of fiveRegime

SOCI Statement of Comprehensive IFRS terminology for Income and Expenditure AccountIncome

SOFP Statement of Financial IFRS terminology for Balance SheetPosition

SLR Service Line Reporting

Non-Operating Expenditure items appearing below EBITDA in the Statement of ComprehensiveItems/Expenditure Income i.e. Depreciation, Amortisation, Impairments, Interest, PDC

Finance Report – as at Month 3 – 2012/13Glossary of Terms



25th

July 2012


Subject: Minutes of Audit Committee meetings 14th

May 2012 and 1st

June 2012Report By: Mr Trevor Robinson, Non-executive DirectorAuthor: Mr Alan Jones, Associate Director of Finance – Corporate ServicesAccountable Executive Director: Mrs Gail Nolan, Chief Finance Officer

GLOSSARY

Abbreviation In FullCIP Cost Improvement Programme



TitleApprox. Length


To advise the Board of the Audit Committee meeting agenda for the 14th

May 2012 and 1st

June 2012 and ofany key decisions/outcomes made by the Audit Committee.


AUDIT COMMITTEE 14TH

MAY 2012

Actions from Previous Meetings Action Matrix: was reviewed and approved Audit Committee Workplan: was reviewed and approved Deferred Items: the Committee received explanations for items deferred until a future meeting (Health Tourism update

and Quality Governance Committee Annual Report) Consultant Appraisals/Revalidation Process: the Chief Human Resources Officer gave an update on the Trust’s

approach to medical staff revalidation Consultant Job Planning: the Chief Human Resources Officer gave an update on progress in addressing issues in

connection with consultant job planning Evolution System: the Committee noted the implementation of the upgrade to the system which completed the

outstanding action Debtor Account Overseas Visitor: the Associate Director of Finance – Corporate Services updated the Committee on

progress with discussions with the UK Border Agency Temporary Staffing Services Follow-up: the report gave assurance to the Committee that all outstanding actions had

now been implemented.Counter FraudThe Trust’s Local Counter Fraud Specialist presented his Annual Report for 2011/12Internal AuditThe Trust’s Chief Internal Auditor presented the following papers: Audit Plan 2012/13: the audit plan for 2012/13 provided for 400 man days of work. The Committee agreed that the

daily charge rate for internal should be revisited. Annual Report 2011/12 and Head of Internal Audit Opinion: the report summarised the work undertaken by Internal

Audit during 2011/12. The Committee noted that in overall terms, significant assurance had been given around theTrust’s system of internal control.

Progress Report 2012/13: the report showed progress with the audit plan for the year and provided assurance that thenumber of overdue outstanding audit recommendations was continuing to fall.

Audit Report – Clinical Audit: the Committee reviewed this audit report which gave moderate assurance around theTrust’s clinical audit processes. The Committee requested a follow-up report in six months.

Audit Report – Payroll: this report provided significant assurance around the Trust’s payroll systemsExternal AuditThe Audit Manager from PricewaterhouseCoopers provided an update on the work which had commenced for the audit ofthe Trust’s 2011/12 accounts and the approach to be taken to the audit of the Trust’s Quality Accounts.Annual Accounts



25th

July 2012


The Associate Director of Finance gave an update on the following: Annual Accounts: the Trust’s draft accounts had been submitted on time and the audit had commenced. One issue

had arisen at a national level around the agreement of balances exercise but the Trust had responded appropriately Annual Governance Statement: the draft Annual Governance Statement had been rewritten following new guidance

received at the end of March. The Committee recommended some minor amendments. Going Concern Review: the Committee received the annual going concern review and approved the paper.Overall Governance ArrangementsThe Committee reviewed the Annual Report of the Trust’s Finance and Performance Committee.Statutory Audit Appointments ConsultationThe Committee received a briefing on the consultation process for the appointment of statutory auditors to NHS bodies.The Committee agreed to support the reappointment of PricewaterhouseCoopers.

AUDIT COMMITTEE 1ST

JUNE 2012This meeting’s primary focus was to review the finalised 2011/12 accounts and receive a report fromPricewaterhouseCoopers on their audit of the accounts. It was confirmed that the Trust’s finance team had given apresentation of the Trust’s accounts to all of the Trust’s directors prior to the meeting and the Audit Committee meetingtherefore focussed upon receiving a report from the Trust’s external auditor.

The auditor confirmed that the accounts and supporting working papers were of a high standard and that he expected toissue an unqualified audit opinion subject to the receipt of some further assurances around the Trust’s CIP plans for2012/13.

The Committee agreed to recommend adoption of the accounts (including the Annual Governance Statement) to the TrustBoard and to recommend the signing of the Directors’ Representation Letter.

The Committee also received a presentation on the Trust’s Quality Accounts from the Chief Medical Officer.


No significant risks identified


For consideration by the Board.

IMPLICATIONS:

Financial: None

HR / Equality & Diversity: None

Governance: None

Legal: None

REVIEW:


DATA QUALITY:

Data/information Source: n/aData Quality Controls: n/aData Limitations: n/a



25th

July 2012


Subject: Finance and Performance Committee Minutes from 28th May 2012Meeting

Report By: Ms S Tubb, Senior Independent DirectorAuthor: Mr A Jones, Associate Director of Finance – Corporate ServicesAccountable Executive Director: Mrs G Nolan, Chief Finance Officer

GLOSSARY

Abbreviation In FullLTFM Long Term Financial ModelCIP Cost Improvement ProgrammePMR Provider Management RegimeKPI Key Performance Inidcator



TitleApprox. Length


To advise the Board of the Finance and Performance Committee meeting agenda for the 28th

May 2012 and ofany key decisions/outcomes made by the Finance and Performance Committee.


Actions from Previous Meetings Action Matrix: was reviewed and approved Assisted Discharges Update: the Chief Executive Officer gave an update on the joint work with Coventry City Council

which was progressing wellFinance ReportsThe Chief Finance Officer gave a report on the following: Analytical Review of the 2011/12 Annual Accounts: the report explained the movement between the Trust’s

accounts for 2010/11 and 2011/12. The report included a section on lessons learned and the Committee asked for aprocess to be put in place to track actions resulting from the lessons learned.

Annual Financial Plan 2012/13 Update: the report included minor revisions to the Trust’s financial plan for 2012/13which the Committee agreed to recommend to the Trust Board

Long Term Financial Model: the report set out the key assumptions upon which the LTFM would be based. It wasagreed that further work on downside scenario planning would go to the Trust Board Seminar in June.

CIP Planning: the paper set out an approach to CIP planning for the future. It was agreed that further reports on CIPplanning would go to future Trust Board meetings.

Integrated Finance Report - Month 1 2012/13: the report was first one in the new format for monthly financereporting. The report was an integrated report providing details of performance against revenue budgets, balancesheet, cashflow and capital. It also included analysis of specialty financial performance and focussed upon exceptionswhich needed to be escalated. The Committee welcomed the new style report and made some suggestions for minorchanges.

Provider Management Regime (PMR) - Finance Elements: the report explained changes to the PMR. Finance Risk Register: the report provided details of key financial risks to the Trust.Operational Performance Reports:The Interim Chief Operating Officer gave a report on the following: Key Performance Indicators (KPI): the report provided information on the Trust’s key non-financial performance

indicators and flagged those areas which were in exception – escalation reports were provided for these as follows: Escalation Report: Referral to Treatment Times/Long Waiters: the report provided an update on the Trust’s plans

to ensure waiting times meet the national target and assurance was given that the plans remained on target. Escalation Report: A&E Action Plan: the paper set out the Trust’s plans to improve performance against the four

hour A&E target. The Committee requested a further report to its next meeting. Escalation Report: Delayed Transfers of Care – Escalation Report: the report explained the progress made in

reducing delayed transfers of care and identified the key risks. The Committee requested a further report to its next



25th

July 2012


meeting.Finance Committee Administrative MattersThe Chief Finance Officer gave a report on the following: Board Governance Assurance Framework – Finance Elements: the report set out the Trust’s response to the

finance elements of the Board Governance Assurance Framework. F&P Committee Work plan 2012/13: minor changes to the workplan were agreed.


Key risks identified included: Financial performance and the identification of CIPs Operational risks associated with referral to treatment times, A&E four hour target and delayed transfers of

care


For consideration by the Board

IMPLICATIONS:

Financial: As summarised in key issues above

HR / Equality & Diversity: None

Governance: None

Legal: None

REVIEW:


DATA QUALITY:




25th

July 2012

Subject: Foundation Trust Project

Report By: Andrew Hardy, Chief Executive Officer

Author: Janet White, Director of Engagement & Foundation Trust ProjectDirector

Accountable Executive Director: Andrew Hardy, Chief Executive Officer

GLOSSARYAbbreviation In FullDH Department of HealthCIPs Cost Improvement Programmes


POWERPOINT PRESENTATION? Yes NoNB Presentations need to be submitted for inclusion in Board papersTitleApprox. Length

PURPOSE OF THE REPORT / PRESENTATION:To present the new Tripartite Formal Agreement for UHCW’s FT application (attached).

SUMMARY OF KEY ISSUES:New timeline and actions within it

SUMMARY OF KEY RISKS:UHCW’s proposal for an alternative DH submission date of 1

stJune 2013 has been agreed by DH.


The Trust Board are asked to RECEIVE and ACCEPT this report.

IMPLICATIONS:Financial: Financial performance this year.

Importance of achievement of CIPs, work to increase predicted surplus andachieve financial assumptions for down-side scenarios.

HR / Equality & Diversity: Recruitment and maintenance of a representative and diverse membership.

Governance: New date for achieving Foundation Trust status.

Legal: Legal constitution and completion of necessary assessment phases.


DATA QUALITY:


1

Supporting all NHS Trusts to achieve NHS Foundation Trust status by April 2014

Tripartite Formal Agreement between:

− University Hospitals Coventry & Warwickshire NHS Trust − NHS Midlands & East − Department of Health

Introduction This tripartite formal agreement (TFA) confirms the commitments being made by the NHS Trust, their Strategic Health Authority (SHA) and the Department of Health (DH) that will enable achievement of NHS Foundation Trust (FT) status before April 2014. Specifically the TFA confirms the date (Part 1 of the agreement) when the NHS Trust will submit their “FT ready” application to DH to begin their formal assessment towards achievement of FT status. The organisations signing up to this agreement are confirming their commitment to the actions required by signing in part 2a. The signatories for each organisation are as follows:

NHS Trust – Andrew Hardy, Chief Executive Officer SHA – Sir Neil McKay, Chief Executive DH – David Flory, Deputy NHS Chief Executive, NTDA Chief Executive Designate

In addition the lead commissioner for the Trust will also sign the agreement to ensure commissioner support exists for the actions that need to be undertaken locally as well as agreeing to resolve any commissioner issues. The information provided in this agreement does not replace the SHA assurance processes that underpin the development of FT applicants. The agreed actions of all SHAs will be taken over by the Provider Development Authority (PDA) when that takes over the SHA provider development functions.

2

The objective of the TFA is to identify the key strategic and operational issues facing each NHS Trust (Part 4) and the actions required at local, regional and national level to address these (Parts 5, 6 and 7). Part 8 of the agreement covers the key milestones that will need to be achieved to enable the FT application to be submitted to the date set out in part 1 of the agreement. Standards required to achieve FT status The establishment of a TFA for each NHS Trust does not change, or reduce in anyway, the requirements needed to achieve FT status. That is, the same exacting standards around quality of services, governance and finance will continue to need to be met, at all stages of the process, to achieve FT status. The purpose of the TFA for each NHS Trust is to provide clarity and focus on the issues to be addressed to meet the standards required to achieve FT status. Alongside development activities being undertaken to take forward each NHS Trust to FT status by April 2014, it is paramount that high quality services are maintained. To remove any focus from quality healthcare provision in this interim period would completely undermine the wider objectives of all NHS Trusts achieving FT status, to establish autonomous and sustainable providers best equipped and enabled to provide the best quality services for patients.

3

Part 1a - Date when NHS foundation trust application will be submitted to Department of Health

June 2013 (Original plan not achieved – October 2011)

Part 2a - Signatories to agreements By signing this agreement the following signatories are formally confirming:

− their agreement with the issues identified; − their agreement with the actions and milestones detailed to support

achievement of the date identified in part 1; − their agreement with the obligations they, and the other signatories, are

committing to; as covered in this agreement.

Andrew Hardy Chief Executive Officer University Hospitals Coventry & Warwickshire Hospitals Trust

Date: 23/5/12

Sir Neil McKay Chief Executive NHS Midlands and East

Date: 24/5/12

David Flory DH SRO for Foundation Trust Pipeline

Date:12 July 2012

Part 2b – Commissioner agreement In signing, the lead commissioner is committing to support the process and the actions of the local organisations as well as resolving any local commissioning issues pertinent to the FT application.

Stephen Jones Chief Executive of Arden Cluster

Date: 23/5/12

4

Part 3 – NHS Trust summary

Short summary of services provided, geographical/demographical information, main commissioners and organisation history

Required information Current CQC registration (and any conditions): Registered without conditions Financial data

2009/10 £m

2010/11 £m

2011/12** £m

Total income 465.2 472.9 479.3

EBITDA 55.8 50.8 46.9

Operating surplus\deficit* 10.2 4.2 1.5

CIP target 14.9 25.0 28.0

CIP achieved recurrent 12.9 22.9 15.1

CIP achieved non-recurrent 0 0 5.3

*Breakeven performance adjusted for impairments and IFRIC 12 **Based on 2011/12 draft final accounts

The NHS Trust’s main commissioners See below: NHS Coventry & NHS Warwickshire – Arden Cluster West Midlands Specialised Commissioning Group Summary of PFI schemes (if material) At the end of 2002 the Trust signed a PFI contract to finance and construct a new University Hospital based in Coventry which also provided for the provision of certain equipment and the provision of both hard and soft facilities management services to both the University Hospital and the existing Hospital of St Cross. The primary PFI contractor or Special Purpose Vehicle (SPV) is the umbrella organisation created by the PFI Consortium and is Coventry and Rugby Hospital Company (CRHC) which is a part of the HCP Social Infrastructure Limited (UK) Limited. CRHC owns the building and subcontracts the provision of non-clinical support services to:

• ISS Mediclean Limited – (Soft Facilities Management)

• Vinci Group – (Hard Facilities Management)

• Skanska Construction – (Construction)

• GE Medical Systems – (Equipment provider)

The primary term of the contract is 37 years; in December 2042 the ownership of the hospital will be transferred in full to UHCW.

The unitary payment is a charge of approximately £73 million per annum, payable quarterly in advance.

Further information UHCW is located in the West Midlands and is one of the largest teaching hospitals in England

5

housing one of the UK’s largest PFI hospitals. It provides both general acute hospital services to approximately 500,000 people from Coventry and Rugby and tertiary/specialist hospital services to over one million people from Coventry, Warwickshire and beyond (mainly West Midlands but also including Leicestershire and Northamptonshire). The University Hospital in Coventry is one of the most modern healthcare facilities in Western Europe, whilst the Hospital of St Cross in Rugby is important in sustaining a local service to local people. From March 2012 the Trust became one of the three designated Adult Major Trauma centres in the West Midlands. In March 2011 the Trust employed 5,951 staff (WTE). In 2010/11 the Trust managed 1,380 beds (1,090 inpatient beds and 154 day case beds at University Hospital and 136 beds at the Hospital of St Cross) and 32 operating theatres. Approximately 94% of referrals originated from within Coventry and Warwickshire with c.59% of referrals from NHS Coventry. For 2012/13 the Arden Cluster hold the contract for themselves and Associates, which include all other remaining West Midlands PCTs plus Northamptonshire PCT, Leicestershire County and Rutland PCT and Leicester City PCT. The West Midlands Specialised Commissioning Group is our coordinating commissioner for specialised services, co-ordinating the contract on behalf of all the NHS Midlands and East PCTs and the four LCCBs. The other main Associate to this contract is the East Midlands Specialised Commissioning Group. In total, the value of our healthcare contracts in 2012/13 is £389 million. The Trust has a programme/project management approach to its FT application, with an established FT Office and a Foundation Trust Project Director, supported by a dedicated FT Finance Manager and Membership Manager, alongside administrative support. An FT Steering Committee, chaired by the Chief Executive Officer that includes all Trust Executive Directors, Trust Board Secretary and SHA representation has been in operation and will continue, overseeing all aspects of the Trust’s FT application work. A project team, populated by appropriate business work stream leads and clinical leads for Medical, Nursing and other Healthcare professions has been in place similarly. The original TFA date was not achieved as the level of surplus being indicated was not considered adequate for the application to proceed. The Trust needs to be able to demonstrate the achievement of its financial plan which will include higher levels of surplus in the early years and delivery of fully worked up efficiency targets. Monitor’s recent announcement of its assumptions about future years’ efficiency requirements has also meant that the Trust needs time to review and amend its plans. The Trust’s Chief Executive Officer is the Executive Lead for the FT Project. All usual programme management tools (timelines and project plans with appropriate dependencies and milestones identified, risk & issue logs, appropriate action plans, communications and engagement plans & logs etc. etc.) have been and will continue to be utilised. There is monthly reporting to the public session of the Trust Board and updated, RAG rated action plans, with mitigation actions where necessary, go to the FT Steering Committee.

6

Part 4 – Key issues to be addressed by NHS trust

Key issues affecting NHS Trust achieving FT

Strategic and local health economy issues

Service reconfigurations Site reconfigurations and closures Integration of community services

Not clinically or financially viable in current form Local health economy sustainability issues

Contracting arrangements

Financial

Current financial Position Level of efficiencies / QIPP PFI plans and affordability

Other Capital Plans and Estate issues Loan Debt

Working Capital and Liquidity

Quality and Performance Quality and clinical governance issues

Service performance issues

Governance and Leadership

Board capacity and capability, and non-executive support

Please provide any further relevant local information in relation to the key issues to be addressed by the NHS Trust:

Commissioning Strategy/intentions Local commissioners are developing a new clinical service strategy, the implications of which will need to be taken into account. The contract between the Commissioning Cluster and Trust is nearing agreement. UHCW will work with partners to develop the new service strategy.

Level of efficiencies/QIPP The Trust plan for 2011/12 contained a CIP requirement of £28m. The delivery for 2011/12 was £20.4m. The Trust Board agreed the financial plan for 2012/13 at the end of March. This takes into account the final 2012/13 contract agreement with Commissioners, including QIPP and the internal assessment of inflationary and other cost pressures. The financial plan contains a CIP requirement of £28.8m. This efficiency requirement is above the implied efficiency rate required by the Operating Framework. The Trust’s CIP for 2012/13 will be delivered through a combination of specialty and corporate work streams; proposals are currently being evaluated for quality impact and profile. The Trust’s strategic plans acknowledge the requirement to reduce length of stay in order to release existing capacity to support additional volumes of activity. The Trust continues to work with the PCT Cluster and Clinical Commissioning Groups to align its capacity with emerging local commissioning intentions designed to deliver the clinical service strategy.

7

PFI Plans and Affordability Our liquidity is currently susceptible to movements in PFI balance sheet charges, specifically the short term PFI finance lease creditor, that are out of the Trust’s control. These movements occur as a direct consequence of adopting IFRS. The adoption of IFRS meant increased depreciation and PDC charges for the Trust. The relatively fixed nature of the Unitary Payment means that the Trust has a reduced cost base to target for efficiency meaning finding further CIPs is challenging. Our PFI Unitary Payment is due quarterly in advance which causes a high cash requirement at these times. This has an average cash requirement of £23m per quarter.

Other Capital Plans and Estate issues There are currently a number of pre-commitments on the Trust’s internally generated funds:

• Working Capital and Capital Investment Loan repayments

• PFI finance lease principal repayments

• PFI life-cycling costs (including significant equipment replacement programmes)

This means there are reduced internally generated funds to spend on other capital projects. The capital programme for 2012/13 and the following 4 years was approved as part of the Board’s consideration of the financial plan at the end of March. Given the Trust’s weak liquidity position currently the capital programme for the next four year period will be limited initially to those schemes required to meet statutory compliance standards and service continuity pressures; careful profiling of schemes will be required to restrict in year investment to levels affordable within the balance of internally generated cash where possible. The Trust will work with commissioners and the Midlands and East SHA to devise a borrowing strategy that supports ‘invest to save’ and strategically essential schemes linked to the generation of revenue surplus.

Loan Debt The Trust currently has two outstanding loans that have helped to maintain liquidity in prior years:

• Working Capital Loan

• £2m outstanding as at 31st March 2012

• Loan fully paid as at 31st March 2013

• Capital Investment Loan

• £11.25m outstanding as at 31st March 2012

• Loan fully paid as at 31st March 2020

There is an indicative requirement, given the capital pressures as outlined above, that the Trust will wish to seek further loan financing in 2012/13.

Working Capital and Liquidity Liquidity out-turned at 16.3 days for 2011/12 (based on draft final accounts). The current forecast for 2012/13 is 12.5 days. In the short term the Trust is looking at a number of ways of strengthening its liquidity position:

8

o Capital Investment Loans o Tighter working capital management o Generation of surpluses

Generation of surpluses in future years is assumed to improve the liquidity position in the long term.

Board Capacity and Capability A number of known changes at Board level are taking place over the next 3 – 6 months and the new board members will need support to ensure the Trust’s board capacity and capability is at appropriate levels within the timescales required. The Trust is currently completing its Board Governance Assurance Framework self-assessment and actions, including non-mandatory modules, and is using a combination of external and internal support to ensure actions identified are completed and the Board is well prepared for Foundation Trust status.

Performance delivery

A&E – The challenge to achieve the 95% KPI and sustained improvement going forward has been recognised internally and externally. The Trust has invited in, with commissioner support, ECIEST, who have led a full review of processes and procedures internally and externally and have offered recommendations around best practice to be introduced. In partnership with our other local health organisations, an A&E action plan has been produced which is led by our commissioners and progressed and monitored by our respective Executive teams. There has also been an agreement to encourage patient flow, where there will be a target of discharges daily alongside a daily target of assisted discharges.

RTT - There is a commitment and plans to deliver to meet and achieve, in full, the KPI in all specialties. However, in one area (Trauma and Orthopaedics) there is still a recognised risk. We continue to source and introduce additional capacity, as well as working with our commissioners with the development and introduction of new clinical pathways which are proving successful with regards to overall activity. Pressure ulcers – There is a strong commitment at UHCW to deliver the SHA’s aspiration to eliminate pressure ulcers. The Trust has developed a programme of awareness, training, monitoring and performance management to deliver this. Additionally, equipment and training resource has now been allocated to assist in the delivery during 2012/13. The Trust has fully implemented the Patient Safety Thermometer System across all wards and departments which will monitor progress against the SHA performance trajectory.

9

Part 5 – NHS Trust actions required

Key actions to be taken by NHS Trust to support delivery of date in part 1 of agreement


Integration of community services

Financial

Current financial position

CIPs

Other capital and estate plans

Quality and Performance

Local / regional QIPP

Service Performance

Quality and clinical governance

Governance and Leadership Board Development

Other key actions to be taken (please provide detail below)

Describe what actions the Board is taking to assure themselves that they are maintaining and improving quality of care for patients.

• Board Assurance Framework in place and Board Governance Assurance Framework self-assessment underway

• Incident and risk management processes embedded in the organisation

• Board reporting programme includes Quality and Patient Safety reports and quality is on every agenda

• Board approve the Quality Account

• Board is carrying out the Quality Governance Framework Assessment

• Trust regularly participates in national audits and action from surveys

• Board members regularly take part in patient safety walk-arounds

• Patient and staff stories told at Trust Board (10/year from April 2012)

• Patient experience reports to Quality Governance Committee

• Patient stories regularly reported to Trust Board

• Net Promoter Score reported to Trust Board, including weekly and ward/specialty breakdown

• Patient Revolution and Quality Strategies in draft form and will go for Board sign off during Q1 2012/13

Please provide any further relevant local information in relation to the key actions to be taken by the NHS Trust with an identified lead and delivery dates: • PFI payments

The Trust needs to work to ensure the current arrangement with commissioners, that allows the Trust make these payments, continues with the advent of GP Consortia, in order to fulfil its unitary payment obligations. Chief Finance Officer is identified lead. Timescale is ongoing and awaiting further

10

clarification around Local Health Economy financial arrangements in the future.

• Level of Efficiencies/CIPs The Trust will put in place appropriate service transformation measures with robust performance management to ensure these efficiencies/CIPs are achieved. This will be delivered through the revised organisational structure which came into place on 1st April 2012. This is based on specialty management groups each headed by a clinical director, supported by a modern matron and general manager; the integrated performance framework will be led by the Chief Executive with executive support from the Chief Medical Officer, Chief Nursing Officer, Chief HR Officer and Chief Finance Officer. The Trust is pursuing a two pronged approach to CIP delivery involving traditional cost improvements within clinical specialty management groups and a number of cross-cutting organisation-wide schemes. A programme management office approach is being adopted to support scheme identification and to hold project leads to account for delivery with escalation to the Chief Officers’ Group.

Timescale is ongoing throughout the 2012/13 year and beyond to enable full and thorough system change and performance management.

• Programme management

The Trust will maintain and strengthen as appropriate its programme management approach in respect of actions associated with its FT application. A formal PMO will be implemented in Q1 2012; the remit will cover IBP strategic developments, specialty reviews, CIP, QIPP and CQUIN initiatives. SMGs and Corporate functions will be accountable via the PMO to the Trust’s Chief Officers Group. A benefits realisation group will critically challenge project proposals for cash/benefits to ensure tangible translation into practice including patient safety. The PMO will support project planning including training and coaching for project leads and teams and will complement the Trust’s organisational development agenda. Chief Finance Officer is identified lead.

Timescale is ongoing through to achievement of FT statusA new organisational structure has been operational from 1

st April 2012 which will improve the alignment of quality,

performance and CIP delivery. A fully integrated performance regime is being implemented and the structure with clinical leads should enforce a culture of transformation from the clinical body. The intention of the new structure is that it is clinically driven / clinically owned and based on sound business practice i.e. financial / customer focus and delivery of agreed objectives. The new organisation structure is designed to meet the needs of the organisation (goals, objectives and culture). It is designed to be a structure which best helps the organisation through the unrelenting focus on delivery and achievement of objectives. The organisational arrangements have been developed with clear and explicit objectives these are summarised below

• Provide high quality healthcare to the patients we serve;

• Support reliable planning of capacity, delivery of activity in line with contracts and achievement of all access and other targets;

• Ensure robust performance management of delivery;

• Develop a culture of wide ownership of the Trust’s objectives and a desire to achieve them;

• Introduce functional focus in line with service objectives rather than ‘tribal encampments’;

• Streamline the existing structure to achieve efficiency savings without compromising on service quality.

There is clear and unambiguous line of sight from the Trust Board/Chief Officers Group to the frontline clinical groups all of which have the underpinning operational polices to

11

ensure that performance and delivery is key focus, this is underpinned and supported by a very robust performance management regime. The key element that is being introduced and that will link together delivery of performance with effective review will be the creation of a system of central control. This will be called the ‘Delivery team’. This is a team is comprised of senior trust Executive/Clinical management including those who are directly responsible for and will oversee delivery against objectives, achievement of KPI’s and linking planning to performance performance daily. The Chief Operating Officer is identified lead. This post has recently been appointed to with the individual due to take up post shortly. In the interim the Trust has a Director of Delivery who is covering the vacancy. Timescale is ongoing throughout 2012/13 and beyond to enable full and thorough system change and performance management.

• Other Capital and Estate Plans The Trust will need to secure a funding solution for capital expenditure that enables it to continue to drive improvements to liquidity, whilst at the same time, maintaining and improving its Estate.

Chief Finance Officer is lead.

12

Part 6 – SHA actions required

Key actions to be taken by SHA to support delivery of date in part 1 of agreement


Local health economy sustainability issues (including reconfigurations)

Contracting arrangements

Transforming Community Services

Financial

Regional and local QIPP

Quality and Performance Quality and clinical governance

Service Performance

Governance and Leadership

Board development activities

Other key actions to be taken (please provide detail below)

Please provide any further relevant local information in relation to the key actions to be taken by the SHA with an identified lead delivery dates:

• The SHA is working closely with the Trust to ensure delivery of its FT trajectory within a challenging financial context within the Arden cluster.

13

Part 7 – DH actions required

Key actions to be taken by DH to support delivery of date in part 1 of agreement


Alternative organisational form options

Financial

NHS Trusts with debt

Short/medium term liquidity issues

Current/future PFI schemes

National QIPP workstreams

Quality and Performance

- Governance and Leadership

Board development activities

Other key actions to be taken (please provide

detail below

Please provide any further relevant local information in relation to the key actions to be taken by DH with an identified lead and delivery dates: The Trust may wish to approach DH during 2012/13 for a further working capital loan.

14

Part 8 – Key milestones towards achievement of date agreed in part 1

Date Milestone March 2012 SHA Interviews with the board, SHA initial meeting with the

commissioners

March 2012 SHA/UHCW discussion of IBP/LTFM & PMR escalation meeting

March 2012 Self-assessment completion of BGAF

May 2012 * Review meeting with SHA CEO & Chair to review quality, finance, performance and progress against TFA milestones

June 2012 * Review meeting with SHA CEO & Chair to review quality, finance, performance and progress against TFA milestones

July/August 2012 * Review meeting with SHA CEO & Chair to review quality, finance, performance and progress against TFA milestones

Late July/Early Aug 2012

Financial Position Review Meeting

September 2012 * Review meeting with SHA CEO & Chair to review quality, finance, performance and progress against TFA milestones

October 2012 * Review meeting with SHA CEO & Chair to review quality, finance, performance and progress against TFA milestones

Late Oct/Early Nov 2012

Financial Position Review Meeting

November 2012 * Submit 1st draft of IBP/LTFM and authorization for HDD1 refresh

November 2012 * Review meeting with SHA CEO & Chair to review quality, finance, performance and progress against TFA milestones

December 2012 HDD1 Refresh (TBC with SHA & appointed auditors)

December 2012 Trust complete self-assessment against quality dashboard and submit to the SHA

Early January 2013 * Submit high quality draft of IBP/LTFM to SHA

Late Jan/Feb 2013 Financial Position Review Meeting

Late Jan/Feb 2013 * FT Readiness Review SHA/UHCW, inc. PMR escalation meeting

Late February 2013 * Final Draft of the IBP/LTFM to the SHA

March 2013 CQC Opinion received

March 2013 HDD2 Refresh (TBC with SHA & appointed auditors)

April 2013 NTDA interview with lead HDD reviewer (TBC with SHA & appointed auditors)

Early April 2013 * Complete IBP/LTFM and appendices submitted

Late April 2013 Financial Position Review Meeting

Early May 2013 * NTDA/UHCW Board to Board (Full Voting Board), includes review of PMR

1st June 2013 Submit FT application to the DH

* Dates TBC by SHA/NTDA and frequency of review meetings subject to level of escalation under PMR (provider management regime)

Actions in response to any failure to meet milestones will be agreed by the Trust’s chair and CEO with the SHA/NTDA. The milestones agreed in the above table will be monitored by senior DH and SHA leaders until the NTDA takes over formal responsibility for this delivery. Progress against the milestones agreed will be monitored and managed at least quarterly, and more frequent where necessary as determined by the SHA (or NTDA subsequently).

15

Part 9 – Key risks to delivery

Risk Mitigation including named lead Achievement of national performance targets (A&E, RTT)

Joint work and action plans with commissioners around A&E target. Robust internal management of performance around both A&E and delayed discharges. New performance management approach alongside new organisational/delivery structure. Chief Nurse & Chief Operating Officer are leads.

Achievement of required levels of efficiencies (CIPs)

Appropriate service transformation measures with robust performance management. Chief Nurse & Chief Operating Officer are leads (with support from Chief Finance Officer).

Board capacity and capability (number of new board members)

BGAF Board development (internal and external) Induction programme (Chief Executive Officer and Chairman are leads)

Documents

TRUST BOARD MEETING TO BE HELD ON WEDNESDAY 25 JULY … › clientfiles › files › Board Papers... · 2017-09-18 · 02.07.12 April 2012 294 High RR Alcohol related mental disorders