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Public Agenda
Trust Board of Directors Room 219, Second Floor, Trust Headquarters, North Manchester General Hospital
28 May 2015 9.30am
Owner Attached Time
1) Welcome and Apologies
JJ Verbal 0930
2) Declaration of Interests
JJ Verbal
3) a) b) c)
Procedural Business Minute of Meeting held on 26 March 2015 Matters Arising Action checklist
JJ JJ GB
Attached Attached
4)
Chairman’s Remarks
JJ Verbal 0935
5)
Chief Executive’s Report
GF To follow 0940
6) a) b) c)
Performance and Assurance Integrated Performance Report Strategic Risk Register CQC Registration Annual Review 2014/15
BS GB GB
Attached Attached Attached
0955 1030 1035
7) a) b) c) d)
Quality, Clinical and Patient Issues Clinical Governance Review Mortality Report Medical and Revalidation Appraisal Dr Kershaw’s Hospice
GH AS AS JW
To follow Attached Attached Attached
1040 1100 1105 1110
8) a)
Strategy and Partnerships Trust Programmes Update
SG
Attached
1115
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9) a)
Business and Commercial IM&T Strategy
BS
Attached
1120
10) a)
Regulatory No items
11) a) b) c) d) e) f)
Minutes of Board Sub-Committees Audit Committee – 7 April 2015 Trust Programmes Board – 24 March 2015 Trust Programmes Board – 21 April 2015 Quality and Performance Committee – 24 March 2015 Quality and Performance Committee – 28 April 2015 Quality and Performance Committee Highlight Report – 26 May 2015
RA SG SG SD SD SD
Attached Attached Attached Attached Attached Tabled
1140
12) Date of Next Meeting Thursday 25 June 2015, Room 219, Trust HQ at 9.30am
JJ 1150
13) Resolved That representatives of the press and other members of the public be excluded from the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.
JJ
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Minute
Trust Board of Directors Willow Suite, Norton Grange Hotel, Manchester Road, Castleton, Rochdale
26 March 2015 9am
Owner Timescale
Present Mr J Jesky, Chairman Mr R Ahmad, Non-Executive Director Mrs W Cardiff, Non-Executive Director Mrs S Dixon, Non-Executive Director Dr G Fairfield , Chief Executive Mrs C Guereca, Non-Executive Director Mr J Lenney, Director of Workforce and OD Mrs C Mayer, Non-Executive Director Mr H Mullen, Director of Operations Mrs M Ollerenshaw, Non-Executive Director Mrs K Salmon-Jamieson, Acting Chief Nurse Dr A Sinniah, Acting Medical Director Mr B Steven, Deputy Chief Executive / Director of Finance
In Attendance Mr G Barclay, Assistant Chief Executive / Board Secretary Ms S Good, Director of Strategy and Commercial Dev’t Mr A Lynn, Head of Communication Mr J Wilkes, Director of Estates and Facilities
Public One member of staff and one staff side representative.
01/15 Welcome The Chairman welcomed everyone to the meeting.
02/15
Declarations of Interest The Chairman declared that he had joined the Board of Buxton Festival. Mr Barclay reported that Dr Sinniah had completed his declaration of interests form on joining the Board, and had no interests to declare. Dr Sinniah had confirmed that he subscribed to the Codes of Conduct and Accountability.
03/15 a)
Procedural Business Minute of the Trust Board of Directors Meeting dated 18 December 2014 The minute was submitted and approved.
Item
3a
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b)
Action Checklist The Board reviewed each item on the checklist, noted the updates and agreed to close a number of actions where appropriate. The Action Checklist was updated and noted.
04/15 Chairman’s Remarks The Chairman stated that:
Work on Devo Manc was progressing and he had attended a recent meeting for Trust Chairs where it had been agreed to re-instate such a meeting on a regular basis.
Along with Dr Fairfield he had met with the Chairman and Chief Executive of Central Manchester Foundation Trust.
He had attended a recognition event for MedEquip4Kids at the Children’s A&E unit at The Royal Oldham Hospital to thank them for their generous support both for providing equipment to that department and for their fundraising over a number of years.
05/15 Chief Executive’s Report Dr Fairfield spoke to her report which summarised key national, local and Trust issues and developments. In particular, she commented on:
Health Select Committee report on complaints and raising concerns;
Freedom to Speak Up;
Investigation report into Morecambe Bay Trust;
Savile Report;
The Chancellor’s recent budget statement;
Devo Manc. Dr Fairfield said that she had been co-opted onto the programme board jointly chaired by Simon Stephens and Sir Howard Bernstein;
Pride in Pennine – Chief Executive’s Challenge on health, wellbeing and sickness absence had generated 15,000 contributions from staff within two weeks;
Ebola;
Duty of Candour;
Safer Sharps EU Directive. Mrs Salmon Jamieson said that the Trust had been visited by the HSE on 18 March 2015 and would be issued with a notice of contravention which would take the form of a formal letter and a fee for intervention. The HSE were satisfied that the Trust had an improvement plan and therefore at this stage would not issue and improvement / enforcement notice or take any action to prosecute;
Changes in the Executive and Senior Team The report was noted.
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06/15 Integrated Performance Report Mr Steven spoke to the report and said that the Quality and Performance Committee had reviewed, in detail, many of the indicators presented in the report. Quality
HCAI – The Trust had exceeded the year end upper threshold for C-Difficile at the end of month 11 with 67 cases against a year end upper threshold of 62. There had been 5 MRSA cases reported year to date. Mrs Salmon Jamieson said that she was starting a new campaign “Don’t wait to isolate” as this was the key area where action was needed. A new risk assessment would also be introduced. Further work by the ward teams would also reinforce professional standards and the work required at ward level, in contrast to what appeared to be a current focus on the Infection Prevention and Control Team. Mrs Dixon supported this approach and commended the emphasis on work at ward level.
Pressure sores – Mrs Salmon-Jamieson said that a new risk assessment and been introduced and further action planning was underway.
Safe Nursing and Midwifery staffing levels – the Trust met the 80% fill rate standard in February (all wards met the standard).
It was agreed that the Mortality Report, currently presented separately on the agenda, should be integrated into the next iteration of the Integrated Performance Report.
Operational Performance
Referral to Treatment - all three RTT standards were achieved in February.
All of the national cancer standards were achieved for Q3 and for January. All local cancer targets had been achieved for Q3 and January with the exception of the 62 day GP referral reallocated standard.
4 hour urgent care standard – Mr Mullen said that North Manchester General Hospital would achieve the year end standard for the first time. This was a significant achievement and turn-around of previous performance. The CCG was particularly keen to celebrate this and held a view that the North Manchester health economy was performing better than ever before. The Chairman asked Mr Mullen to arrange for a letter of commendation to staff from the Board and for Board member visits to recognise this achievement. Mr Mullen said that The Royal Oldham Hospital continued to experience difficulties in achieving the standard and there were issues relating to admissions and delayed discharges. The adult social care budget in Oldham had reduced by 50% over recent years. There were
BS HM
May 2015
Item
3a
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c40 more patients classed as delayed discharges at The Royal Oldham Hospital compared to North Manchester General Hospital. Along with Dr Sinniah, he had met with the Chief Executive of Oldham Council to discuss this matter. Mr Mullen also acknowledged that there were further improvements that could be made within the Trust and he would look to the new medical leadership team of Divisional Medical Director and Clinical Directors, once fully in post, to take this forward with medical and other clinical staff.
Finance
For the eleven months to February 2015 the Trust had delivered a deficit of £1.9m (before technical adjustments), an adverse variance of £0.8m. The Trust had received £9m of non-recurrent deficit funding from the TDA for 2014/15 which had allowed the forecast outturn position to be revised to break-even. Achieving this position would still require tight financial control and achievement of all planned CIPs to the end of the year. Income was above plan by £2.3m. Expenditure was above plan by £3.3m. Capital expenditure had been £11.13m against a plan of £16.9m. The cash position remained positive at £59m (£20.1m above plan). The continuity of service risk rating had increased to 4 with a year end forecast of 3.5.
Workforce
Sickness absence remained high at 6.05% in February (5.71 year to date).
Regulatory Assessments
The Monitor’s Risk rating remained three (amber) but Mr Steven cautioned that this might turn red due to the combination of some targets being missed for successive quarters.
The report was noted.
07/15 Staff Survey Report Mr Lenney spoke to the report which gave a brief outline of the results from the staff survey conducted in the autumn of 2014. Over 2,700 members of staff had taken part. Whilst the overall engagement score had again improved from 3.58 to 3.61 the results remained significantly below average in comparison to other NHS providers. Mr Lenney said that the Trust was beginning a journey to better engage with its workforce and to improve staff morale and staff satisfaction. The current Pride in Pennine – Chief Executive’s Challenge with its focus on health, well-being and engagement would be used as the launchpad for actions to address the issues raised. Dr Fairfield said that the Pride in Pennine Chief
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Executive’s Challenge had already generated significant interest and she was particularly pleased that staff side were keen to be involved in addressing the issues raised. Mrs Mayer said that she acknowledged that changing culture and attitudes would take time but she felt that the Trust still had significant work to do. Dr Fairfield said that the right team with the right ideas were now in place to implement a whole series of actions which would in turn see change take place. The Chairman said that the national staff survey appeared to give worse results than the Trust’s own internal intelligence gathering. Mr Lenney said that the national staff survey methodology was robust and allowed for comparisons to be made across the country. He said that while the survey highlighted areas for improvement, the Trust Board needed to remember that the Trust employed thousands of very committed staff who delivered high standards of care. Mrs Cardiff asked about examples of good practice. Mr Lenney said that there were some examples highlighted in the survey. He said it would be important to understand the needs and motivators for different staff teams and groups as they many need different approaches. Mrs Ollerenshaw asked whether managers debriefed their teams on the survey results for their areas. Mr Lenney said that action plans were developed at local level but more work was needed on this to ensure that they addressed specific departmental issues. Mrs Ollerenshaw asked whether the departmental scores were taken into account during managers’ PDRs. Mr Lenney said this should form part of the overall service performance review process as there would be many factors other than the actions of any individual which would impact on the score for a department. However, he was keen to introduce 360 degree appraisals. Mrs Cardiff suggested that the Trust should encourage staff views and feelings to be expressed at every 1-1 meeting in a way that allowed that collective intelligence to rise through the Trust. Mr Lenney said that he planned to devote time and energy to improving the PDR process in the first instance. Mrs Dixon asked whether there was enough resource allocated to address all of the issues identified in the survey. Mr Lenney said that the Executive Team were reviewing the financial plans for 2015/15. He said that while everyone recognised the need for investment in this area, there were other financial challenges which also had to be considered. Mrs Dixon asked whether mid year surveys were undertaken. Mr Lenney said that one third of the staff was surveyed through the Staff Friends and Family Test in three of the four quarters of the year and all staff received
Item
3a
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the national staff survey in the fourth quarter. Dr Fairfield said that the Trust had thousands of staff comments and views from the Pride in Pennine work and she would be cautious about carrying out any further surveys other than periodic pulse checks. She added that it was interesting to read through Pride in Pennine which issues really mattered to staff and could improve their daily working lives and in turn the care they were able to provide. The Trust had to act on these comments and views. The report was noted.
08/15 Strategic Risk Register / Board Assurance Framework Mr Barclay spoke to the revised Strategic Risk Register and Board Assurance Framework which had been previously considered at the Board risk workshop on 13 January 2015. Mr Barclay reminded the Board of the earlier work by the Board in the summer of 2014 to identify the significant risks and the development of the risk register and assurance framework, through the Quality and Performance Committee, since that time. He said that the revised format set out the controls, assurances and gaps much more clearly. The Board Assurance Framework was directly linked to the Trust’s corporate priorities. Mr Barclay said that most of the more recent work since January 2015 on revising the Strategic Risk Register and Board Assurance Framework had been led by the new Director of Clinical Governance who would also now review the risk management strategy and policy within the Trust. Board members said that the new Stratgeic Risk Register and Board Assurance Framework were very clear, comprehensive and logical. The Strategic Risk Register and Board Assurance Framework were approved and it was agreed that the Board should receive a monthly report on significant risks with the full Strategic Risk Register and Board Assurance Framework submitted on a quarterly basis.
GB
09/15 Mortality Report Dr Sinniah spoke to the report and stated that while the Trust’s HSMR had risen in November 2014, this was due to incomplete data submission and would be resolved for the December submission when he expected the previous positive trends to continue. Setting aside the incomplete data submission, Mrs Mayer asked Dr Sinniah whether he was satisfied with progress being made on the various actions set out for The Royal Oldham Hospital. Dr Sinniah said that he was content with progress at present and would expect implementation of
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actions to continue. Mrs Mayer asked about lowering the threshold for triggering individual concerns to below 95. Dr Sinniah said that he had discussed this with Dr Prudham and the Director of Clinical Governance and they had come to the conclusion that they did not feel that the threshold should be lowered to 85. They were of the view that there was appropriate monitoring of individual performance in place and that there could be valid reasons for individual dip in mortality. Monitoring of trends would be more important and he acknowledged that further work was required in this area. He said that the appointment of new Clinical Governance Managers at Divisional level would have a positive impact, along with standardising of reporting and the agendas for the morbidity and mortality meetings which was being led by the Director of Clinical Governance. Dr Fairfield commented on the significant work undertaken over the last year to refocus the Trust. She said that a key part of this had been to put clinical leadership at the centre of the Trust and once the final elements were in place at Directorate level work could be taken forward at a faster pace. Mrs Guereca and Mrs Ollersnshaw asked why Fairfield General Hospital had a higher acuity that the other hospitals. Dr Sinniah explained that Rochdale Infirmary managed lower acuity patients meaning that higher acuity patients formed a greater proportion of patients admitted to Fairfield General Hospital. The Chairman proposed that the report should be made available to Consultants across the Trust so that they were aware of the level of detail considered by the Board, although it was also acknowledged that it had been agreed earlier in the meeting that the mortality reports should be integrated within the Integrated Performance Report. The report was noted.
AS
10/15 Review of how the Trust Applies the Mental Health Act Mrs Salmon-Jamieson spoke to the report of an external review on how the Trust applied the Mental Health Act. The report had been received by the Senior Management Team and the SMT had accepted the recommendations which would need to be followed through to ensure that the Trust fully complied with the requirements under the Act. The Chief Nurse would be the Executive lead, with implementation being taken forward by the Director of Clinical Governance. Dr Fairfield asked that Mrs Good, who remained a registered Mental Health Nurse, be involved in supporting the implementation of the recommendations.
KSJ / SG
Item
3a
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The Chairman asked that arrangements be made for reports to be brought to the Board on implementing the recommendations and on compliance with the Act. The report was noted.
KSJ
11/15 Review of Complaints Handling within the Trust Mrs Salmon- Jamieson spoke to her paper which described a benchmarking exercise undertaken against the PHSO report on expectations for raising concerns and complaints which had been published in November 2014. She said that while it was acknowledged there had been improvements in the quality of Trust complaint responses and a reduction in the number of dissatisfied complainants, this had been at the expense of a significant deterioration in the speed of complaint response. Further work was needed to ensure that each complainant was provided with a person centred experience that ultimately offered a comprehensive, assurance based and timely response. Mrs Dixon welcomed the review and the emphasis on face to face contact at the start of any complaint process. Mrs Guereca said that the review was comprehensive and supported the emphasis on early resolution. She asked whether the reasons for delays in providing responses were explained to complainants. Mrs Salmon-Jamieson said that this was the case and added that there was now an increasing emphasis on meeting with complainants. Mrs Cardiff said that in view of the forthcoming new arrangements for visits to wards and departments it would be helpful for Non-Executive Directors to have some training and advice on how to handle any issues raised by patients. Dr Fairfield said that this paper was an example of another area within the Trust which had been subject to a comprehensive review. Since taking up post she had received all complaints responses for personal review and acknowledged that some of the delays in providing final responses had arisen because she had sent draft responses back for further investigation or more information and had also insisted that local clinical managers in Divisions and Directorates review investigation reports and draft responses, all of which had added to the length of time taken. With the finalising of the new management arrangements, the implementation of the other recommendations described in the paper and an increase in the capacity and profile of the PALS service, she expected response times to reduce. The report was noted.
KSJ
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12/15 Trust Programmes Update Mrs Good reported as follows:
Six of the eight programme manager posts in the PMO had been filled and she expected all to be in place by June;
Transformation Delivery Managers, to be embedded in the Divisions, had been recruited;
Clinical Service Transformation - the see one, do one, teach one process was underway;
CIP – on target to achieve 2014/15 objectives. £20m of CIP for 2015/16 had been identified. The external consultancy support provided for 2014/15 was being evaluated and consideration was being given a engaging further support in 2015/16, directly linked to the Clinical Transformation Strategy, while also supporting further development of internal capability and capacity;
Workforce and Leadership – the programme would be re-launched;
Foundation Trust – there was a need to focus on FT member engagement. Feedback on the draft IBP submitted in December was due in the next week with the next iteration of the IBP due in September 2015. A Board to Board session with the TDA was anticipated in June 2015.
Mrs Ollerenshaw stated that the Trust had previously established a Service Delivery Unit, essentially a PMO, several years ago, supported by external consultants and with the intention to transfer skills to Trust staff. She said that this had had some initial success but had then faltered. She asked what would be different this time to ensure that the same good intentions were delivered. Mrs Good said that filling the PMO posts would free up capacity and the Transformation Programme Managers would be embedded in the Divisions. Mrs Guereca commented on the stakeholder engagement event held the previous evening as part of the Clinical Service Transformation. She described this as a fantastic event attended by c70 senior clinical leaders from the Trust, CCGs, local authorities, TDA, NWAS and neighbouring Trusts. She said that it had been good to see clinicians presenting and leading the engagement with partners.
13/15 Social Services Integration in North Manchester Mr Mullen spoke to his report which set out the latest position on the “Early Adopter” health and social care integration programme within North Manchester. The papers et out the service model for phase 1 of the proposed integration and highlighted key enablers and risks alongside the joint Trust / Manchester City Council governance arrangements for the programme.
Item
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Management arrangements for 120 staff would transfer from the City Council to the Trust on 1 April 2015. The budget would remain with the City Council in the first instance. The report was noted.
14/15 Data Quality Assurance Framework Mr Steven summarised the main elements of the report which was a key document in allowing the Board to sign off the Quality Accounts in due course. The report was noted.
15/15 Minutes of Board Sub-Committees The minute of meeting of the Audit Committee dated 10 February 2015 was submitted and noted. The minute of meeting of the Trust Programme Board dated 27 January 2015 was submitted and noted. The minute of meeting of the Trust Programme Board dated 17 February 2015 was submitted and noted. The minute of meeting of the Quality and Performance Committee dated 12 December 2014 was submitted and noted. The minute of meeting of the Quality and Performance Committee dated 20 January 2015 was submitted and noted. The minute of meeting of the Quality and Performance Committee dated 24 February 2015 was submitted and noted. Mrs Dixon tabled and spoke to the Highlight Report from the meeting of the Quality and Performance Committee held on 24 March 2015 and commented specifically on the SUI review, the Health and Safety Report, Quality Priorities and the improvement in RTT performance. Dr Fairfield said that she found the Highlight Report very helpful. She added that along with Mr Barclay she would be reviewing reporting arrangements across the entire committee structure.
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16/15 Papers for Information and Acceptance Medical and Dental Undergraduate and Post Graduate Update – noted. Freedom of Information Annual Report 2014 – noted. Eliminating Mixed Sex Accommodation – Declaration of Compliance – the Board approved the declaration. Equality Reports – Patient Equality Report and Staff Equality Report – approved. Board Agenda Planner – Mr Barclay said that he had prepared the planner and would reviewed it with Dr Fairfield as part of the review of sub-committee reports referred to earlier in the meeting and would then discussed the planner with the Chairman.
GB
17/15 Date of Next Meeting Thursday 28 May 2015
18/15 Resolved That representatives of the press and other members of the public be excluded from the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.
Item
3a
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Title of Report
The Integrated Performance Report
Executive Summary
The report provides information about the Trust’s key performance areas
Actions requested
The Quality & Performance Committee and the Board are asked to:- 1. Review the information submitted 2. Note that development of the Integrated Performance Report is
continuing, with the following changes: – (1) Compliance dates have been added; (2) Quality Section: a new Harm Free care KPI, a new FFT KPI; 2 KPIs for cancer quality; (3) Workforce Section: Mandatory training KPI updated; Vacancy KPI added – (4) Work is also underway to incorporate an expanded suite of mortality KPIs.
Corporate Objectives supported by this paper: Links to corporate objectives are specified in the report’s scorecard
Risks: The risks identified in this report are picked up in the relevant risk register.
Public and/or patient involvement: Key performance indicators within this report are derived from the expectations of patients and the public.
Resource implications: Failure to achieve the performance indicators could result in loss of income.
Communication: Through management structures
Have all implications been considered? YES NO N/A
Assurance X
Contract X
Equality and Diversity X
Financial / Efficiency X
HR X
Information Governance Assurance X
IM&T X
Local Delivery Plan / Trust Objectives X
National policy / legislation X
Sustainability X
Name Brian Steven
Job Title Deputy Chief Executive and Director of Finance & IM&T
Date May 2015
Email [email protected]
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spec
tive
s, f
acili
tati
ng
fair
ch
alle
nge
To p
rovi
de
a su
mm
ary
of
con
trac
t in
dic
ato
rs,
sho
w a
dd
itio
nal
d
etai
led
info
rmat
ion
, an
d a
d h
oc
rep
ort
s
Pu
rpo
se
Item
6a
Page 17 of 196
(1)
Su
mm
ary
In
teg
rate
d S
co
reca
rd
O
vera
ll 5
8%
of
ind
icato
rs w
ere
met
(gre
en
)
Tre
nd
Re
d P
erf
orm
ance
Ris
ksTr
en
dR
ed
Pe
rfo
rman
ce R
isks
Gre
en
s6
Ele
ctiv
e a
ctiv
ity
vs p
lan
Gre
en
s3
Inco
me
vs
Pla
n
Re
ds
4D
ay c
ase
act
ivit
y vs
pla
nR
ed
s4
Surp
lus
/ D
efi
cit
vs P
lan
No
n-E
lect
ive
len
gth
of
stay
CIP
Ach
ieve
me
nt
- ve
rsu
s P
lan
The
atre
pro
du
ctiv
ity
Cas
h B
alan
ce v
s P
lan
Gre
en
s10
MR
SAG
ree
ns
4S&
A
Re
ds
3H
and
ove
r o
f ca
re c
om
m (
OP
<10d
y)R
ed
s4
Ban
k &
Age
ncy
sp
en
d,
Re
adm
issi
on
sFF
T -
pla
ce t
o w
ork
PD
Rs
Gre
en
s10
A&
E 4
ho
urs
Gre
en
s1
Re
ds
4C
ance
r 62
day
scr
ee
nin
g n
atio
nal
Re
ds
3
Can
cer
62 d
ay G
P r
eal
loca
ted
loca
l
6 w
ee
k d
iagn
ost
ic t
est
s
Pe
rfo
rman
ceP
erf
orm
ance
PerformanceBusiness Capability Quality
Regulatory
AssessmentsWorkforceFinance
TDA
- O
vers
igh
t &
Esc
alat
ion
Stat
us
Leve
l 3 (
Inte
rve
nti
on
) d
ue
to F
inan
ce S
core
an
d 4
Qu
alit
y
ind
icat
ors
Mo
nit
or'
s R
isk
Ass
ess
me
nt
Fram
ew
ork
- 2
Acc
ess
& O
utc
om
e
me
tric
s o
ver
a ti
me
& C
oSS
R <
3
Tre
nd
s K
ey
Be
tte
r th
an la
st p
eri
od
Sam
e a
s la
st p
eri
od
Wo
rse
th
an la
st p
eri
od
Page 18 of 196
(2)
EX
EC
UT
IVE
SU
MM
AR
Y
Bu
sin
ess C
ap
ab
ilit
y
SLR
Q3 K
PI
perf
orm
ance t
ells
a s
imila
r sto
ry a
s r
eport
ed f
or
Q2 w
ith 3
specia
ltie
s (
11%
) not m
akin
g a
contr
ibution t
o o
verh
eads a
nd a
fu
rther
16 (
57%
) not m
akin
g a
surp
lus. W
ork
is u
nderw
ay t
o m
ake b
etter
use o
f S
LR
to c
ontr
ibute
to im
pro
ved p
erf
orm
ance a
nd
org
anis
ational susta
inabili
ty.
This
initia
tive w
ill e
nable
the D
ivis
ions t
o a
ccess im
pro
ved a
nd inte
ractive S
LR
info
rmation s
yste
ms, backed u
p
by a
user
train
ing
packag
e. W
e h
ave a
lso e
xte
nded t
he p
rogra
mm
e o
f deep d
ives t
o incorp
ora
te a
furt
her
8 s
pecia
ltie
s (
wo
rk w
ill s
tart
in
June).
We a
re a
lso u
ndert
akin
g s
om
e w
ork
to m
odel th
e p
ossib
le S
LR
positio
n b
y 1
9/2
0 (
post tr
ansfo
rmation).
Additio
nal
activity h
as b
een c
om
mis
sio
ned f
rom
the T
rust
as p
art
of
the 1
5/1
6 c
ontr
act
for
a s
ele
ction o
f surg
ical
specia
ltie
s t
o s
upport
im
pro
ved a
ccess p
erf
orm
ance.
Pro
vis
ional in
form
ation,
based o
n F
FC
E’s
, in
dic
ate
s t
hat
activity d
eliv
ere
d is b
elo
w t
he levels
pla
nned t
o b
e
achie
ved f
or
Apr-
15.
‘Off
icia
l’ in
form
ation s
how
ing
perf
orm
ance a
gain
st
activity t
arg
ets
, based o
n s
pells
, w
ill b
e a
va
ilable
next
month
. D
eliv
ery
of
activity m
ay influence t
he c
hoic
e o
f pro
vid
ers
made b
y c
om
mis
sio
ners
and t
here
fore
the f
utu
re s
usta
inabili
ty o
f serv
ices.
A n
ew
theatr
e p
roductivity indic
ato
r has b
een a
dded t
o t
he r
eport
follo
win
g c
om
ple
tion o
f th
e n
ew
theatr
e d
ashboard
on 1
9th M
ay.
The
dashboard
will
be u
sed to s
upport
work
to im
pro
ve p
roductivity,
with t
his
and o
ther
KP
Is b
ein
g u
sed t
o info
rm the p
ote
ntial scale
of
impro
vem
ent availa
ble
to t
he T
rust
in t
he L
TF
M m
ovin
g f
orw
ard
.
Work
is o
ng
oin
g to r
evie
w a
nd r
efine, at a m
ore
deta
iled
and o
pera
tional le
vel, t
he k
ey s
erv
ice c
hang
e a
ssum
ptions that
underp
in t
he
various p
ossib
le o
utc
om
es o
f th
e T
rust’s T
ransfo
rmation o
ptions.
Qu
ality
HC
AI
– C
-Diff
was b
ett
er
than t
raje
cto
ry w
ith t
he f
ew
est
num
ber
of
cases r
eport
ed in a
ny A
pri
l. T
here
was 1
MR
SA
in
April, w
hic
h is b
ein
g
investig
ate
d.
SU
Is –
follo
win
g t
he T
rust
com
mis
sio
ned M
ate
rnity R
evie
w a
num
ber
of
incid
ents
were
retr
ospectively
report
ed i
n A
pril. T
og
eth
er
with
C
CG
s the s
tatu
s o
f each incid
ent
is b
ein
g r
evie
wed in M
ay.
The S
afe
ty T
herm
om
ete
r H
arm
Fre
e C
are
KP
I has b
een a
dded t
o t
his
month
’s r
eport
– A
local
targ
et
is b
ein
g d
evelo
ped
for
inclu
sio
n i
n
next
month
’s r
eport
.
A n
ew
FF
T K
PI
has b
een a
dded to this
month
’s r
eport
to r
eflect th
e c
hanges t
o t
he n
ational m
easure
ment
syste
m d
uri
ng
2014-1
5.
Handover
of
care
com
munic
ation –
Inpatient
com
plia
nce s
ignific
antly i
mpro
ved a
nd t
he 9
5%
targ
et
was a
chie
ved f
or
the f
irst
tim
e e
ver
in
Marc
h.
Outp
atient
lett
ers
com
plia
nce h
as a
lso im
pro
ved
over
the y
ear,
but
levelle
d o
ff b
elo
w 9
5%
- W
ith t
he s
upport
of
the P
MO
, additio
nal
actions a
re b
ein
g im
ple
mente
d to a
ddre
ss t
he issues identified
during 1
5-1
6.
2
ne
w
inte
rnal
cancer
qualit
y
KP
Is
have
been
added
to
the
report
to
support
im
pro
vem
ent
of
com
munic
ation
of
clin
ical
path
wa
y
manag
em
ent
info
rmation f
or
patients
on a
cancer
path
way.
Mort
alit
y –
HS
MR
rem
ain
s r
ela
tively
good.-
SH
MI re
main
s a
bove 1
.00 a
nd w
ithin
the e
xpecte
d r
ang
e
Op
era
tio
nal
Perf
orm
an
ce
All
3 n
ational
RT
T s
tandard
s w
ere
achie
ved f
or
the s
eventh
consecutive m
onth
. T
he d
iagnostic 6
week s
tandard
was m
issed i
n A
pril.
Contr
ibuto
ry f
acto
rs inclu
ded r
ecent
cancer
aw
are
ness c
am
paig
n r
ela
ted d
em
and incre
ase f
or
scopes a
nd c
apacity c
onstr
ain
ts –
Clin
ically
urg
ent patients
are
bein
g p
rioritised a
nd a
pla
n h
as b
een s
ubm
itte
d to S
MT
.
Item
6a
Page 19 of 196
7 o
f th
e 9
cancer
targ
ets
were
met
in Q
4.
The T
rust
did
not
meet
1 o
f th
e 7
national
targ
ets
monitore
d b
y t
he T
DA
(th
e 6
2 d
ay t
arg
et
for
scre
enin
g r
efe
rrals
). T
he l
ocally
monitore
d 6
2 d
ay G
P r
efe
rral
reallo
cate
d s
tandard
did
not
achie
ve
for
Jan
-15.
The p
lan a
gre
ed w
ith
com
mis
sio
ners
and d
iscussed w
ith t
he T
DA
is b
ein
g im
ple
mente
d.
The a
gre
ed im
pro
vem
ent
traje
cto
ry f
or
the 6
2 d
ay c
ancer
sta
nda
rds w
as
met fo
r re
ferr
als
receiv
ed fro
m 1
st D
ecem
ber
for
Jan
-15, F
eb-1
5,
and M
ar-
15. T
he I
ST
report
will
be s
ubm
itte
d t
o S
MT
in J
une.
The 4
hour
sta
ndard
wa
s a
chie
ved f
or
Q1 a
nd Q
2.
Whils
t perf
orm
ance h
as i
mpro
ved i
t has r
em
ain
ed b
elo
w t
arg
et
for
the l
ast
7 m
onth
s
Pre
ssure
s r
em
ain
hig
h d
ue t
o h
igh a
cuity,
and b
ed p
ressure
s r
esultin
g f
rom
dela
ys in t
he d
ischarg
e p
rocess.
The T
rust
has a
gre
ed a
pla
n
with t
he T
DA
to i
mple
ment
“The P
erf
ect
Week,”
anticip
ating
that
this
will
hig
hlig
ht
the n
eed t
o e
nsure
com
plia
nce w
ith t
he b
est
pra
ctice
sta
ndard
s o
f w
hic
h t
he T
rust is
already a
ware
. U
pdate
s o
n t
he o
utc
om
es o
f T
he P
erf
ect W
eek w
ill b
e r
eport
ed a
nd incorp
ora
ted in
to p
lans.
F
inan
ce
The f
inal 2015/1
6 A
nnual F
inancia
l P
lan w
as s
ubm
itte
d t
o t
he N
HS
Tru
st
Develo
pm
ent
Auth
ority
on 1
4th M
ay 2
015 f
ore
casting a
year
end
deficit o
f (£
25.8
m),
com
pare
d t
o t
he b
reakeven p
ositio
n r
eport
ed a
t th
e e
nd o
f 2014
-15.
The i
mpro
vem
ent
from
the (
£29.9
m)
deficit p
lan
subm
itte
d o
n 7
th A
pril 2015 w
as a
ppro
ved b
y t
he B
oard
of
Directo
rs a
t th
e 3
0th A
pril C
onfirm
and C
halle
ng
e m
eeting
.
At
Month
1 t
here
wa
s a
n a
dvers
e p
erf
orm
ance o
f £0.5
m a
gain
st
pla
n b
efo
re i
mpairm
ents
and t
echnic
al
adju
stm
ents
. T
he d
eliv
ery
of
the
financia
l pla
n is c
onting
ent
on:
[1]
Deliv
ery
of
PbR
Incom
e;
[2]
Deliv
ery
of
CIP
- £
0.5
m a
dvers
e v
ers
us p
lan a
t M
1 a
nd
is b
ack-loaded t
o t
he
second h
alf o
f th
e y
ear;
[3]
Deliv
ery
of
CQ
UIN
s a
nd c
ontr
act K
PIs
.
The y
ear
to d
ate
Continuity o
f S
erv
ice R
isk R
ating
(C
oS
RR
) re
duced t
o 2
.0,
and t
he f
ore
cast
year
end C
oS
RR
is 1
.0 –
belo
w t
he a
spirant
FT
targ
et of
3.0
W
ork
forc
e
A n
um
ber
of
inte
r-re
late
d W
ork
forc
e K
PIs
have m
issed t
arg
ets
for
som
e t
ime (
S&
A,
Bank a
nd A
gency s
pend,
Sta
ff F
FT
, and P
DR
s).
A
diffe
rent
appro
ach is b
ein
g t
aken in o
rder
to e
nsure
qualit
y o
f care
, perf
orm
ance a
nd f
inancia
l obje
ctives a
re s
usta
inably
met.
The ‘P
ride in
Pennin
e’
CE
O c
halle
ng
e e
vent
on “
Health a
nd A
ttendance”
will
seek s
olu
tions t
hro
ug
h w
ide s
taff
eng
ag
em
ent,
whic
h w
ill r
esult i
n a
pla
n
bein
g d
raft
ed a
t th
e e
nd M
ay,
follo
win
g t
he o
nlin
e w
ork
undert
aken (
Marc
h /
April) a
nd t
he larg
e g
roup m
eeting o
n 2
2nd M
ay.
Recru
itm
ent
initia
tives a
re a
lso u
nderw
ay t
o f
ill v
acancie
s.
Reg
ula
tory
Assessm
en
ts
The C
QC
assessm
ent
of
pote
ntial
risks d
escribed i
n t
he I
nte
llig
ent
Monitoring
Report
show
s t
he r
ating
rem
ain
s a
t band 6
(th
e l
ow
est
risk
cate
gory
) – 1
new
Ele
vate
d R
isk w
as a
dded
; 1 r
isk w
as r
em
oved; and 1
ris
k w
as r
educed fro
m E
levate
d to R
isk in t
he M
ay-1
5 r
eport
.
Both
th
e T
DA
O
vers
ight
and E
scala
tion S
core
and th
e shadow
m
onitoring
ag
ain
st
Monitor’s R
isk A
ssessm
ent
Fra
mew
ork
show
th
at
impro
vem
ent
is n
eeded in o
rder
to p
rogre
ss t
ow
ard
s F
T s
tatu
s.
The T
DA
report
ed a
susta
ined r
ating
of
3,
hig
hlig
hting
the f
ollo
win
g i
tem
s:
financia
l perf
orm
ance,
the M
ate
rnity S
erv
ices R
evie
w c
om
mis
sio
ned b
y the T
rust;
and p
erf
orm
ance a
gain
st:
A&
E, C
-Difficile
, and the S
afe
ty
Therm
om
ete
r ta
rget. M
onitor’s s
hadow
assessm
ent
als
o h
ighlig
hts
failu
re t
o a
chie
ve 2
Access &
Outc
om
es a
reas.
Page 20 of 196
(3)
Inte
gra
ted
Sc
ore
ca
rd
Pri
ori
tyLe
adIn
dic
ato
r n
ame
Fre
qTa
rge
t14
-15
Cu
rre
nt
Pe
rf
Dat
a u
p
toTr
en
d
YTD
15-
16
15-1
6
Fore
cast
2H
MO
utp
atie
nt
1st
vs p
lan
M>=
0%6.
1%6.
1%A
pr-
Mar
n/a
G
2H
MO
utp
atie
nt
Re
vie
w v
s p
lan
M>=
0%2.
8%2.
8%A
pr-
Mar
n/a
G
2H
MEl
ect
ive
inp
atie
nt
vs p
lan
M>=
0%-8
.5%
-8.5
%A
pr-
Mar
n/a
G
2H
MD
ay C
ase
vs
pla
nM
>=0%
-1.2
%-1
.2%
Ap
r-M
arn
/aG
2H
MN
on
-Ele
ctiv
e v
s p
lan
M>=
0%6.
1%6.
1%A
pr-
Mar
n/a
G
2H
MA
&E
atte
nd
s vs
pla
nM
>=0%
6.2%
6.2%
Ap
r-M
arn
/aG
2H
MG
P r
efe
rral
s gr
ow
th v
s la
st y
ear
M>=
0%7.
3%14
.2%
Mar
-15
n/a
G
2, 4
HM
Ord
er
bo
ok
(siz
e o
f w
aiti
ng
list
s)Q
n/a
33,2
4434
,328
Ap
r-15
n/a
2, 4
BS
No
. of
spec
ialt
ies
ma
kin
g a
+ve
con
trib
uti
on
Q28
n/a
25A
pr
-Se
pn
/a
2, 4
BS
Va
lue
(£m
) o
f sp
ecia
ltie
s m
aki
ng
a
con
trib
uti
on
Qtb
cn
/a38
.0A
pr
-Se
pn
/a
2, 4
BS
No
. of
spec
ialt
ies
ma
kin
g a
su
rplu
sQ
28n
/a9
Ap
r -S
ep
n/a
2, 4
BS
Va
lue
(£m
) -s
pec
ialt
ies
ma
kin
g a
surp
lus
Qtb
cn
/a15
.6A
pr
-Se
pn
/a
2, 4
HM
LoS
- El
ect
ive
Inp
atie
nt
(day
s)Q
2.76
2.66
2.52
Jan
-Mar
n/a
G
2, 4
HM
Los
- Non
-Ele
ctiv
e In
pati
ent
(day
s)Q
3.36
3.46
3.65
Jan
-Mar
n/a
tbc
2, 4
HM
The
atre
pro
du
ctiv
ity
Q>=
85%
82.3
%81
.2%
Jan
-Mar
n/a
tbc
2, 4
HM
Ou
tpa
tien
t p
rod
uct
ivit
yQ
tbc
1, 6
, 10
AS
SHM
I (ro
llin
g ye
ar t
o d
ate
)Q
Exp
ect
ed
1.04
1.05
Sep
-14
n/a
G
1, 6
, 10
AS
HSM
RM
<=10
083
.05
74.1
9D
ec-
14n
/aG
1, 6
, 10
GH
C-D
iff
M<=
5572
1A
pr-
151
G
1, 6
, 10
GH
MR
SAM
06
1A
pr-
151
tbc
1, 6
, 10
HM
Cle
anin
g sc
ore
sM
>=88
.5%
94.7
%95
.2%
Ap
r-15
95.2
%G
1, 6
GH
% H
arm
Fre
e C
are
- A
ll h
arm
sM
tbc
94.5
%94
.0%
Ap
r-15
94.0
%
1, 6
GH
Ne
ver
Eve
nts
M0
10
Ap
r-15
0G
1G
HSe
rio
us
Un
tow
ard
Inci
de
nts
Mtb
c76
27A
pr-
15
1G
HN
atio
nal
Saf
e S
taff
ing
RA
G R
atin
gM
>=B
lue
n/a
Blu
eFe
b-1
5N
ew
n/a
G
1G
HSa
fe S
taff
ing
leve
ls -
ove
rall
fil
l ra
teM
>=80
%97
.5%
97.6
%A
pr-
1597
.6%
G
1G
HN
um
ber
of
wa
rds
bel
ow
80
% f
ill
rate
Mn
/a6
0A
pr-
150
1A
SH
and
ove
r o
f ca
re c
om
m (
IP<2
4hr)
M>=
95%
92.7
%95
.1%
Mar
-15
n/a
G
1A
SH
and
ove
r o
f ca
re c
om
m (
OP
<10d
y)M
>=95
%84
.9%
80.3
%M
ar-1
5n
/aM
ar-1
6
1H
MIn
com
plet
e ca
ncer
pat
hway
lett
ers
M0
4913
Ap
r-15
n/a
1H
MO
pe
n c
ance
r p
ath
way
ste
p d
ow
ns
M0
7483
Ap
r-15
n/a
1, 2
, 4H
MR
ead
mis
sio
ns
rate
(28
day
)Q
<=10
011
111
1Ju
l-Se
p11
1tb
c
1,6
HM
Mix
ed
Se
x A
cco
mm
od
atio
nM
00
0A
pr-
150
G
1, 5
GH
FTT
- P
atie
nt
fee
db
ack
targ
ets
me
tM
12N
ew
12M
ar-1
5N
ew
n/a
G
Business Capability Quality
Pe
rfo
rman
ce R
AG
Tre
nd
s
Targ
et
ach
ieve
dB
ett
er
than
last
pe
rio
d
Targ
et
un
de
rach
ieve
dSa
me
as
last
pe
rio
d
Wo
rse
th
an la
st p
eri
od
Pri
ori
tyLe
adIn
dic
ato
r n
ame
Fre
qTa
rge
t14
-15
Cu
rre
nt
Pe
rf
Dat
a u
p
toTr
en
d
YTD
15-
16
15-1
6
Fore
cast
6, 1
0H
MR
TT s
tan
dar
ds
ach
ieve
dM
43
3M
ar-1
53
Oct
-15
6, 1
0H
MC
ance
r st
and
ard
s ac
hie
ved
M9
87
Mar
-15
8Ju
l-15
6, 1
0H
M4
ho
ur
Urg
en
t C
are
Sta
nd
ard
M>=
95%
93.6
%91
.5%
Ap
r-15
91.5
%O
ct-1
5
2, 4
, 10
BS
Co
SRR
vs
TDA
Pla
nM
>=2
4.0
2.0
Ap
r-15
2.0
tbc
2, 4
, 10
BS
Surp
lus
/ D
efi
cit
vs P
lan
(£m
)M
>=0
1.9
-0.5
Ap
r-15
-0.5
tbc
2, 4
, 10
BS
Inco
me
vs
Pla
n (
£m)
M>=
04.
4-0
.8A
pr-
15-0
.8tb
c
2, 4
, 10
BS
Exp
en
dit
ure
Vs
Pla
n (
£m)
M>=
0-4
.80.
2A
pr-
150.
2G
2, 4
, 10
HM
CIP
Ach
ieve
me
nt
- ve
rsu
s P
lan
M>=
34.1
-12.
5-0
.5A
pr-
15-0
.5tb
c
2, 4
, 10
BS
Cas
h B
alan
ce v
s P
lan
(£m
)M
>=0
14.4
-6.7
Ap
r-15
-6.7
tbc
2, 4
, 10
BS
Capi
tal R
esou
rce
Lim
it v
s Pl
an (£
m)
M>=
03.
92.
0M
ar-1
52.
0G
4, 8
JLB
ank
& A
gen
cy S
pe
nd
M<=
8%11
.0%
11.3
%A
pr-
1511
.3%
tbc
4, 8
JLS&
AM
<=4.
0%5.
67%
5.65
%A
pr-
155.
65%
tbc
4, 8
JLTu
rno
ver
Rat
eM
>=8
% &
<=1
1%
9.72
%9.
94%
May
-Ap
rn
/aG
6JL
FFT
- re
com
me
nd
tre
atm
en
tQ
>=67
%65
%71
%Ja
n-M
arn
/aG
7, 8
JLFF
T -
reco
mm
en
d a
s p
lace
to
wo
rkQ
>=61
%56
%59
%Ja
n-M
arn
/atb
c
1, 7
, 8JL
Man
dat
ory
tra
inig
- A
ll s
taff
M>=
85%
89%
88%
Ap
r-15
n/a
7, 8
JLP
DR
co
mp
leti
on
Q>=
90%
68%
68%
Ap
r-M
arn
/atb
c
2 ,4
, 6, 8
JLV
acan
cy R
ate
Mtb
c9.
29%
9.94
%A
pr-
15n
/a
1, 1
0C
QC
IMR
Ris
k B
and
ing
Q>=
56
6M
ay-1
5n
/aG
10
TDA
Esc
alat
ion
& O
vers
igh
tM
53
3M
ar-1
5n
/atb
c
10
Mo
nit
or
Co
SSR
M>=
34
2A
pr-
15n
/atb
c
10
Mo
nit
or
Acc
ess
& O
utc
om
es
M<4
& n
o
esc
alat
ion
33
Mar
-15
n/a
tbc
Workforce RegulatorPerformance FinanceK
ey
Ye
ar e
nd
fo
reca
st
GO
n t
rack
to
de
live
r
AIm
pro
vem
en
t re
qu
ire
d (
com
pli
ance
dat
e)
RN
ot
ach
ievi
ng
& o
ff t
raje
cto
ry, o
r fa
ile
d f
or
the
ye
ar
Item
6a
Page 21 of 196
(4
.1)
Fo
cu
s o
n B
us
ine
ss
Ca
pa
bilit
y
Business Capability
Q3
SLR
per
form
ance
is t
he
sam
e as
Q2
wit
h 3
sp
ecia
ltie
s 11
% n
ot
mak
ing
a co
ntr
ibu
tio
n a
nd
a f
urt
her
16
(5
7% n
ot
mak
ing
a su
rplu
s)
The
SLR
das
hb
oar
d is
bei
ng
red
esig
ned
by
the
BI t
eam
to
be
mo
re u
ser
frie
nd
ly-
tech
nic
al t
esti
ng
wit
h F
inan
ce t
o b
e co
mp
lete
d e
nd
of
May
, pri
or
to t
he
use
r te
stin
g p
has
e. A
tra
inin
g p
acka
ge f
or
SLR
will
be
del
iver
ed b
y th
e e
nd
of
Jun
e.
In a
dd
itio
n t
o t
he
Dee
p D
ives
in 3
pri
ori
ty s
pec
ialt
ies,
8 D
eep
Div
e (l
igh
ts)
hav
e b
een
init
iate
d.
The
15-1
6 a
ctiv
ity
pla
n w
ill b
e tr
ansl
ated
into
th
e o
per
atio
nal
das
hb
oar
d (
AM
R)
du
rin
g M
ay in
ord
er t
o s
up
po
rt p
erfo
rman
ce m
anag
emen
t
The
4 lo
cal C
CG
s h
ave
com
mis
sio
ned
act
ivit
y in
sel
ecte
d s
urg
ical
sp
ecia
ltie
s in
ord
er t
o d
eliv
er im
pro
ved
acc
ess
per
form
ance
at
CC
G le
vel a
nd
to
ac
com
mo
dat
e t
he
actu
al g
row
th in
can
cer
dem
and
up
to
M8
of
14
-15
. Th
e sp
ecia
lty
nee
din
g to
del
iver
th
e la
rges
t ac
tivi
ty in
crea
se is
G
astr
oen
tero
logy
(D
ay C
ases
). A
pla
n h
as b
een
su
bm
itte
d t
o m
itig
ate
the
cap
acit
y lim
itin
g m
edic
al w
ork
forc
e va
can
cies
.
Pro
visi
on
al F
FCE
dat
a sh
ow
s A
pri
l-1
5 a
ctiv
ity
is lo
wer
th
an A
pri
l 14
fo
r al
l PO
Ds.
Gas
tro
ente
rolo
gy h
as s
een
th
e b
igge
st r
edu
ctio
n in
bo
th D
ay C
ase
and
Inp
atie
nt
acti
vity
rel
ativ
e to
Ap
ril 2
01
4;
-159
FFC
E (-
31
%)
and
-4
6 F
FCE
(-1
2%)
resp
ecti
vely
– m
edic
al w
ork
forc
e ca
pac
ity
is t
he
con
stra
int.
In
pat
ien
t b
ed c
apac
ity
is a
lso
a c
on
stra
int
in s
om
e su
rgic
al s
pec
ialt
ies
du
e to
N-E
l pre
ssu
res.
A n
ew t
hea
tre
uti
lisat
ion
KP
I has
bee
n a
dd
ed t
o t
he
rep
ort
. Bas
elin
e in
form
atio
n f
or
14
-15
sho
ws
that
per
form
ance
is b
elo
w t
he
inte
rnal
85
%
targ
et. T
he
new
das
hb
oar
d w
ill s
up
po
rt im
pro
vem
ent
wo
rk.
Thea
tre
staf
f en
gage
men
t ev
ents
fo
r ar
e p
lan
ned
at
eac
h s
ite
du
rin
g Ju
ne.
Sup
po
rtin
g in
form
atio
n
The
Bet
ter
Car
e B
ett
er
Val
ue
aver
age
len
gth
of
stay
b
ench
mar
kin
g in
dic
ato
r an
d D
r Fo
ste
r b
oth
sh
ow
th
at
the
Tru
st h
as a
rel
ativ
ely
goo
d le
ngt
h o
f st
ay.
The
tab
le b
elo
w s
ho
ws
IP a
ctiv
ity
tren
ds
(FFC
Es)
R
isks
Del
iver
y o
f ac
tivi
ty m
ay in
flu
ence
ch
oic
e o
f p
rovi
der
by
com
mis
sio
ner
s.
ALo
S an
d t
hea
tre
pro
du
ctiv
ity
per
form
ance
s n
eed
to
in
form
th
e le
vel o
f sa
vin
gs t
hat
can
be
assu
med
in t
he
LTFM
mo
vin
g fo
rwar
d.
Ind
icat
or
nam
eFr
eq
Targ
et
14-1
5C
urr
en
t
Pe
rf
Dat
a u
p
toTr
en
d
YTD
15-
16
15-1
6
Fore
cast
Ou
tpat
ien
t 1s
t vs
pla
nM
>=0%
6.1%
n/a
Ap
r-15
n/a
n/a
Ou
tpat
ien
t R
evi
ew
vs
pla
nM
>=0%
2.8%
n/a
Ap
r-15
n/a
n/a
Ele
ctiv
e in
pat
ien
t vs
pla
nM
>=0%
-8.5
%n
/aA
pr-
15n
/an
/a
Day
Cas
e v
s p
lan
M>=
0%-1
.2%
n/a
Ap
r-15
n/a
n/a
No
n-E
lect
ive
vs
pla
nM
>=0%
6.1%
n/a
Ap
r-15
n/a
n/a
A&
E at
ten
ds
vs p
lan
M>=
0%6.
2%n
/aA
pr-
15n
/an
/a
GP
re
ferr
als
gro
wth
vs
last
ye
arM
>=0%
7.3%
14.2
%M
ar-1
5n
/aG
Ord
er
bo
ok
(siz
e o
f w
aiti
ng
list
s)Q
n/a
33,2
4434
,328
Ap
r-15
n/a
No
. of
spec
ialt
ies
ma
kin
g a
+ve
con
trib
uti
on
Q28
n/a
25A
pr
-Se
pn
/a
Va
lue
(£m
) o
f sp
ecia
ltie
s m
aki
ng
a
con
trib
uti
on
Qtb
cn
/a38
.0A
pr
-Se
pn
/a
No
. of
spec
ialt
ies
ma
kin
g a
su
rplu
sQ
28n
/a9
Ap
r -S
ep
n/a
Va
lue
(£m
) -s
pec
ialt
ies
ma
kin
g a
surp
lus
Qtb
cn
/a15
.6A
pr
-Se
pn
/a
LoS
- El
ect
ive
Inp
atie
nt
(day
s)Q
2.76
2.66
2.52
Jan
-Mar
n/a
G
Los
- Non
-Ele
ctiv
e In
pati
ent
(day
s)Q
3.36
3.46
3.65
Jan
-Mar
n/a
tbc
The
atre
pro
du
ctiv
ity
Q>=
85%
82.3
%81
.2%
Jan
-Mar
n/a
tbc
Ou
tpa
tien
t p
rod
uct
ivit
yQ
tbc
12-1
313
-14
14-1
52
year
var
1 ye
ar v
ar
Tru
st35
,337
32,8
1731
,572
-3,7
65-1
,245
Surg
ery
14,1
9413
,206
13,2
73-9
2167
Me
dic
ine
995
948
692
-303
-256
W&
C2,
179
1,93
61,
529
-650
-407
Dia
g17
,969
16,7
2716
,078
-1,8
91-6
49
IP A
ctiv
ity
Tre
nd
(FF
CEs
- s
ou
rce
MR
)
Page 22 of 196
(4
.2)
Fo
cu
s o
n Q
ua
lity
Quality
C-D
iff
was
bet
ter
than
tra
ject
ory
fo
r th
e m
on
th w
ith
th
e fe
we
st c
ases
re
po
rted
in a
ny
Ap
ril -
Th
ere
was
1 M
RSA
.
SUIs
– t
he
nu
mb
er r
epo
rted
sig
nif
ican
tly
incr
ease
d in
Ap
ril a
s a
resu
lt o
f re
tro
spec
tive
inci
den
ts a
risi
ng
fro
m t
he
Tru
st c
om
mis
sio
ned
Mat
ern
ity
Rev
iew
– A
mee
tin
g w
ith
CC
Gs
is t
akin
g p
lace
in M
ay t
o a
gree
th
e st
atu
s o
f e
ach
inci
den
t.
Har
m F
ree
Car
e -
A K
PI h
as b
een
ad
ded
to
th
is m
on
th’s
re
po
rt. T
he
TDA
has
his
tori
cally
ap
plie
d a
bla
nke
t ta
rget
of
95
% a
nd
hig
hlig
hte
d n
on
-co
mp
lian
ce w
ith
th
is t
arge
t in
th
eir
mo
nth
ly O
vers
igh
t &
Esca
lati
on
rep
ort
. A lo
cal t
arge
t w
ill b
e ag
ree
d (
the
TDA
is r
evie
win
g th
e 1
5-1
6 t
arge
t).
The
Har
m F
ree
care
KP
Is a
re a
mo
ngs
t th
e su
ite
of
nu
rsin
g m
etri
cs t
hat
are
bei
ng
dep
loye
d t
o im
pro
ve w
ard
leve
l qu
alit
y o
f ca
re p
erfo
rman
ce a
nd
re
po
rted
to
th
e N
urs
ing
& M
idw
ifer
y P
erfo
rman
ce m
eeti
ng.
Han
do
ver
of
care
co
mm
un
icat
ion
– S
ign
ific
ant
imp
rove
men
t in
14
-15
res
ult
ed in
th
e Tr
ust
ach
ievi
ng
com
plia
nce
wit
h t
he
inp
atie
nt
stan
dar
d f
or
the
firs
t ti
me.
Su
pp
ort
ed
by
the
PM
O, w
ork
is o
ngo
ing
to s
ust
ain
ach
ieve
men
t o
f th
e in
pat
ien
t st
and
ard
an
d im
pro
ve o
utp
atie
nt
per
form
ance
.
2 in
tern
al c
ance
r q
ual
ity
KP
Is h
ave
bee
n a
dd
ed t
o t
he
rep
ort
as
area
s fo
r im
pro
vem
ent
– B
oth
are
ab
ou
t h
ow
wel
l can
cer
pat
hw
ay in
form
atio
n is
co
mm
un
icat
ed
by
clin
icia
ns.
Th
e lo
nge
st w
ait
for
an in
com
ple
te c
ance
r le
tte
r w
as 1
6 w
eeks
– A
ll w
aits
are
su
bje
ct t
o a
n e
scal
atio
n p
roce
ss.
The
FFT
KP
I has
bee
n r
evis
ed t
o s
ho
w w
het
her
th
e Tr
ust
is a
n o
utl
ier
for
any
of
the
12 s
core
s u
sin
g th
e TD
A m
eth
od
olo
gy.
Sup
po
rtin
g in
form
atio
n:-
The
Safe
ty T
her
mo
met
er
Har
m F
ree
Car
e –
The
Tru
st is
bet
ter
than
ave
rage
co
mp
ared
to
ac
ute
pro
vid
ers.
The
12
FFT
ind
icat
ors
incl
ud
e 2
qu
esti
on
s (%
lik
ely
to
rec
om
men
d a
nd
% li
kely
to
no
t re
com
men
d)
for
the
follo
win
g se
rvic
es –
(1
) A
&E
(2)
Inp
atie
nt
(3)
Mat
ern
ity
– B
irth
, (4
) M
ater
nit
y A
nte
nat
al (
5)
Mat
ern
ity
– P
ost
nat
al
War
d, (
6)
Mat
ern
ity
– P
ost
nat
al c
om
mu
nit
y –
Tru
st p
erfo
rman
ce f
or
all F
FT K
PIs
is w
ith
in 2
st
and
ard
dev
iati
on
s o
f th
e p
rovi
der
ave
rage
(1
4-1
5 T
DA
met
ho
do
logy
).
The
R /
G r
atin
g fo
r SH
MI h
as b
een
ch
ange
d
to s
ho
w r
ed
if it
is o
uts
ide
of
the
exp
ecte
d
ran
ge
The
follo
win
g in
dic
ato
rs a
re u
nd
er d
evel
op
men
t:
Co
mp
lain
ts
A m
ort
alit
y su
b-s
ecti
on
is b
ein
g d
evel
op
ed
Ind
icat
or
nam
eFr
eq
Targ
et
14-1
5C
urr
en
t
Pe
rf
Dat
a u
p
toTr
en
d
YTD
15-
16
15-1
6
Fore
cast
SHM
I (ro
llin
g ye
ar t
o d
ate
)Q
Exp
ect
ed
1.04
1.05
Sep
-14
n/a
G
HSM
RM
<=10
083
.05
74.1
9D
ec-
14n
/aG
C-D
iff
M<=
5572
1A
pr-
151
G
MR
SAM
06
1A
pr-
151
tbc
Cle
anin
g sc
ore
sM
>=88
.5%
94.7
%95
.2%
Ap
r-15
95.2
%G
% H
arm
Fre
e C
are
- A
ll h
arm
sM
tbc
94.5
%94
.0%
Ap
r-15
94.0
%
Ne
ver
Eve
nts
M0
10
Ap
r-15
0G
Seri
ou
s U
nto
war
d In
cid
en
tsM
tbc
7627
Ap
r-15
Nat
ion
al S
afe
Sta
ffin
g R
AG
Rat
ing
M>=
Blu
en
/aB
lue
Feb
-15
Ne
wn
/aG
Safe
Sta
ffin
g le
vels
- o
vera
ll f
ill
rate
M>=
80%
97.5
%97
.6%
Ap
r-15
97.6
%G
Nu
mb
er o
f w
ard
s b
elo
w 8
0%
fil
l ra
teM
n/a
60
Ap
r-15
0
Han
do
ver
of
care
co
mm
(IP
<24h
r)M
>=95
%92
.7%
95.1
%M
ar-1
5n
/aG
Han
do
ver
of
care
co
mm
(O
P<1
0dy)
M>=
95%
84.9
%80
.3%
Mar
-15
n/a
Mar
-16
Inco
mpl
ete
canc
er p
athw
ay le
tter
s M
049
13A
pr-
15n
/a
Op
en
can
cer
pat
hw
ay s
tep
do
wn
sM
074
83A
pr-
15n
/a
Re
adm
issi
on
s ra
te (
28 d
ay)
Q<=
100
111
111
Jul-
Sep
111
tbc
Mix
ed
Se
x A
cco
mm
od
atio
nM
00
0A
pr-
150
G
FTT
- P
atie
nt
fee
db
ack
targ
ets
me
tM
12N
ew
12M
ar-1
5N
ew
n/a
G
Item
6a
Page 23 of 196
(4
.3)
Fo
cu
s o
n E
lec
tive
Ac
ce
ss
Performance
All
3 R
TT t
arge
ts w
ere
ach
ieve
d f
or
the
7th
mo
nth
.
The
Dia
gno
stic
6 w
eek
targ
et w
as m
isse
d in
Ap
ril d
ue
to in
crea
ses
in c
ance
r d
eman
d a
nd
med
ical
wo
rkfo
rce
cap
acit
y co
nst
rain
ts li
mit
ing
incr
ease
s in
cap
acit
y to
mee
t th
e in
crea
sed
sco
pin
g d
eman
d –
Clin
ical
ly u
rgen
t w
ork
is b
ein
g p
rio
riti
sed
.
The
Ove
rall
No
n-A
dm
itte
d b
ackl
og
red
uce
d in
Mar
-15
- G
astr
o N
on
-Ad
mit
ted
an
d 6
we
ek d
iagn
ost
ic t
arge
ts r
emai
n r
isks
du
e to
an
inab
ility
to
re
cru
it t
he
med
ical
wo
rkfo
rce
that
was
pla
nn
ed f
or
Q4
an
d r
eq
uir
ed t
o m
eet
incr
ease
d s
pec
ialt
y d
eman
d –
Su
bje
ct t
o im
ple
men
tati
on
of
pla
ns
to
mit
igat
e sh
ort
falls
in m
edic
al w
ork
forc
e ca
pac
ity,
it w
ill t
ake
6 m
on
ths
to m
eet
the
targ
et.
Ther
e w
ere
35
sp
ecia
lty
targ
et p
asse
s an
d 9
sp
ecia
lty
targ
et f
ails
incl
ud
ing:
Gas
tro
(In
com
ple
te),
Gen
eral
Su
rger
y (a
ll 3
), U
rolo
gy (
No
n-A
dm
itte
d),
T&
O (
Ad
mit
ted
+ N
on
-Ad
mit
ted
), E
NT
(A
dm
itte
d +
No
n-A
dm
itte
d).
All
spec
ialt
y b
ackl
ogs
we
re w
ith
in t
ole
ran
ce a
t m
on
th e
nd
exc
ept:
EN
T an
d
Gen
eral
Su
rger
y –
ENT
bac
klo
gs h
ave
rem
ain
ed t
he
sam
e (6
ab
ove
to
lera
nce
) an
d G
en
eral
Su
rger
y h
as r
edu
ced
by
6 (
49
abo
ve t
ole
ran
ce).
Bo
th
spec
ialt
ies
hav
e ex
per
ien
ced
sit
e b
ed p
ress
ure
s. G
ener
al S
urg
ery
/ C
olo
rect
al is
als
o b
ein
g ad
vers
ely
affe
cted
by
Gas
tro
cap
acit
y p
ress
ure
s. –
It is
an
tici
pat
ed t
hat
a r
edu
ctio
n o
f b
ackl
ogs
will
res
ult
in s
pec
ialt
y le
vel t
arge
t fa
ils f
or
thes
e sp
ecia
ltie
s d
uri
ng
Q1
of
15
-16
. Up
dat
es h
ave
bee
n
pro
vid
ed t
o C
CG
s.
B
ench
mar
ks (
Mar
-15)
Nat
ion
al p
erfo
rman
ce r
emai
ns
bel
ow
tar
get
Ad
mit
ted
- E
ng
86
.8%
, (fa
il) w
ith
87
ou
t o
f 1
67
fai
ling
– 5
GM
tru
sts
faile
d
No
n-a
dm
itte
d E
ng
95
.1%
wit
h 5
5 o
ut
of
195
fai
ling
– 4
GM
tru
sts
faile
d
Inco
mp
lete
– E
ng
93
.1%
wit
h 4
0 o
ut
of
194
faili
ng
– 2
GM
tru
sts
faile
d
52
wee
ks –
En
g to
tal 4
71
acro
ss 4
5 p
rovi
der
s –
GM
9 a
cro
ss 1
pro
vid
er
6 w
eeks
dia
gno
stic
– E
ng
1.5
% (
fail)
wit
h 8
5 f
ails
ou
t o
f 3
84 p
rovi
der
s –
4 G
M f
ails
Ele
ctiv
e A
cce
ss S
tan
dar
ds
Fre
qTa
rge
t14
-15
Cu
rre
nt
Pe
rf
Dat
a u
p
toTr
en
dY
TD
RTT
- A
dm
itte
dM
>=90
%87
.491
.0A
pr-
1591
.0
RTT
- N
on
-Ad
mit
ted
M>=
95%
96.0
96.7
Ap
r-15
96.7
RTT
Inco
mp
lete
M>=
92%
94.6
96.9
Ap
r-15
96.9
Nu
mb
er
of
RTT
sp
eci
alty
fai
lsM
015
29
Ap
r-15
9
RTT
- 5
2 w
ee
k In
com
ple
teM
00
0A
pr-
150
Ad
mit
ted
bac
klo
gM
<=35
021
823
7A
pr-
1523
7
No
n-A
dm
itte
d b
ackl
og
M<=
1345
494
354
Ap
r-15
354
6 w
ee
k d
iagn
ost
icM
<1%
0.4
2.3
Ap
r-15
2.3
Tota
l in
com
ple
te p
ath
way
sM
n/a
M24
,857
Ap
r-15
24,8
57
0
20
0
40
0
60
0
80
0
1,0
00
21-Sep-14
05-Oct-14
19-Oct-14
02-Nov-14
16-Nov-14
30-Nov-14
14-Dec-14
28-Dec-14
11-Jan-15
25-Jan-15
08-Feb-15
22-Feb-15
08-Mar-15
22-Mar-15
05-Apr-15
19-Apr-15
03-May-15
Ad
mit
ted
Ba
cklo
g
To
lera
nc
e
Tra
jec
tory
To
tal
02
00
40
06
00
80
01
,00
01
,20
01
,40
01
,60
0
30-Mar-14
30-Apr-14
31-May-14
30-Jun-14
31-Jul-14
31-Aug-14
30-Sep-14
31-Oct-14
30-Nov-14
31-Dec-14
31-Jan-15
28-Feb-15
31-Mar-15
30-Apr-15
No
n-A
dm
itte
d B
ack
log
To
lera
nce
Tra
ject
ory
To
tal
Page 24 of 196
(4
.3)
Fo
cu
s o
n C
an
ce
r A
cc
es
s
Performance
The
Tru
st a
chie
ved
all
of
the
nat
ion
al c
ance
r ta
rget
s m
on
ito
red
by
the
TDA
in M
arch
, bu
t m
isse
d t
he
62
day
scr
een
ing
targ
et f
or
Q4
du
e to
2
un
avo
idab
le p
atie
nt
pat
hw
ay b
reac
hes
(o
ne
was
a la
te r
efer
ral f
rom
an
oth
er t
rust
aft
er d
ay 6
2 a
nd
th
e o
ther
was
fo
r cl
inic
al r
easo
ns)
.
The
loca
l Gre
ater
Man
ches
ter
62
GP
rea
lloca
ted
per
form
ance
tar
get
for
Jan
-15
was
no
t ac
hie
ved
an
d it
is a
nti
cip
ate
d t
hat
it w
ill m
iss
for
Feb
-15–
C
linic
al p
ath
way
var
iati
on
is a
co
ntr
ibu
tory
fac
tor
that
has
bee
n id
enti
fied
th
rou
gh b
reac
h a
nal
ysis
.
2w
w d
eman
d a
cro
ss a
ll tu
mo
ur
site
fo
r Q
3 o
f 2
014
-15
incr
ease
d b
y 1
9%
co
mp
ared
to
Q3
of
20
13-1
4 –
Nat
ion
al d
eman
d (
stan
dar
dis
ed f
or
the
Tru
st’s
cas
e m
ix)
incr
ease
d b
y 1
2%
. Po
ten
tial
ch
ange
s in
NIC
E gu
idel
ines
du
rin
g 1
5-1
6 m
ay c
on
trib
ute
to
fu
rth
er in
crea
ses
in c
ance
r d
eman
d.
The
can
cer
imp
rove
men
t p
lan
(d
iscu
ssed
wit
h T
DA
an
d c
om
mis
sio
ner
s) is
bei
ng
imp
lem
ente
d. A
tra
ject
ory
of
refe
rral
s re
ceiv
ed f
rom
Dec
emb
er
has
bee
n a
gree
d f
or
the
62
day
tar
get
and
was
met
fo
r Ja
n-1
5, F
eb-1
5, a
nd
Mar
-15
. Th
e m
ain
co
mp
on
ents
of
the
pla
n a
re: (
1)
imp
rove
men
t in
sy
stem
s an
d p
roce
sses
(2
) cl
ear
clin
ical
dec
isio
n m
akin
g b
y co
nsu
ltan
ts, (
3)
incr
ease
d c
ance
r ca
pac
ity
at t
he
fro
nt
of
the
pro
cess
, in
par
ticu
lar
focu
ssed
in a
reas
wh
ere
can
cer
awar
enes
s ca
mp
aign
s ar
e d
ue.
The
Inte
nsi
ve S
up
po
rt T
eam
has
als
o b
een
invi
ted
to
rev
iew
sys
tem
s an
d p
roce
sses
– T
he
IST
rep
ort
will
be
com
ple
ted
in J
un
e.
It is
pre
dic
ted
th
at a
ll 9
can
cer
stan
dar
ds
will
be
met
fro
m J
uly
on
war
ds.
Follo
win
g En
glan
d’s
fai
lure
of
the
nat
ion
al 6
2 d
ay G
P r
efe
rral
tar
get
for
the
fift
h c
on
secu
tive
qu
arte
r th
e TD
A in
tro
du
ced
wee
kly
can
cer
PTL
re
po
rtin
g co
mm
enci
ng
20
th M
ay f
or
all o
f it
s p
rovi
der
s.
Nat
ion
al B
ench
mar
kin
g (Q
4):
–
Nat
ion
al p
erfo
rman
ce w
as s
imila
r to
Q3
:-
2 w
w –
En
g 9
4.7
% -
(24
pro
vid
er f
ails
)– N
o G
M f
ails
Bre
ast
2w
w -
En
g 9
4.7
% (
21 f
ails
) –
No
GM
fai
ls
31
day
fir
st –
En
g 9
7.5
%, (
18
fai
ls)
- N
o G
M f
ails
31
day
dru
g –
Eng
99
.5%
(9
fails
) -
No
GM
fai
ls
31
day
su
rger
y –
Eng
94
.9%
(31
fai
ls)
– N
o G
M f
ails
62
day
GP
nat
ion
al –
En
g 8
2.3
% (
fail
for
5th
co
nse
cuti
ve q
uar
ter)
(8
3 f
ails
) -
1 G
M t
rust
s fa
il
62
day
scr
een
ing
– En
g 9
1.4
% (
51 f
ails
) –
5 G
M f
ails
62
day
up
grad
e –
Eng
89
.4%
- n
o n
atio
nal
tar
get
62
day
loca
l rea
lloca
ted
GM
sta
nd
ard
- J
an-1
5
62
day
rea
lloca
ted
– E
ng
n/a
–G
M 8
4.4
% (
fail)
- 5
G
M f
ails
Can
cer
Acc
ess
Sta
nd
ard
sFr
eq
Targ
et
Last
year
Cu
rre
nt
Pe
rf
Dat
a u
p
toTr
en
dY
TDQ
1Q
2Q
3Q
4
2 w
ee
k A
ll c
ance
rsM
>=93
%96
.897
.2Fe
b-1
595
.295
.295
.195
.295
.5
2 w
ee
k b
reas
t sy
mp
tom
atic
M>=
93%
93.8
98.7
Feb
-15
93.2
89.3
93.0
94.6
97.7
31 d
ay in
itia
l de
cisi
on
to
tre
atM
>=96
%99
.710
0.0
Feb
-15
99.8
99.8
99.8
99.8
99.6
31 s
ay s
ub
seq
ue
nt
dru
gM
>=98
%99
.710
0.0
Feb
-15
100.
010
0.0
100.
010
0.0
100.
0
31 d
ay s
ub
seq
ue
nt
surg
ery
M>=
94%
99.7
100.
0Fe
b-1
510
0.0
100.
010
0.0
100.
010
0.0
62 d
ay G
P r
efe
rre
d n
atio
nal
M>=
85%
89.3
81.5
Feb
-15
85.3
85.6
85.1
85.9
83.8
62 d
ay G
P r
efe
rre
d r
e-a
llo
cate
dM
>=85
%86
.481
.9Ja
n-1
580
.082
.078
.979
.181
.9
62 d
ay s
cre
en
ing
M>=
90%
92.9
71.4
Feb
-15
94.9
94.1
100.
091
.984
.6
62 d
ay u
rge
nt
up
grad
eM
>=85
%91
.189
.7Fe
b-1
588
.488
.189
.387
.281
.9
20
14
-15
Item
6a
Page 25 of 196
(4
.3)
Fo
cu
s o
n U
rge
nt
Ca
re A
cc
es
s
Performance K
ey p
oin
ts:
The
4 h
ou
r ta
rget
was
ach
ieve
d f
or
Q1
an
d Q
2 o
f 1
4-1
5. W
hils
t p
erfo
rman
ce h
as im
pro
ved
th
e ta
rget
was
mis
sed
fo
r th
e la
st 7
mo
nth
s.
Pre
ssu
res
rem
ain
hig
h a
cro
ss t
he
hea
lth
eco
no
my
as a
re
sult
of:
-
o
Hig
her
dem
and
acu
ity,
wh
ich
has
co
ntr
ibu
ted
to
ext
end
ed le
ngt
hs
of
stay
s
o
Del
ayed
dis
char
ges,
wh
ich
bu
ilt u
p o
ver
the
win
ter
ho
liday
per
iod
hav
e su
bse
qu
entl
y n
ot
bee
n c
lear
ed –
Th
ere
are
curr
entl
y 1
47
m
edic
ally
fit
pat
ien
ts in
th
e d
isch
arge
pro
cess
acr
oss
th
e h
osp
ital
sit
es,
wh
ich
is c
irca
30
% h
igh
er t
han
it w
as la
st y
ear.
14
7 p
atie
nts
in t
he
dis
char
ge p
roce
ss e
qu
ate
s to
19%
of
the
Med
ical
bed
sto
ck. A
cute
bed
occ
up
ancy
incr
ease
d f
rom
88
% in
Q3
to
91
% in
Q4
, hig
her
th
an t
he
reco
mm
end
ed 8
5% t
o c
op
e w
ith
dem
and
an
d f
low
vo
lati
lity.
Del
ays
attr
ibu
tab
le t
o s
oci
al c
are
asse
ssm
ents
rem
ain
an
issu
e, w
hic
h is
b
ein
g e
scal
ated
acr
oss
th
e h
ealt
h e
con
om
y. T
he
TDA
has
ad
op
ted
th
e Tr
ust
’s a
pp
roac
h a
nd
inst
itu
ted
we
ekly
rep
ort
ing
of
pat
ien
ts
med
ical
ly f
it f
or
dis
char
ge f
or
all o
f it
s p
rovi
der
s co
mm
enci
ng
20
th M
ay.
The
pla
n a
gree
d w
ith
th
e TD
A t
o im
ple
men
t “T
he
Per
fect
We
ek”
init
iati
ve s
tart
ing
in J
un
-15
on
a s
ite
-by-
site
ro
tati
on
al b
asis
is b
ein
g p
rogr
esse
d.
Fro
m r
evie
w o
f fi
nd
ings
wh
ere
this
init
iati
ve h
as a
lrea
dy
bee
n u
sed
, it
is a
nti
cip
ated
th
at t
he
ou
tco
mes
of
“Th
e P
erfe
ct W
eek”
will
hig
hlig
ht
the
nee
d t
o m
eet
bes
t p
ract
ice
stan
dar
ds
that
th
e Tr
ust
is a
war
e o
f fr
om
wo
rk p
revi
ou
sly
un
der
take
n w
ith
EC
IST.
E.g
., A
ccu
rate
est
imat
ed
dat
e o
f d
isch
arge
; ou
tco
me
focu
ssed
dai
ly b
oar
d r
ou
nd
s in
th
e m
orn
ing;
ad
her
ence
to
Inte
rnal
Pro
fess
ion
al S
tan
dar
ds
by
clin
ical
te
ams;
tim
ely
asse
ssm
ent
at t
he
fro
nt
do
or
(A&
E); d
isch
arge
pro
cess
es c
om
ple
ted
ear
lier
in t
he
day
; rev
iew
of
pat
ien
ts s
tayi
ng
mo
re t
han
a w
eek.
Act
ion
s su
pp
ort
ed b
y th
e n
atio
nal
Sys
tem
Res
ilien
ce f
un
din
g w
ill g
rad
ual
ly c
ease
du
rin
g M
ay.
Nu
rsin
g va
can
cies
acr
oss
inp
atie
nt
med
ical
ser
vice
s an
d A
&E
med
ical
wo
rkfo
rce
vaca
nci
es c
on
tin
ue
to b
e an
issu
e.
The
Tru
st is
co
nti
nu
ing
to w
ork
wit
h h
ealt
h e
con
om
y p
artn
ers
at t
he
syst
em R
esili
ence
Gro
up
Mee
tin
gs a
nd
dai
ly e
scal
atio
n c
alls
to
exp
edit
e
issu
es a
nd
imp
rove
per
form
ance
. It
is p
red
icte
d t
hat
th
e A
&E
targ
et w
ill b
e ac
hie
ved
fro
m O
ct-1
5.
Ben
chm
arki
ng
(Ap
r-1
5)
Engl
and
per
form
ance
was
93
.31
% (
fail)
, wit
h 9
8
fails
fro
m 1
40
pro
vid
es w
ith
a t
ype
1 A
&E
– 5
of
the
8 G
M p
rovi
der
s fa
iled
Engl
and
per
form
ance
was
bel
ow
th
e 9
5%
tar
get
for
the
8th
co
nse
cuti
ve m
on
th -
per
form
ance
fo
r th
e ye
ar w
as 9
3.3
1%
- p
erfo
rman
ce w
as 9
5.2
1%
fo
r th
e p
revi
ou
s ye
ar
In M
arch
En
glan
d r
epo
rted
52
bre
ach
es o
f th
e 1
2
ho
ur
tro
lley
wai
t st
and
ard
– G
M h
ad n
o b
reac
hes
o
f th
e st
and
ard
Urg
en
t C
are
Acc
ess
Sta
nd
ard
sFr
eq
Targ
et
14-1
5C
urr
en
t
Pe
rf
Dat
a u
p
toTr
en
dQ
2Q
3Q
4Y
TDQ
1
4 h
ou
r Tr
ust
urg
en
t ca
reM
>=95
%93
.691
.5A
pr-
1595
.191
.592
.291
.591
.5
4 h
ou
r FG
H u
rge
nt
care
M>=
95%
90.2
84.6
Ap
r-15
93.5
85.7
88.0
84.6
84.6
4 h
ou
r R
OH
urg
en
t ca
reM
>=95
%91
.491
.2A
pr-
1593
.788
.589
.791
.291
.2
4 h
ou
r N
MG
H u
rge
nt
care
M>=
95%
95.2
92.4
Ap
r-15
95.2
94.3
94.3
92.4
92.4
4 h
ou
r R
I urg
en
t ca
reM
>=95
%98
.598
.1A
pr-
1599
.398
.098
.398
.198
.1
12 h
ou
r tr
oll
ey
wai
tsM
00
0A
pr-
150
00
00
2014
-15
2015
-16
Page 26 of 196
(4
.4)
Fo
cu
s o
n F
ina
nc
e
Finance
The
fin
al 2
015/
16 A
nn
ual
Fin
anci
al P
lan
was
su
bm
itte
d t
o t
he
NH
S Tr
ust
Dev
elo
pm
ent
Au
tho
rity
on
14
th M
ay 2
01
5 f
ore
cast
ing
a ye
ar e
nd
def
icit
o
f £
25.8
m, c
om
par
ed t
o t
he
bre
akev
en p
osi
tio
n r
epo
rte
d a
t th
e en
d o
f 2
014
-15
.
The
un
der
lyin
g d
efic
it h
as d
eter
iora
ted
by
£8
.4m
fro
m £
20
.7m
in 2
01
4-1
5 t
o a
yea
r e
nd
fo
reca
st o
f £
29.1
m in
201
5-1
6.
The
thre
e ke
y ar
eas
for
the
Tru
st t
o f
ocu
s o
n a
re: e
nsu
rin
g d
eliv
ery
of
inco
me
wit
hin
del
egat
ed
bu
dge
ts; d
eliv
ery
of
£3
3.8
m C
IP; a
nd
clo
se
mo
nit
ori
ng
of
the
cash
po
siti
on
.
The
Co
nti
nu
ity
of
Serv
ice
Ris
k R
atin
g ye
ar t
o d
ate
has
red
uce
d t
o 2
, an
d a
fo
reca
st y
ear
en
d r
atin
g o
f 1
- b
oth
of
wh
at a
re b
elo
w t
he
rati
ng
of
3
req
uir
ed o
f as
pir
ant
FTs
* I &
E S
urp
lus/
(Def
icit
) b
efo
re im
pai
rmen
ts a
nd
tec
hn
ical
ad
just
men
ts
Div
isio
nal
per
form
ance
aga
inst
201
5-1
6 C
IP t
arge
t o
f £
33
.8m
Fin
anci
al t
arge
ts: T
he
Tru
st r
epo
rte
d a
£3
.3m
def
icit
wh
ich
is £
0.5
m b
elo
w
pla
n a
t th
e en
d o
f A
pri
l 20
15.
Tota
l in
com
e p
osi
tio
n a
t M
on
th 1
sh
ow
s an
un
der
per
form
ance
of
£0
.8m
Mai
nly
du
e to
un
der
per
form
ance
aga
inst
Pb
R e
xclu
ded
hig
h c
ost
d
rugs
, wh
ich
are
fu
nd
ed o
n ‘p
ass
thro
ugh
’ bas
is (
off
sets
exp
end
itu
re)
Po
siti
on
ass
um
es t
hat
th
e Tr
ust
has
ach
ieve
d it
co
ntr
acte
d a
ctiv
ity.
H
ow
ever
, ear
ly in
dic
atio
ns
are
ther
e m
ay b
e u
nd
er p
erfo
rman
ce -
Th
is
will
be
valid
ated
an
d r
ep
ort
ed
in t
he
Mo
nth
2 f
inan
ce r
epo
rt.
Op
era
tin
g e
xpe
nd
itu
re p
osi
tio
n s
ho
ws
an u
nd
er s
pen
d o
f £
0.2
m.
Ho
wev
er, t
his
incl
ud
es:
CIP
an
d d
eco
mm
issi
on
ing
slip
pag
e o
f £
0.6
m; a
nd
No
n p
ay b
ud
get
ove
rsp
end
of
£0
.3m
mai
nly
in m
edic
al a
nd
su
rgic
al
con
sum
able
s (e
xclu
din
g u
nd
er-s
pen
d o
n P
bR
exc
lud
ed h
igh
co
st d
rugs
o
ffse
t b
y in
com
e).
Pay
bu
dge
ts h
ow
ever
, are
un
der
-sp
ent
by
£0
.4m
mai
nly
du
e to
si
gnif
ican
t n
um
ber
of
vaca
nci
es m
ain
ly in
Co
rpo
rate
an
d D
iagn
ost
ics.
Th
e p
osi
tio
n in
clu
des
a r
ise
in a
gen
cy s
pen
d b
y £0
.4m
ab
ove
pla
n.
Ris
ks o
P
rem
ium
co
sts
staf
f b
oth
nu
rsin
g an
d m
edic
al
o
Man
agin
g co
st o
f n
urs
ing
inve
stm
ents
wit
hin
th
e fu
nd
ing
iden
tifi
ed f
or
20
15-1
6
o
The
del
iver
y in
fu
ll o
f th
e £
33
.8m
CIP
tar
get
o
Del
iver
y o
f co
ntr
act
KP
Is a
nd
CQ
UIN
s
Pla
n (
£'m
)
Actu
al
(£'m
)
Va
ria
nce
£'m
I&E
Surp
lus/(
Defic
it)
-2.8
-3.3
-0.5
Capital E
xpenditure
1.1
0.9
0.2
Cash B
ala
nce
51.1
44.4
-6.7
Item
6a
Page 27 of 196
(4
.5)
Fo
cu
s o
n W
ork
forc
e
Workforce
Seve
ral i
nte
r-re
late
d W
ork
forc
e K
PIs
co
nti
nu
e to
be
mis
sed
. o
O
ngo
ing
vaca
nci
es h
ave
incr
ease
d s
ince
last
mo
nth
as
a re
sult
of
an in
crea
se in
est
ablis
hm
ent
(46
FTE
) an
d a
dec
reas
e o
f st
aff
actu
ally
in
po
st (
16
FTE)
.
o
S&A
incr
ease
d s
ince
last
mo
nth
, was
hig
her
th
an A
pri
l 20
14
, an
d m
isse
d t
he
seas
on
ally
pro
file
d t
arge
t.
o
Spen
d o
n t
emp
ora
ry s
taff
ing
rem
ain
s h
igh
wit
h t
he
incr
ease
ove
r th
e la
st y
ear
bei
ng
dri
ven
by
agen
cy s
taff
ing.
o
St
aff
Frie
nd
s an
d F
amily
Tes
t St
aff
FFT
resu
lts
Q4
imp
rove
d f
or
bo
th in
dic
ato
rs, w
ith
th
e re
com
men
dat
ion
fo
r tr
eatm
ent
hit
tin
g 7
1%
(ab
ove
tar
get)
an
d r
eco
mm
end
atio
n a
s a
pla
ce t
o w
ork
bei
ng
bel
ow
tar
get
at 5
9%.
Imp
rovi
ng
atte
nd
ance
an
d r
ecru
itm
ent
and
ret
enti
on
are
hig
h p
rio
riti
es f
or
new
act
ion
in o
rder
to
en
sure
: (1
) su
stai
ned
qu
alit
y o
f ca
re;
(2)
per
form
ance
tar
gets
are
met
; (3
) th
e in
crea
sin
g sp
end
ing
on
tem
po
rary
sta
ff is
ad
dre
ssed
. New
act
ion
s in
clu
de:
o
Th
e ‘P
rid
e in
Pen
nin
e’ C
EO c
hal
len
ge e
ven
t o
n “
Hea
lth
an
d A
tten
dan
ce”
– A
pla
n w
ill b
e d
raft
ed a
nd
pu
blis
hed
at
the
end
of
May
bas
ed
on
sta
ff e
nga
gem
ent
resp
on
ses
at t
he
May
larg
e m
eeti
ng
and
th
e o
nlin
e w
ork
sho
p w
hic
h r
an d
uri
ng
Mar
ch a
nd
Ap
ril.
o
Rec
ruit
men
t in
itia
tive
s ar
e al
so o
ngo
ing
A
nn
ual
S&
A b
ench
mar
kin
g d
ata
(20
13-1
4)
so
urc
e i-
view
NH
S En
glan
d w
ide
3.9
5%, N
HS
Engl
and
Acu
te P
rovi
der
s 3
.73
%
No
rth
Wes
t re
gio
n a
ll p
rovi
der
s 4
.44
%,
Ind
icat
or
nam
eFr
eq
Targ
et
14-1
5C
urr
en
t
Pe
rf
Dat
a u
p
toTr
en
d
YTD
15-
16
15-1
6
Fore
cast
Ban
k &
Age
ncy
Sp
en
dM
<=8%
11.0
%11
.3%
Ap
r-15
11.3
%tb
c
S&A
- T
ota
lM
<=4.
2%5.
67%
5.65
%A
pr-
155.
65%
tbc
S
&A
- S
ho
rt T
erm
Mn
/a2.
74%
2.74
%A
pr-
152.
74%
S
&A
Lo
ng
Term
Mn
/a2.
91%
2.91
%A
pr-
152.
91%
Turn
ove
r R
ate
M>=
8 &
<=1
1%9.
72%
9.94
%M
ay-A
pr
n/a
G
Staf
f FF
T -
reco
mm
en
d t
reat
me
nt
Q>=
67%
65%
71%
Jan
-Mar
n/a
G
Staf
f FF
T -
reco
mm
en
d a
s p
lace
to
wo
rkQ
>=61
%56
%59
%Ja
n-M
arn
/atb
c
Man
dat
ory
tra
inig
- A
ll s
taff
M>=
85%
89%
88%
Ap
r-15
n/a
G
PD
R c
om
ple
tio
n (
12 m
on
th r
oll
ing)
Q>=
90%
68%
68%
Ap
r-M
arn
/atb
c
Vac
ancy
Rat
eM
n/a
9.29
%9.
94%
Ap
r-15
n/a
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
Apr-13May-13Jun-13Jul-13
Aug-13Sep-13Oct-13
Nov-13Dec-13Jan-14Feb-14Mar-14Apr-14
May-14Jun-14Jul-14
Aug-14Sep-14Oct-14
Nov-14Dec-14Jan-15Feb-15Mar-15Apr-15
S&
A %
Ra
te O
ve
r T
ime
To
tal
S&
A r
ate
Sh
ort
Te
rm r
ate
Lo
ng
te
rm r
ate
0%
2%
4%
6%
8%
10%
12%
14%
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
Ban
k &
Age
ncy
Sp
en
d a
s a
% o
f To
tal P
ay
% T
arge
t le
vel
% b
ank
and
age
ncy
rate
Page 28 of 196
(4
.6)
Fo
cu
s o
n R
eg
ula
tor
Pers
pe
cti
ve
s
CQ
C I
nte
llig
en
t M
on
ito
rin
g R
ep
ort
- P
ub
lis
he
d M
ay 2
01
5 (
So
urc
e:
CQ
C)
The C
QC
cate
gorises tru
sts
into
one o
f 6 s
um
mary
bands,
with b
and 1
repre
senting
hig
hest risk a
nd b
and 6
with t
he low
est. T
hese b
ands h
ave
been a
ssig
ned b
ased o
n t
he p
roport
ion o
f in
dic
ato
rs that have b
een identified a
s ‘risk’ or
‘ele
vate
d r
isk’ or
if there
are
know
n s
erious c
oncern
s
(e.g
. tr
usts
in s
pecia
l m
easure
s)
trusts
are
cate
gorised a
s b
and 1
*. F
or
the tru
sts
assig
ned a
cate
gory
based o
n the p
roport
ion o
f in
dic
ato
rs,
the
CQ
C h
as u
sed the follo
win
g thre
shold
s:
Perc
enta
ge s
core
(ro
w 7
in t
able
belo
w)
Band 1
>=
7.0
%, B
and 2
>=
5.5
%, B
and 3
>=
4.5
%, B
and 4
>
=3.5
%,
Band 5
>=
2.5
%,
Band 6
<2.5
%
1
Pri
ori
ty b
an
din
g f
or
ins
pe
cti
on
6
(L
ow
est
ris
k b
an
din
g)
Ba
nd
6 r
ati
ng
fo
r 4
co
ns
ec
uti
ve
qu
art
ers
1
Nu
mb
er
of
‘Ele
va
ted r
isks’
1
Nu
mb
er
of
risks e
xce
ed
ing
th
e ‘e
leva
ted
’ th
resh
old
s
2
Nu
mb
er
of
risks
2
Nu
mb
er
of
risks id
en
tio
fie
d t
hat
do n
ot e
xce
ed
th
e ‘e
leva
ted
’ th
resh
old
3
Ov
era
ll s
co
re
4
Nu
mb
er
of
risks +
2 x
Nu
mb
er
of
Ele
va
ted
ris
ks
4
Nu
mb
er
of
app
lica
ble
in
dic
ato
rs
96
N
um
ber
of
indic
ato
rs t
hat
are
ap
plic
ab
le to
th
e T
rust
for
the
se
rvic
es it
pro
vid
es
5
Maxim
um
possib
le s
co
re
192
T
he s
co
re t
hat
the
Tru
st
wo
uld
re
ce
ive
if
it h
ad f
lag
ged
as e
leva
ted r
isk fo
r e
ve
ry s
ingle
a
pp
lica
ble
in
dic
ato
r in
th
e m
ode
l (r
ow
4 x
2)
6
Pe
rcen
tag
e s
co
re
2.0
8%
O
ve
rall
risk s
co
re (
row
3)
/ m
axim
um
possib
le s
co
re (
row
5)
De
tails
of
ris
ks
C
om
me
nt
1
Ele
va
ted
Ris
k
NH
S S
taff
Su
rve
y –
KF
9 T
he p
rop
ort
ion
of
sta
ff r
ece
ivin
g s
up
port
fro
m im
me
dia
te m
ana
ge
rs (
1 S
ep
-14
to
31 D
ec-1
4)
Ne
w r
isk
2
Ris
k
Co
mp
osite
in
dic
ato
r: I
n-h
osp
ita
l m
ort
alit
y -
Pa
ed
iatr
ic a
nd c
on
gen
ita
l d
iso
rde
rs a
nd
pe
rin
ata
l m
ort
alit
y
R
isk r
edu
ce
d
from
Ele
va
ted
3
Ris
k
Co
mp
osite
ris
k r
atin
g f
or
Sic
kn
ess A
bse
nce
(so
urc
e E
SR
1 J
an
-14 –
31
De
ce
mb
er-
14)
– [5
out
of
6 s
ub-i
nd
ica
tors
mis
se
d]
Exis
tin
g r
isk
Deta
ils
of
ris
ks
re
mo
ve
d s
inc
e t
he D
ec
em
ber
rep
ort
1.
TD
A e
sca
latio
n s
co
re (
leve
l 2
– in
terv
en
tio
n f
or
Ju
n-1
4)
Item
6a
Page 29 of 196
T
DA
– O
ve
rsig
ht
an
d e
sc
ala
tio
n r
ep
ort
- P
ub
lis
he
d M
arc
h 2
015 (
so
urc
e:
TD
A)
O
utc
om
e o
f m
odera
tion m
eeting
Su
mm
ary
: D
ue t
o f
inancia
l positio
n a
nd a
ccess targ
ets
the T
rust cannot be d
e-e
scala
ted u
ntil suitable
fin
ancia
l pla
ns a
nd a
ccess r
ecovery
tr
aje
cto
ries h
ave b
een p
rovid
ed a
nd im
ple
mente
d.
Qu
ality
: Q
ualit
y T
eam
are
support
ing the T
rust on a
num
ber
of Q
ualit
y I
mpro
vem
ent
are
as,
inclu
din
g f
urt
her
work
to r
espond t
o t
he f
indin
gs
of
the r
ecent exte
rnal m
ate
rnity r
evie
w.
Desk T
op R
evie
w is t
akin
g p
lace o
n t
he 1
3 M
ay 2
015 a
nd the T
rust
aw
aitin
g a
Chie
f In
specto
r of
Hospitals
(C
IH)
inspection d
ate
. T
he T
rust fa
iled
to m
eet
A&
E 4
hour
wait (
92.8
%)
for
Marc
h 2
015. T
he T
rust
did
not m
eet th
e h
arm
fre
e c
are
sta
ndard
(93.9
%)
for
Marc
h 2
015.
Fin
an
ce:
M12 is b
reakeven,
£11.9
m a
head o
f th
e p
lanned d
eficit o
f £11.9
m. T
his
positio
n is d
riven b
y n
ational str
uctu
ral support
fu
ndin
g a
nd
over-
perf
orm
ance o
n n
on e
lective a
ctivity w
hic
h is o
ffset by b
ank a
nd a
gency c
osts
to c
over
sic
kness a
nd a
dditio
nal capacity a
s w
ell
as n
on
-deliv
ery
of
both
work
forc
e a
nd L
OS
CIP
schem
es.
CIP
deliv
ere
d in y
ear
was £
21.4
m; £12.7
m b
ehin
d p
lan a
nd w
ith £
7.7
m d
eliv
ere
d n
on
-re
curr
ently.
Su
sta
inab
ilit
y:
The T
rust m
ust deliv
er
a s
usta
inable
fin
ancia
l pla
n,
a p
ositiv
e o
utc
om
e fro
m a
CIH
s v
isit a
nd a
ccess targ
ets
.
Page 30 of 196
M
on
ito
r R
isk A
ss
es
sm
en
t F
ram
ew
ork
– S
ha
do
w m
on
ito
rin
g r
ep
ort
Ta
rge
tQ
1Q
2Q
3Q
4Q
1P
eri
od
Co
nti
nu
ity o
f S
erv
ice
s R
isk R
ati
ng
42
2.5
3.0
4.0
2.0
Ap
r-1
5
Liq
uid
ity
43
33
43
Ap
r-1
5
Capital serv
icin
g c
apacity
41
23
41
Ap
r-1
5
Gre
en
Re
dR
ed
Re
dR
ed
Re
dV
ar
18 w
eeks A
dm
itte
d [
C]
90%
11
00
0A
pr-
15
18 w
eeks N
on-A
dm
itte
d [
C]
95%
10
00
0A
pr-
15
18 w
eeks Incom
ple
te [
C]
92%
00
00
0A
pr-
15
A&
E 4
hours
[D
]95%
00
11
1A
pr-
15
GP
refe
rred
85%
Scre
enin
g r
efe
rred
90%
Surg
ery
94%
Dru
gs
98%
31 d
ay c
ancer
initia
l tr
eatm
ent
96%
00
00
n/a
Ma
r-1
5
GP
refe
rred
93%
Bre
ast
sym
pto
matic
93%
C-
Diff
icile
vs o
bje
ctive
61
11
11
0A
pr-
15
refe
rral to
tre
atm
ent
info
50%
refe
rral in
fo50%
treatm
ent
activi
ty info
50% 0
53
33
2V
ar
0A
pr-
15
n/a
n/a
n/a
Ma
r-1
5
n/a
Ma
r-1
5
2015-1
6
n/a
Ja
n-1
5
2014-1
5
Finance
Go
ve
rna
nce
Ris
k R
ati
ng
(in
tern
al
ass
ess
me
nt)
ACCESS & OUTCOMES METRICS
62 d
ay
cancer
0
11
11
31 d
ay
cancer
00
2 w
eek
cancer
10
Go
ve
rna
nce
Ris
k R
ati
ng
Sco
re f
or
Acce
ss &
Ou
tco
me
s
Data
com
ple
teness
: com
munity
serv
ices
Cert
ification a
gain
st
com
plia
nce v
s r
equirem
ents
regard
ing
access t
o h
ealth c
are
for
people
with learn
ing d
isabili
tyP
ass
0
n/a
00
0 n/a
n/a
0 0 n/a0
Key
Po
ints
:-
This
sh
ado
w m
on
ito
rin
g re
po
rt is
in
clu
ded
to
fac
ilita
te f
amili
arit
y w
ith
M
on
ito
r’s
asse
ssm
ent
syst
em in
su
pp
ort
of
pro
gres
s to
FT
stat
us.
P
erfo
rman
ce a
gain
st b
oth
Fin
ance
an
d
Acc
ess
& O
utc
om
es M
etri
cs n
eed
s to
su
stai
nab
ly im
pro
ve in
ord
er t
o
pro
gres
s to
FT
stat
us.
Th
e C
oSR
R is
cu
rren
tly
a 2
.0, t
he
year
en
d f
ore
cast
is 1
.0, b
oth
of
wh
ich
are
b
elo
w t
he
sco
re o
f 3
.0 r
equ
ired
fo
r an
as
pir
ant
FT.
Taki
ng
the
mo
st r
ece
nt
per
form
ance
, w
hils
t th
e n
um
ber
of
Acc
ess
&
Ou
tco
mes
fai
ls r
emai
ns
bel
ow
th
e tr
igge
r th
resh
old
of
4, t
he
follo
win
g w
ou
ld t
rigg
er a
red
sta
tus
(1)
A&
E 2
q
uar
ters
fai
led
ou
t o
f la
st 4
; (2
) P
red
icte
d 6
2 d
ay G
P r
eallo
cate
d t
arge
t n
on
-ach
ieve
men
t fo
r 3
or
mo
re
con
secu
tive
qu
arte
rs.
Acc
ess
& O
utc
om
e F
ails
: -
(1)
4 h
ou
r A
&E
(2)
It is
est
imat
ed t
hat
th
e 62
day
GP
loca
l rea
lloca
ted
tar
get
is n
ot
ach
ieve
d Q
4 t
o d
ate
(Ja
n-1
5 d
ata
pu
blis
hed
by
Net
wo
rk)
– it
is a
nti
cip
ate
d t
hat
all
can
cer
targ
ets
will
be
ach
ieve
d f
or
Q2
an
d A
&E
for
Q3
of
15
-16
.
Item
6a
Page 31 of 196
(5)
AP
PE
ND
ICE
S
(Ap
pe
nd
ix 1
) A
cu
te C
on
tra
ct
Pe
rfo
rma
nc
e S
um
mary
Re
po
rt
The a
ssessed f
inancia
l im
pact of
contr
act
KP
Is a
nd C
QU
INs is facto
red into
the T
rust’s f
inancia
l perf
orm
ance
report
s.
Co
ntr
ac
t K
PIs
The T
rust
is c
urr
ently n
ot
achie
vin
g t
he f
ollo
win
g c
ontr
act
KP
Is that pote
ntially
have a
fin
ancia
l penalty:-
1.
MR
SA
(M
1 is 1
) 2.
A&
E 4
hour
targ
et
– 9
5%
(M
1 9
1.5
%)
3.
Am
bula
nce H
andovers
(181 o
ver
30 m
inute
s b
ut le
ss t
han 6
0 m
inute
s,
and 2
5 o
ver
60 m
inute
s)
4.
28 d
ay c
ancelle
d o
pera
tions s
tandard
(1 b
reach Q
1 to d
ate
) 5.
Inpatient ele
ctive d
ischarg
e s
um
maries w
ithin
24 h
ours
(pro
vis
ional in
form
ation t
o b
e v
erified)
CQ
UIN
s 1
4-1
5
The r
isk t
o incom
e is d
ependent
on t
he d
eta
ils o
f in
div
idual C
QU
INs –
96%
of
CQ
UIN
s w
ere
achie
ved f
or
14-1
5,
com
pare
d to 9
6%
in 1
3-1
4.
Q4 e
vid
ence h
as b
een s
ubm
itte
d f
or
r re
vie
w b
y c
om
mis
sio
ners
.
CQ
UIN
s 1
5-1
6
The C
QU
IN v
alu
e is £
11
.1m
. T
he n
ational A
EC
CQ
UIN
(£1.7
m)
has b
een a
gre
ed in p
rincip
le w
ith t
he f
inal deta
ils to b
e a
gre
ed w
ith
com
mis
sio
ners
. A
ll C
QU
IN d
ocum
enta
tion is b
ein
g c
onsolid
ate
d a
nd r
e-r
evie
wed a
s p
art
of th
e a
ssessm
ent
and r
eport
ing
pro
cess.
Page 32 of 196
(A
pp
en
dix
2)
Sa
fe N
urs
ing
& M
idw
ifery
Sta
ffin
g b
y W
ard
Are
a (
Ap
r-15)
Sit
e N
am
e
To
tal
mo
nth
ly
pla
nn
ed
sta
ff h
ou
rs
To
tal
mo
nth
ly
actu
al
sta
ff
ho
urs
To
tal
mo
nth
ly
pla
nn
ed
sta
ff h
ou
rs
To
tal
mo
nth
ly
actu
al
sta
ff
ho
urs
To
tal
mo
nth
ly
pla
nn
ed
sta
ff h
ou
rs
To
tal
mo
nth
ly
actu
al
sta
ff
ho
urs
To
tal
mo
nth
ly
pla
nn
ed
sta
ff h
ou
rs
To
tal
mo
nth
ly
actu
al
sta
ff
ho
urs
Ave
rag
e f
ill
rate
- r
eg
iste
red
nu
rse
s/
mid
wiv
es
(%
)
Ave
rag
e
fill
ra
te -
ca
re s
taff
(%)
Ave
rag
e f
ill
rate
-
reg
iste
red
nu
rse
s/
mid
wiv
es
(%
)
Ave
rag
e
fill
ra
te -
ca
re s
taff
(%)
Bir
ch H
ill H
osp
ital
900
908
1,11
01,
125
600
550
630
630
100.8
%101.4
%91.7
%100.0
%
Fair
fie
ld G
en
era
l Ho
spit
al20
,040
18,9
5316
,395
15,5
6311
,300
11,2
756,
405
6,30
594.6
%94.9
%99.8
%98.4
%
No
rth
Man
che
ste
r G
en
era
l Ho
spit
al45
,068
44,7
0024
,559
23,5
1325
,340
26,0
1011
,255
10,4
9599.2
%95.7
%102.6
%93.2
%
Ro
chd
ale
Infi
rmar
y2,
014
1,98
41,
084
1,08
091
093
063
062
098.5
%99.7
%102.2
%98.4
%
Ro
yal O
ldh
am H
osp
ital
49,4
1048
,094
26,4
5625
,605
28,7
2528
,325
12,0
0011
,290
97.3
%96.8
%98.6
%94.1
%
Tru
st T
ota
l11
7,43
111
4,63
869
,604
66,8
8566
,875
67,0
9030
,920
29,3
4097.6
%96.1
%100.3
%94.9
%
Da
yN
igh
t
Day
Fil
l Rat
eN
igh
t Fi
ll R
ate
Re
gis
tere
d m
idw
ive
s
/nu
rse
sC
are
Sta
ffR
eg
iste
red
mid
wiv
es
/nu
rse
sC
are
Sta
ff
War
d n
ame
Ma
in W
ard
Sp
ecia
lty
To
tal
mo
nth
ly
pla
nn
ed
sta
ff h
ou
rs
To
tal
mo
nth
ly
actu
al
sta
ff
ho
urs
To
tal
mo
nth
ly
pla
nn
ed
sta
ff h
ou
rs
To
tal
mo
nth
ly
actu
al
sta
ff
ho
urs
To
tal
mo
nth
ly
pla
nn
ed
sta
ff h
ou
rs
To
tal
mo
nth
ly
actu
al
sta
ff
ho
urs
To
tal
mo
nth
ly
pla
nn
ed
sta
ff h
ou
rs
To
tal
mo
nth
ly
actu
al
sta
ff h
ou
rs
War
d 1
(C
CU
)32
0 -
CA
RD
IOLO
GY
1848
.75
1605
1383.7
51207.5
1235
1230
620
490
86.8
%87.3
%99.6
%79.0
%
War
d 1
0 (I
TU/H
DU
)19
2 -
CR
ITIC
AL
CA
RE
MED
ICIN
E24
152257.5
412.5
202.5
1550
1510
240
130
93.5
%49.1
%97.4
%54.2
%
War
d 1
1a31
4 -
REH
AB
ILIT
ATI
ON
1395
1522.5
1792.5
1672.5
620
800
970
935
109.1
%93.3
%129.0
%96.4
%
War
d 1
1b (
Stro
ke)
314
- R
EHA
BIL
ITA
TIO
N13
87.5
1312.5
1417.5
1357.5
620
650
620
610
94.6
%95.8
%104.8
%98.4
%
War
d 1
410
0 -
GEN
ERA
L SU
RG
ERY
1117
.51132.5
1035
945
620
640
310
290
101.3
%91.3
%103.2
%93.5
%
War
d 1
831
4 -
REH
AB
ILIT
ATI
ON
1530
1477.5
1822.5
1635
930
1270
600
590
96.6
%89.7
%136.6
%98.3
%
War
d 2
130
0 -
GEN
ERA
L M
EDIC
INE
1395
1425
1728.7
51702.5
930
1000
635
630
102.2
%98.5
%107.5
%99.2
%
War
d 5
110
- TR
AU
MA
& O
RTH
OP
AED
ICS
915
922.5
517.5
510
620
590
210
210
100.8
%98.6
%95.2
%100.0
%
War
d 6
300
- G
ENER
AL
MED
ICIN
E16
27.5
1635
1380
1327.5
940
955
640
650
100.5
%96.2
%101.6
%101.6
%
War
d 7
300
- G
ENER
AL
MED
ICIN
E31
802925
2662.5
2527.5
1780
1750
530
560
92.0
%94.9
%98.3
%105.7
%
War
d 8
430
- G
ERIA
TRIC
MED
ICIN
E12
52.5
1162.5
1087.5
1102.5
670
650
620
530
92.8
%101.4
%97.0
%85.5
%
War
d 9
300
- G
ENER
AL
MED
ICIN
E27
82.5
2415
1965
1725
1250
1310
970
930
86.8
%87.8
%104.8
%95.9
%
Fair
field
Gen
era
l H
osp
ital
Ave
rag
e f
ill
rate
-
reg
iste
red
nu
rse
s/
mid
wiv
es
(%
)
Ave
rag
e
fill
ra
te -
ca
re s
taff
(%)
Da
yN
igh
tD
ay
Nig
ht
Re
gis
tere
d m
idw
ive
s
/nu
rse
sC
are
Sta
ffR
eg
iste
red
mid
wiv
es
/nu
rse
sC
are
Sta
ffA
ve
rag
e f
ill
rate
-
reg
iste
red
nu
rse
s/
mid
wiv
es
(%
)
Ave
rag
e
fill
ra
te -
ca
re s
taff
(%)
Item
6a
Page 33 of 196
War
d n
ame
Ma
in W
ard
Sp
ecia
lty
To
tal
mo
nth
ly
pla
nn
ed
sta
ff h
ou
rs
To
tal
mo
nth
ly
actu
al
sta
ff
ho
urs
To
tal
mo
nth
ly
pla
nn
ed
sta
ff h
ou
rs
To
tal
mo
nth
ly
actu
al
sta
ff
ho
urs
To
tal
mo
nth
ly
pla
nn
ed
sta
ff h
ou
rs
To
tal
mo
nth
ly
actu
al
sta
ff
ho
urs
To
tal
mo
nth
ly
pla
nn
ed
sta
ff h
ou
rs
To
tal
mo
nth
ly
actu
al
sta
ff h
ou
rs
An
teN
atal
War
d50
1 -
OB
STET
RIC
S13
501290
431.2
5405
890
820
60
60
95.6
%93.9
%92.1
%100.0
%
C3&
C4
100
- G
ENER
AL
SUR
GER
Y19
501923.7
51395
1331.2
5670
700
200
200
98.7
%95.4
%104.5
%100.0
%
C5
100
- G
ENER
AL
SUR
GER
Y13
87.5
1410
915
900
620
630
610
560
101.6
%98.4
%101.6
%91.8
%
CC
U G
432
0 -
CA
RD
IOLO
GY
1155
1080
457.5
405
620
620
300
300
93.5
%88.5
%100.0
%100.0
%
Ch
ild
ren
s17
1 -
PA
EDIA
TRIC
SU
RG
ERY
2325
2550
817.5
495
1550
1810
300
70
109.7
%60.6
%116.8
%23.3
%
D5
301
- G
AST
RO
ENTE
RO
LOG
Y14
851443.7
5840
810
605
685
300
300
97.2
%96.4
%113.2
%100.0
%
D6
301
- G
AST
RO
ENTE
RO
LOG
Y14
47.5
1425
795
697.5
610
650
310
310
98.4
%87.7
%106.6
%100.0
%
E130
0 -
GEN
ERA
L M
EDIC
INE
1556
.25
1597.5
1586.2
51597.5
930
1190
1080
1020
102.7
%100.7
%128.0
%94.4
%
E3300 -
GE
NE
RA
L M
ED
ICIN
E16
27.5
1695
1878.7
51830
920
980
930
740
104.1
%97.4
%106.5
%79.6
%
E5300 -
GE
NE
RA
L M
ED
ICIN
E93
7.5
1515
1200
1185
650
1060
610
600
161.6
%98.8
%163.1
%98.4
%
F1300 -
GE
NE
RA
L M
ED
ICIN
E11
251267.5
930
922.5
620
810
305
310
112.7
%99.2
%130.6
%101.6
%
F310
0 -
GEN
ERA
L SU
RG
ERY
1447
.51462.5
945
952.5
620
650
320
330
101.0
%100.8
%104.8
%103.1
%
F510
0 -
GEN
ERA
L SU
RG
ERY
1612
.51605
922.5
862.5
630
630
605
580
99.5
%93.5
%100.0
%95.9
%
F610
0 -
GEN
ERA
L SU
RG
ERY
1635
1642.5
802.5
810
620
630
320
320
100.5
%100.9
%101.6
%100.0
%
G3
HD
U19
2 -
CR
ITIC
AL
CA
RE
MED
ICIN
E18
751875
405
382.5
1260
1180
230
220
100.0
%94.4
%93.7
%95.7
%
H3
300
- G
ENER
AL
MED
ICIN
E27
902872.5
1852.5
1830
1380
1460
720
660
103.0
%98.8
%105.8
%91.7
%
H4
300
- G
ENER
AL
MED
ICIN
E13
951372.5
1447.5
1417.5
930
1000
770
750
98.4
%97.9
%107.5
%97.4
%
I511
0 -
TRA
UM
A &
OR
THO
PA
EDIC
S20
551867.5
1665
1470
1090
1115
790
740
90.9
%88.3
%102.3
%93.7
%
I611
0 -
TRA
UM
A &
OR
THO
PA
EDIC
S13
951218.7
51203.7
51226.2
5740
760
470
445
87.4
%101.9
%102.7
%94.7
%
ITU
192
- C
RIT
ICA
L C
AR
E M
EDIC
INE
2782
.52625
247.5
172.5
1860
1725
140
50
94.3
%69.7
%92.7
%35.7
%
J3/J
435
0 -
INFE
CTI
OU
S D
ISEA
SES
2400
2355
1372.5
1327.5
1390
1435
750
750
98.1
%96.7
%103.2
%100.0
%
J630
0 -
GEN
ERA
L M
EDIC
INE
1331
.25
1350
986.2
51016.2
5620
645
620
590
101.4
%103.0
%104.0
%95.2
%
Lab
ou
r W
ard
501
- O
BST
ETR
ICS
3941
.25
3660
802.5
480
2690
2370
600
310
92.9
%59.8
%88.1
%51.7
%
Po
stN
atal
War
d50
1 -
OB
STET
RIC
S17
551740
862.5
855
1170
1130
350
340
99.1
%99.1
%96.6
%97.1
%
SCB
U50
1 -
OB
STET
RIC
S20
92.5
1950
255
262.5
1510
1410
00
93.2
%102.9
%93.4
%#D
IV/0
!
STU
100
- G
ENER
AL
SUR
GER
Y17
101702.5
150
150
930
970
00
99.6
%100.0
%104.3
%#D
IV/0
!
Re
gis
tere
d m
idw
ive
s
/nu
rse
sC
are
Sta
ffR
eg
iste
red
mid
wiv
es
/nu
rse
sC
are
Sta
ffA
ve
rag
e f
ill
rate
-
reg
iste
red
nu
rse
s/
mid
wiv
es
(%
)
Ave
rag
e
fill
ra
te -
ca
re s
taff
(%)
No
rth
Man
ch
este
r G
en
era
l H
osp
ital
Da
yN
igh
tD
ay
Nig
ht
Ave
rag
e f
ill
rate
-
reg
iste
red
nu
rse
s/
mid
wiv
es
(%
)
Ave
rag
e
fill
ra
te -
ca
re s
taff
(%)
Page 34 of 196
War
d n
ame
Ma
in W
ard
Sp
ecia
lty
To
tal
mo
nth
ly
pla
nn
ed
sta
ff h
ou
rs
To
tal
mo
nth
ly
actu
al
sta
ff
ho
urs
To
tal
mo
nth
ly
pla
nn
ed
sta
ff h
ou
rs
To
tal
mo
nth
ly
actu
al
sta
ff
ho
urs
To
tal
mo
nth
ly
pla
nn
ed
sta
ff h
ou
rs
To
tal
mo
nth
ly
actu
al
sta
ff
ho
urs
To
tal
mo
nth
ly
pla
nn
ed
sta
ff h
ou
rs
To
tal
mo
nth
ly
actu
al
sta
ff h
ou
rs
Flo
yd U
nit
- B
HH
314
- R
EHA
BIL
ITA
TIO
N93
7.5
1005
1155
1065
620
660
620
490
107.2
%92.2
%106.5
%79.0
%
CA
U -
RI
300
- G
ENER
AL
MED
ICIN
E16
53.7
51601.2
5495
558.7
5620
630
320
340
96.8
%112.9
%101.6
%106.3
%
Oas
is U
nit
- R
I30
0 -
GEN
ERA
L M
EDIC
INE
465
465
465
465
280
320
270
270
100.0
%100.0
%114.3
%100.0
%
Ave
rag
e
fill
ra
te -
ca
re s
taff
(%)
Ave
rag
e f
ill
rate
-
reg
iste
red
nu
rse
s/
mid
wiv
es
(%
)
Ave
rag
e
fill
ra
te -
ca
re s
taff
(%)
Ave
rag
e f
ill
rate
-
reg
iste
red
nu
rse
s/
mid
wiv
es
(%
)
Bir
ch
Hill H
osp
ital &
Ro
ch
dale
Infi
rmary
Re
gis
tere
d m
idw
ive
s
/nu
rse
sC
are
Sta
ffR
eg
iste
red
mid
wiv
es
/nu
rse
sC
are
Sta
ff
Nig
ht
Da
yN
igh
tD
ay
War
d n
ame
Ma
in W
ard
Sp
ecia
lty
To
tal
mo
nth
ly
pla
nn
ed
sta
ff h
ou
rs
To
tal
mo
nth
ly
actu
al
sta
ff
ho
urs
To
tal
mo
nth
ly
pla
nn
ed
sta
ff h
ou
rs
To
tal
mo
nth
ly
actu
al
sta
ff
ho
urs
To
tal
mo
nth
ly
pla
nn
ed
sta
ff h
ou
rs
To
tal
mo
nth
ly
actu
al
sta
ff
ho
urs
To
tal
mo
nth
ly
pla
nn
ed
sta
ff h
ou
rs
To
tal
mo
nth
ly
actu
al
sta
ff h
ou
rs
A&
E O
bse
rva
tio
n W
ard
300
- G
ENER
AL
MED
ICIN
E48
7.5
555
337.5
262.5
370
400
225
140
113.8
%77.8
%108.1
%62.2
%
A2
314
- R
EHA
BIL
ITA
TIO
N10
801012.5
1188.7
51125
550
600
340
360
93.8
%94.6
%109.1
%105.9
%
AM
U30
0 -
GEN
ERA
L M
EDIC
INE
4185
3855
2835
2872.5
2790
2900
2110
2030
92.1
%101.3
%103.9
%96.2
%
An
ten
atal
War
d50
1 -
OB
STET
RIC
S13
72.5
1282.5
540
502.5
880
760
90
80
93.4
%93.1
%86.4
%88.9
%
CC
U32
0 -
CA
RD
IOLO
GY
915
937.5
60
45
620
610
020
102.5
%75.0
%98.4
%#D
IV/0
!
Cri
tica
l Car
e19
2 -
CR
ITIC
AL
CA
RE
MED
ICIN
E55
27.5
5257.5
502.5
495
3670
3370
100
90
95.1
%98.5
%91.8
%90.0
%
F150
2 -
GYN
AEC
OLO
GY
1650
1402.5
952.5
855
580
610
330
330
85.0
%89.8
%105.2
%100.0
%
F10
300
- G
ENER
AL
MED
ICIN
E14
101571.2
51770
1762.5
930
910
620
620
111.4
%99.6
%97.8
%100.0
%
F11
823
- H
AEM
ATO
LOG
Y21
03.7
52047.5
896.2
5783.7
5930
920
500
420
97.3
%87.4
%98.9
%84.0
%
F3 (
Ch
ild
ren
s)17
1 -
PA
EDIA
TRIC
SU
RG
ERY
2340
2272.5
990
993.7
51560
1600
00
97.1
%100.4
%102.6
%#D
IV/0
!
F730
0 -
GEN
ERA
L M
EDIC
INE
1417
.51432.5
1395
1372.5
900
950
630
630
101.1
%98.4
%105.6
%100.0
%
F830
0 -
GEN
ERA
L M
EDIC
INE
937.
5963.7
51222.5
1192.5
620
600
530
370
102.8
%97.5
%96.8
%69.8
%
F930
0 -
GEN
ERA
L M
EDIC
INE
1406
.25
1432.5
1807.5
1642.5
930
1030
780
730
101.9
%90.9
%110.8
%93.6
%
G1
300
- G
ENER
AL
MED
ICIN
E13
91.2
51365
1650
1642.5
620
660
640
630
98.1
%99.5
%106.5
%98.4
%
G2
300
- G
ENER
AL
MED
ICIN
E15
52.5
1605
1380
1290
600
660
615
590
103.4
%93.5
%110.0
%95.9
%
Lab
ou
r W
ard
501
- O
BST
ETR
ICS
4170
4170
930
772.5
2780
2630
605
425
100.0
%83.1
%94.6
%70.2
%
Po
stn
atal
War
d50
1 -
OB
STET
RIC
S18
67.5
1807.5
1245
1192.5
1190
1100
560
340
96.8
%95.8
%92.4
%60.7
%
SCB
U50
1 -
OB
STET
RIC
S67
87.5
6517.5
517.5
607.5
4470
4320
70
80
96.0
%117.4
%96.6
%114.3
%
T310
0 -
GEN
ERA
L SU
RG
ERY
1890
1777.5
1335
1275
620
610
620
610
94.0
%95.5
%98.4
%98.4
%
T4/S
TU10
0 -
GEN
ERA
L SU
RG
ERY
2085
2062.5
877.5
780
930
930
300
310
98.9
%88.9
%100.0
%103.3
%
T510
0 -
GEN
ERA
L SU
RG
ERY
1792
.51650
1357.5
1365
770
650
620
620
92.1
%100.6
%84.4
%100.0
%
T610
0 -
GEN
ERA
L SU
RG
ERY
1372
.51170
843.7
5712.5
450
440
180
170
85.2
%84.4
%97.8
%94.4
%
T710
0 -
GEN
ERA
L SU
RG
ERY
2962
.52775
2325
2227.5
1540
1450
1250
1280
93.7
%95.8
%94.2
%102.4
%
Ave
rag
e
fill
ra
te -
ca
re s
taff
(%)
Ave
rag
e f
ill
rate
-
reg
iste
red
nu
rse
s/
mid
wiv
es
(%
)
Ave
rag
e
fill
ra
te -
ca
re s
taff
(%)
Ro
yal O
ldh
am
Ho
sp
ital
Re
gis
tere
d m
idw
ive
s
/nu
rse
s
Ca
re S
taff
Re
gis
tere
d m
idw
ive
s
/nu
rse
s
Ca
re S
taff
Ave
rag
e f
ill
rate
-
reg
iste
red
nu
rse
s/
mid
wiv
es
(%
)
Da
yN
igh
tD
ay
Nig
ht
Item
6a
Page 35 of 196
The
pre
vio
us s
ectio
n o
utlin
es fo
r th
e T
rust B
oa
rd t
he
actu
al sta
ffin
g le
ve
ls a
ga
inst
pla
nn
ed
on
da
y a
nd
nig
ht
sh
ifts
acro
ss t
he
Tru
st
an
d illu
str
ate
s th
e a
va
ilab
ility
of
sta
ff h
ou
rs r
oste
red
an
d a
ctu
ally
ava
ilab
le a
t th
e p
oin
t of
ca
re.
Futu
re r
ep
ort
s w
ill b
e r
efine
d o
ve
r tim
e w
ith
in
clu
sio
n o
f qu
alit
y m
etr
ics. T
he
fo
llow
ing s
ectio
n inclu
de
s a
n o
ve
rvie
w o
f th
e “
sta
ffin
g s
tatu
s”
of
wa
rds. T
he
sta
ffin
g s
tatu
s
is a
n a
sse
ssm
en
t m
ade
by t
he
nu
rse in
cha
rge
of
the s
hift
rela
tive
to t
he
actu
al sta
ff o
n d
uty
an
d t
he
de
ma
nd f
or
nu
rsin
g c
are
. T
he
sta
tus info
rms t
he
ris
k a
sse
ssm
en
ts t
ha
t m
ust b
e u
nde
rtaken
wh
en
a w
ard
is d
ecla
red
“am
be
r” o
r “r
ed
”:
Gre
en
A
ctu
al sta
ffin
g le
ve
ls a
t o
r gre
ate
r th
an
100
% o
f p
lan
ned
Y
ell
ow
S
taff
ing v
ery
slig
htly le
ss t
han
pla
nn
ed
(le
ss th
an
8 h
ou
rs o
r 2
5%
, w
hic
he
ve
r is
re
ache
d f
irst)
, b
ut n
o c
are
lik
ely
to
be
“mis
sed
” as a
resu
lt;
no
“R
ed
Fla
g”
eve
nts
rep
ort
ed
A
mb
er
Sta
ffin
g le
ss th
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Page 36 of 196
Gre
en S
hifts
87.2
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87.8
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Item
6a
Page 37 of 196
Actual RN: Bed ratio (April) – Wards where 1 nurse is looking after more than 8 beds (shaded cells). The Harm Free Care score from the National Safety Thermometer has been added to this month’s report - Scores below 95% are shaded in the table.
Site Ward Division
Trained Nurse:
Bed ratio - Early
Trained Nurse:
Bed ratio - Late
Trained Nurse:
Bed ratio - Night
ST Harm Free
Score
BHH Floyd Unit - BHH Medicine 9.00 9.30 10.50 100.00%
FGH Ward 6 Medicine 7.01 9.15 8.93 65.22%
FGH Ward 11a Medicine 6.89 6.99 9.33 100.00%
FGH Ward 11b (Stroke) Medicine 6.94 7.17 9.78 95.00%
FGH Ward 18 Medicine 7.44 8.90 8.52 60.00%
FGH Ward 21 Medicine 7.80 9.07 7.52 87.50%
NMGH C3 Surgery 6.28 5.35 11.20 100.00%
NMGH C5 Surgery 6.23 7.13 9.50 94.44%
NMGH D5 Surgery 4.52 5.03 8.18 100.00%
NMGH E1 Medicine 7.53 8.83 7.28 88.89%
NMGH E3 Medicine 7.50 8.90 8.08 89.90%
NMGH F1 Medicine 5.87 8.36 7.20 91.67%
NMGH F3 Surgery 6.18 6.49 9.39 64.74%
NMGH F5 Surgery 5.93 7.73 11.37 95.65%
NMGH F6 Surgery 5.33 7.35 10.62 95.24%
NMGH I5 Surgery 7.76 9.35 9.84 90.62%
NMGH I6 Surgery 6.62 8.27 10.76 100.00%
NMGH J6 Medicine 5.67 6.55 8.17 94.12%
ROH A2 Medicine 7.45 9.30 8.60 94.44%
ROH F1 W&Cs 8.55 8.43 11.26 100.00%
ROH F7 Medicine 8.03 8.37 8.11 92.00%
ROH F8 Medicine 7.79 8.59 8.50 90.00%
ROH F9 Medicine 8.19 8.82 8.28 79.17%
ROH F10 Medicine 7.20 8.20 8.13 87.50%
ROH G1/Discharge Unit Medicine 7.63 8.38 10.68 90.48%
ROH G2 Surgery 7.29 8.47 12.50 100.00%
ROH T3 Surgery 6.44 8.56 13.93 85.71%
ROH T5 Surgery 6.67 8.61 12.22 96.00%
ROH T6 Surgery 4.68 6.41 10.93 100.00%
ROH T7 Surgery 6.95 8.00 9.43 87.10%
Page 38 of 196
New national ward staffing RAG rating system A new ward staffing level RAG rating scoring system will be introduced in 2015-16.
Provisional information published shows that the Trust is rated as Blue (ok). Trusts rated as Red will be contacted by their regulatory body (TDA, etc.)
Details There are 3 possible ratings based on a comparison of results:-
Green is amongst the best / better than other providers
Blue is okay / within expected ranges
Red is amongst the worst / worse than other providers
Grey is no data available, or not relevant for the provider The Trust appears to be ranked within the middle band of providers. Our overall rating is blue (ok) because all of the KPIs are within their expected ranges - see details below:-
Measure Result Rating Inpatient Survey Q30: whether there enough nurses on duty to care for you in hospital? Weighted response (0-10). Q30 Weighted mean
Within expected range 7.65
Blue (OK)
Staff Survey Q7g whether sufficient staff (5-1) Q7 Weighted response
Within expected range 3.68
Blue (OK)
Staff Survey Q3a % staff having an appraisal in last 12 months (%) Q3a.1 Percentage "Yes"
Within expected range 84.62%
Blue (OK)
Staff Survey Q1 Mean % staff completing mandatory training (%) Q1a-f Mean Percentage "Yes"
Within expected range 72.33%
Blue (OK)
Percentage Staff Sickness data 12 Month Average to Aug 2014, Acute vs Other trusts (%) - 12 Month to Aug 2014 Average
Within expected range 6.3%
Blue (OK)
Safer staffing November Fill rates (%) Overall Fill Rate
Within expected range 98%
Blue (OK)
Total All within expected ranges Blue (OK)
The aggregate score is based on the “weakest link” -
Red if any of the 5 measures are red - 31 Trusts are rated as red overall
Green if any of the 5 are green AND there are no reds - green and reds do not cancel each other out - 23 Trusts are rated as green overall
Blue = all of 5 measures are blue Work will be undertaken to cross reference the data to ESR reports in relation to nursing staff Sickness,
Item
6a
Page 39 of 196
Page 1
Title of Report Strategic Risk Register
Executive Summary
The report outlines the Trust’s current strategic risks. It had previously been agreed that the strategic risks would be considered by the Quality & Performance Committee monthly to enable discussion and thereafter proposals to the Trust Board. The Q&P Committee asked for a risk relating to maternity services to be included on the strategic risk register. The attached wording was submitted to the Q&P Committee on 26 May 2015. A verbal update will be provided to the Board meeting.
Actions requested
The Board is asked to review and if appropriate, make any changes to the Strategic Risk Register.
Corporate Objectives supported by this paper: All corporate objectives.
Risks: As outlined within the paper.
Public and/or patient involvement: N/A.
Resource implications: There are potential resources implications within all of the actions needed to mitigate the strategic risks. These will be considered by each executive director and an assurance given that these are in the planning round for 2015/16.
Communication: For the Board.
Have all implications been considered? YES NO N/A
Assurance X
Contract X
Equality and Diversity X
Financial / Efficiency X
HR X
Information Governance Assurance X
IM&T X
Local Delivery Plan / Trust Objectives X
National policy / legislation X
Sustainability X
Item
6b
Page 40 of 196
Page 2
Name Gavin Barclay
Job Title Assistant Chief Executive
Date May 2015
Email [email protected]
Page 41 of 196
Page 3
Strategic Risk Register
1. Introduction This report outlines the Trust’s current strategic risks. It had previously been agreed that the strategic risks would be considered by the Quality & Performance Committee monthly to enable discussion and thereafter proposals to the Trust Board. Two risk scores are depicted; residual risk and target risk. For the purpose of this document, the residual risk is the risk today, when all of the existing controls and mitigations that we currently have in place are taken into consideration. The target risk is the risk which the organisation will find acceptable. This is linked to the Trust’s risk appetite, which is the level of risk that an organisation is prepared to accept, before action is deemed necessary to reduce it. The Trust’s risk appetite framework is outlined within the Trust’s risk management policy and this will be reviewed, as part of the review of risk management processes within the Trust. The scoring system is outlined below.
Score Level of harm (NPSA Cat.)
Risk category
15 - 25 Catastrophic Significant
10 – 12
Major High
8 - 9 Moderate Moderate
4 - 6 Minor Low
1 - 3 Negligible Very Low
Item
6b
Page 42 of 196
Page 4
The Trust’s current strategic risks are:-
Strategic Risk Residual Risk
Rating
Target Risk
Rating
Failure to achieve operational performance targets, caused by increased demand and lack of capacity, resulting in potential regulatory involvement, reputational damage to the Trust and compromising the FT application.
20 10
Failure to become a financially and clinically viable Trust, caused by internal and external factors, leading to enforcement/regulatory action being taken.
20 10
Failure to meet financial duties for due to income and expenditure issues and failure to implement CIP plans in a timely manner resulting in a COSRR which would adversely impact on the FT timetable
16 12
Failure to provide adequate nursing staffing levels in some wards caused by wards not having required establishments and inability to fill vacancies which may result in pressure on ward staff, potential impact on patient care and impact on Trust access and financial targets.
16 12
Failure to recruit/retain consultant and middle grade doctors in some specialities, caused by inadequate NHS workforce planning and increased competition within the NHS and beyond, leading to increased locum usage with potential quality, operational (e.g. increased Length of Stay) and financial implications.
16 12
Failure to manage attendance effectively, caused by a number of contributing factors – e.g. vacancy rates, sickness rates, variation in applications of policy (especially triggers) may result in increased sickness absence costs and increased bank and agency costs and adversely impact on patient safety and care
16 12
Lack of staff engagement caused by a number of contributing factors (disaffection, site focus, lack of processes, lack of management focus (capability), lack of communication, variation in holding to account), resulting in a significant strategic and operational impact, potential harm to patients and staff, sickness absence, recruitment and retention difficulties and reputational damage
16 12
Clinical variation, caused by lack of systems/process or failure of systems/to follow process leading to potential patient harm, inefficiencies and potential regulatory action for the organisation.
16 12
Increased incidence of Carbapenemase Producing Enterobacteeriaceae (CPE) within the Trust, caused by higher prevalence with the Greater Manchester area, may result in patient harm from sporadic infections, clusters and outbreaks and adversely impact on operational activity and patient flow.
15 10
Service failure caused by lack of systems/process or failure of systems/to follow process leading to operational
15 12
Page 43 of 196
Page 5
Strategic Risk Residual Risk
Rating
Target Risk
Rating
disruption, patient harm and / or regulatory involvement.
Inability to influence the external strategic environment caused by uncertainty due to Healthier Together, Devo Manc, integrated care agenda and other strategic agendas resulting in others determining the services and future of the Trust
12 8
Aggregate impact of commissioning decisions leading to the Trust becoming clinically or financially unsustainable
12 8
2. Proposed New Risk
Strategic Risk Residual Risk
Rating
Target Risk
Rating
Service failure affecting individual patients, regulatory involvement and / or reputational damage arising from failure to fully implement, to a level which meets the assurance needs of the Board and Commissioners, the improvement plan arising from the external review of maternity services.
20 6
3. Recommendations The Quality & Performance Committee is asked to review and if appropriate, make proposals to the Trust Board in relation to any changes to the Strategic Risk Register. The Committee is asked to approve or amend the description and grading of the additional Risk relating to maternity services. Gavin R Barclay Assistant Chief Executive May 2015
Item
6b
Page 44 of 196
Title of Report Care Quality Commission Registration Annual Review
Executive Summary
This paper confirms that the Trust has maintained unconditional registration with the Care Quality Commission throughout 2014/15 and details the various inspections that have taken place throughout the year across all sites. The paper also highlights:
Changes from Essential Standards to Fundamental Standards against which the CQC will focus on key lines of enquiry relating to safe, effective, caring, responsive and well-led
A Maternity Outlier Alert in respect of Perinatal Mortality
Chief Inspector of Hospitals, Intelligent Monitoring Report and the Trust’s risk banding
Statement of Purpose updates
Change to Nominated Individual with the CQC for registration purposes.
With effect from 1 April 2015, responsibility for the management of the entire CQC regulations, processes and assurance transferred from the Assistant Chief Executive to the Chief Nurse’s portfolio. The Director of Clinical Governance will ensure compliance with the CQC regulations and processes on behalf of the Chief Nurse.
Actions requested
The Board is asked to consider whether any further actions are required to ensure compliance with the CQC Standards in order to maintain the Trust’s unconditional registration.
Risks: Failure to maintain unconditional registration will highlight poor patient care or staff experience, attract negative comment, undermine relationships with stakeholders and affect the Foundation Trust application.
Public and/or patient involvement: None
Resource implications: None
Communication: Reports from CQC visits are publicised when they occur and details are included in the Quality Account.
Item
6c
Page 45 of 196
Have all implications been considered? YES NO N/A
Assurance X
Contract X
Equality and Diversity X
Financial / Efficiency X
Information Governance Assurance X
HR X
IM&T X
Local Delivery Plan / Trust Objectives X
National policy / legislation X
Sustainability X
Name Gavin Barclay
Job Title Assistant Chief Executive
Date May 2015
Email [email protected]
Page 46 of 196
C:\Users\244991-Admin\AppData\Local\Temp\cd949330-eaa1-42c7-b5ab-6bdc523949c6.doc
CARE QUALITY COMMISSION REGISTRATION ANNUAL REVIEW 2014-15
1. Introduction
The Pennine Acute Hospitals NHS Trust is required to register with the Care Quality Commission (CQC) and its current registration status is compliant with the regulations. The CQC has not taken enforcement action against the Pennine Acute Hospitals NHS Trust during the period 2014/15 nor has the CQC taken any enforcement action against The Pennine Acute Hospitals NHS Trust since its inception. The Pennine Acute Hospitals NHS Trust has not been required to participate in any special reviews or investigations by the CQC during the reporting period. The CQC is an independent national body responsible for regulating the quality of care provided by NHS trusts, social services and independent care providers. The CQC continually monitors whether The Pennine Acute Hospitals NHS Trust, and other care providers, are meeting their essential standards of quality and patient safety. Their particular focus is on patient outcomes in terms of the delivery of a quality experience of care. The CQC pays particular attention to what people say about the service. The intelligence which is used by the CQC to make an assessment upon the Trust’s performance against the statutory standards is obtained from external sources, including the Parliamentary Health Service Ombudsman, service users through a dedicated web site, mortality alerts, national inpatient and staff surveys and through Health watch, local charities and voluntary organisations. The Trust also undertakes a rigorous annual cycle of self assessment, evidence production and assurance against the quality standards. The CQC carries out a routine formal review of services to audit and review service outcomes against the essential standards for each service location. The review includes unannounced visits to the Trust premises so that teams of CQC Inspectors can speak with and observe the interactions between patients and staff and the quality of care being provided. The CQC has recently change the basis on which it will assess services. CQC inspections are now focused on five key lines of enquiry domains, determining whether services are:-
Safe
Effective
Caring
Responsive to people’s needs
Well-led
Item
6c
Page 47 of 196
C:\Users\244991-Admin\AppData\Local\Temp\cd949330-eaa1-42c7-b5ab-6bdc523949c6.doc
2. Inspections during the Year
The Board will be aware that the Trust was inspected by the CQC on 8 & 9 November 2013 as part of a routine inspection to check that essential standards of quality and safety were being met. Although this was a routine inspection, it was unannounced. The following outcomes were assessed and standards met:- Outcome 1 Respecting and involving people who use services Outcome 5 Meeting nutritional needs Outcome 13 Staffing Outcome 16 Assessing and monitoring the quality of service provision Action was needed for Outcome 4 - Care and welfare of service users. The CQC judged that this had a minor impact on people using the service. The Trust produced and submitted an action plan which aimed to return the Trust to a compliance state by 31 March 2014. The detailed action plan addressed the points raised by the CQC, these being:-
Malnutrition Universal Screening Tool (MUST) to be completed within 24 hours of admission.
MUST and rescreening to be completed as per Trust guidelines.
Individualised care plans to be in place for all patients who are nutritionally compromised.
Fluid balance and food charts to be completed. North Manchester General Hospital was re-inspected by the CQC on 26 June 2014. The Trust subsequently received a compliance report from the CQC on which shows the standard with regard to Outcome 4 – Care and welfare of users was being met. Other than the above re-inspection, the Trust has not been inspected during 2014/15. Future CQC inspections will be in the form of Chief Inspector of Hospitals visit. The Trust does not yet have a date for the CIH visit, although in line with the national timetable a visit can be expected prior to 31 March 2016.
3. Maternity Outlier Alert For Perinatal Mortality On 13 October 2014, the Trust received an outlier alert from the CQC. The Trust’s response was submitted to the CQC on 21 November 2014.
The alert noted a statistical increase in perinatal mortality. However, when this was investigated it was found that the data used by the CQC did not take into account the reconfiguration of maternity and neonatal services in Greater Manchester and the Trust’s designation as a level 3 unit at The Royal Oldham
Page 48 of 196
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Hospital. Once this had been taken into account the Trust was found to be “as expected”.
4. Chief Inspector of Hospitals As reported to the Board in last year’s annual report, as part of the Trust’s preparation for our Chief Inspector of Hospital’s visit, the former Governance Director led a series of mock inspections during 2014/15. The results of the inspections were considered by the former Clinical Governance & Quality Committee in the summer of 2014. With the publication of the fundamental standards, and the new inspection process, the Trust will be reviewing its clinical governance arrangements to ensure they align to the new standards. This agenda will be led by the newly appointed Director of Clinical Governance and Deputy Chief Nurse, reporting to the Chief Nurse. This will include, commissioning an external ‘mock Keogh’ review inviting peer review from external Trusts, ensuring that the existing ward metrics are aligned to the fundamental standards, that a safety walk round programme is put in place, again aligned to the fundamental standards and to further improve ward to Board reporting, working to develop composite quality reporting as part of the Integrated Performance Report.
5. Intelligent Monitoring Report (IMR) The IMR is a surveillance model which sets out a range of information held for each acute and specialist Trust. The IMR is issued quarterly by the CQC and subsequently shared and discussed at the Quality & Performance Committee. Summary level data is included in the monthly Integrated Performance Report for the Trust Board. The CQC surveillance model sets out a range of information held for each acute and specialist Trusts. The information is based on over 150 indicators that look at a range of information including patient experience, staff experience and statistical measures of performance. Each Trust is banded into six bands - Band 1 is the highest level of risk and band 6 is the lowest level of risk. Since the CQC has been producing the Intelligent Monitoring Report, the Trust’s bandings have been as follows:-
October 2013 - band 3 (mid range)
March 2014 - band 6 – (lowest risk)
July 2014 – band 6
October 2014 – band 6 The CQC has taken the results of their intelligent monitoring work and grouped the 160 acute NHS trusts into six priority bands for inspection based on the likelihood that people may not be receiving safe, effective, high quality care.
The indicators will be used to raise questions about the quality of care but will not be used on their own to make final judgements. The judgements will
Item
6c
Page 49 of 196
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continue to be based on a combination of what is found at inspection, national surveillance data and local information.
6. Statement of Purpose It is a statutory obligation of the Trust to notify the CQC of any changes in our premises or the type of services provided. The Statement of Purpose has been updated in December 2014 and is next due for review in June 2015 as part of its 6-monthly review cycle.
7. Nominated Individual From 1 April 2014, Mr Gavin Barclay, Assistant Chief Executive / Board Secretary has been the Nominated Individual for the Trust’s CQC registration. In line with the portfolio change described in section 10 a new nominated individual is required. This action remains outstanding.
8. Regulatory Update
A number of new measures are being introduced as part of the government’s response to the Francis Inquiry’s recommendations and are intended to help improve the quality of care and transparency of providers by ensuring that those responsible for poor care can be held to account.
These include:-
New fundamental standards which will define the basic standards of safety and quality that should always be met, and introduce criminal penalties for failing to meet some of them. These came into force in April 2015. The Quality & Performance Committee received a report on this in December 2014.
A new fit and proper persons requirement means that all Directors of NHS bodies must pass a test proving they are fit and proper persons. The CQC will be able to insist on the removal of Directors that fail. This came into effect on 27 November 2014. The Board received a report on this in November 2014.
The duty of candour will require NHS bodies to be open and transparent with service users about their care and treatment, including when it goes wrong. This came into effect on 27 November 2014. The Quality & Performance Committee received a report on this in December 2014.
9. Management / Portfolio Change With effect from 1 April 2015, responsibility for the management of the entire CQC regulations, processes and assurance transferred from the Assistant Chief Executive to the Chief Nurse’s portfolio. The Director of Clinical Governance will ensure compliance with the CQC regulations and processes on behalf of the Chief Nurse.
Page 50 of 196
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10. Action Required The Board is asked to consider whether any further actions are required to ensure compliance with CQC essential standards in order to maintain the Trust’s unconditional registration. Gavin Barclay Assistant Chief Executive April 2015
Item
6c
Page 51 of 196
1
Title of Report
Mortality Information Report (December 2015 position)
Executive Summary
Mortality report providing the Board with an update on progress with the mortality reduction project. The report offers a series of key performance indicators (KPIs) to assist the Board with monitoring the progress of this work. These indicators incorporate those required to monitor the mortality corporate objectives.
Actions requested
The Board is asked to note the contents of this report, progress against the plan, and suggest any new actions identified to improve the current position with regards to mortality.
Corporate Objectives supported by this paper: Objective 1 – Improving Patient Safety - Reduction in standardised mortality
Risks: Board Risk Register: – Poor quality of care provided to patients as measured by HSMR if higher than expected mortality is not noticed and addressed at Trust site and speciality level.
Public and/or patient involvement: N/A
Resource implications: N/A
Communication: Regular mortality reduction bulletin to staff. Communications through the Trust governance structures. Dedicated section on Trust Intranet site. Regular programme of visits to teams
Have all implications been considered? YES NO N/A
Assurance √
Contract √
Equality and Diversity √
Financial / Efficiency √
HR √
Information Governance Assurance √
IM&T √
Local Delivery Plan / Trust Objectives √
National policy / legislation √
Sustainability √
Name Anton Sinniah
Job Title Medical Director
Date May 2015
Email [email protected]
Item
7b
Page 52 of 196
2
Mortality Information Report May 2015 Contents
Section Sub Title Page
1.0 Introduction 3
2.0 Approach
3
3.0 Summary
3
4.0 HSMR and Crude Mortality Rates 4
4.1 North West Peers 4
4.2 HSMR by Month 5
4.3 HSMR by Site 5
4.4 Acuity by Site 6
4.5 HSMR by Day of Admission 7
4.6 SHMI 10
4.7 Crude Mortality Rate 12
5.0 KPIs 12
5.1 Palliative Care Coding 12
5.4 Depth of Coding (Co-morbidities) 14
5.7 Consultant Review of Death Alerts 14
Page 53 of 196
3
Mortality Information Report May 2015 (December position) 1.0 Introduction
This report reflects the rebased Mortality position for the Trust up to the end of December 2014 and includes the latest data from Dr Foster updated on 13th April 2015.
2.0 Approach
The Dr Foster data is reviewed routinely with in-depth analysis particularly for areas showing no improvement or an adverse variance.
3.0 Summary
3.1 HSMR.
December April to December Pennine 74.3 83.05 (NW 93.0) Oldham 71.07 87.11 North Manchester 69.2 87.7 Bury 86.03 81.65 Rochdale 22.5 33.6
3.2 The Mortality Validation Tool is now fully live across the Trust. Following on from the winter pressures for the consultants and the staffing issues within the coding department, the compliance of the consultants using the tool has not been monitored effectively. A report from the software company is being amended to provide details of the number of patients signed off by the consultant and the number of patients reviewed. The second version of the Tool will allow Consultants to carry out a clinical review at the same time as validating the coding. This is still in development with Woodward Associates Ltd (company who developed the tool) the latest update is that this will be ready for a demonstration by the 14/5/15.
3.3 Mortality Reduction Partnership (CQUIN: Mortality Reduction) - An audit was undertaken of 50 consecutive death casenotes and 45 were analysed. The audit tool is based on the NHS Institute Mortality Review Tool combined with the global trigger tool. The audit included a clinical review by Deputy Medical Directors. Meetings have taken place with CCG mortality leads for North Manchester and Bury. An education event has also taken place in February for Bury GP’s.
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4.0 HSMR and Crude Mortality Rates 4.1 North West Peers
The graphs below show how the Trust is performing against its North West peers* for the period April to December 2014 plus April 2013 to March 2014. The Trust is below the North West average of 93.0 with an HSMR for the 9 month period to December 2014 of 82.7. The Trust is in the best position within the North West (when using 2013/14 as the benchmark)
108.0107.0105.2104.799.9 99.7 98.2 97.0 94.9 94.7 93.2 92.6 92.2 89.9 88.6 88.6 88.4 86.5 84.9 84.6 83.1 82.7
0
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40
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80
100
120
140
HSMR NW Acute Providers - April to December 2014
HSMR NW Average
119.3110.5107.9107.5106.0105.9104.8104.4104.1103.7102.8101.7100.8 98.8 98.7 98.6 97.1 96.0 94.0 93.9 91.1
85.2
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140
HSMR NW Acute Providers - April 2013 to March 2014
HSMR NW Average
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*The peer performance includes any patients treated at Pennine who were also seen at other providers for related
care during their spell, known as the super spell. The number of super spells during the period may vary and
therefore the impact on the HSMR will differ slightly when comparing Pennine only based reports as a result.
4.2 HSMR by Month The 12 month rolling HSMR up to the end of December is 85.83.This is a decrease of 1.62 compared to the November refreshed and rebased position of 87.45. The chart below shows the trend over the last 33 months comparing month by month and year on year.
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2012/13 100.3 110.2 93.2 97.4 98.9 107.7 93.9 90.2 100.8 107.0 96.3 95.4
2013/14 100.5 84.2 95.0 81.1 92.6 97.4 89.8 92.7 78.3 92.4 93.0 95.2
2014/15 90.2 80.6 93.4 77.7 78.7 85.2 81.1 89.7 74.3
20
30
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50
60
70
80
90
100
110
120 HSMR Year on Year 2012/13, 2013/14 and 2014/15
4.3 HSMR by Site
A further breakdown by site is displayed below.
102.3
92.5
125.0
74.280.478.579.1
91.5
71.7
89.1
75.9
95.0
87.5
78.1
94.5
85.1
92.0
69.2
83.477.6
67.4
78.083.6
86.9
78.2
93.086.3
30.8
42.3
23.226.3
19.3
48.2
91.9
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ROHROHROHROHROHROHROHROHROHNMGHNMGHNMGHNMGHNMGHNMGHNMGHNMGHNMGHBuryBuryBuryBuryBuryBuryBuryBuryBury RI RI RI RI RI RI RI RI RI
HSMR by Site of Diagnosis and Month of Discharge
April to December 2014
The graphs below show the comparison between the rebased 2013/14 and the most recent 9 months to December 2014. All sites are now showing an improvement on last year’s position.
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87.11 84.7 81.65
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Royal Oldham Hospital North Manchester General Hospital
Fairfield General Hospital Rochdale Infirmary
HSMR April to December 2014 , by Site
HSMR PAT HSMR Target
4.4 Acuity by Site (Actual % HSMR against Expected % HSMR April – December 2014) It is clear from the graphs below that FGH has the sicker patients as on average 9.6% of all non-elective patients in the 9 month period were expected to die compared to both Oldham and NMGH.
7.9 7.58.3 8.6
6.57.4
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9.6 9.8 9.510.2
9.2 8.99.6
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FGH Acuity (Non Elective) - April to December 2014
Rate (%) Exp. (%)
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5.4
6.8
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6.3 6.55.9 6.2
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ALL Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Oldham Acuity (Non-Elective) - April to December 2014
Rate (%) Exp. (%)
5.0
6.7
4.65.1 5.3
3.7
5.1 4.95.8
6.9
5.7 5.8 5.75.2
5.76.2
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ALL ALL ALL ALL ALL ALL ALL ALL
ALL Sunday Monday Tuesday Wednesday Thursday Friday Saturday
NMGH Acuity (Non-Elective) - April to December 2014
Rate (%) Exp. (%)
4.5 HSMR by Day of Admission The graphs below show the comparison between the rebased 12 month period 2013/14 and the most recent 9 month period to December 2014.
79.4487.4 83.76
75.8287.84
73.76
92.83
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HSMR by Day of Admission - April to December 2014
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92.48 91.46 87.55 90.04 85.67100.56
90.55
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HSMR by Day of Admission - April 2013 to March 2014
The breakdown by site shows that patient admitted to Oldham on Sundays having a HSMR greater than 100. This is mirrored in the HSMR observed deaths by day of admission.
Monday TuesdayWednesd
ayThursday Friday Saturday Sunday
Bury 87.8 84.17 71.05 82.25 92.47 74.71 76.26
NMGH 80.15 88.5 93.46 71.16 89.54 79.94 96.73
RI 41.52 31.48 59.68 32.76 42.62 0 0
ROH 77.31 96.81 91.57 75.63 88.98 71.05 106.08
020406080
100120140
Non-Elective HSMR by day of the week - April to December 2014
Bury
NMGH
RI
ROH
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Bury 87.91 75.94 87.68 80.11 82.45 86.63 89.29
NMGH 91.7 93.55 90.66 88.68 90.41 104.64 82.7
RI 44.1 44.32 36.92 22.07 51.65 62.46 84.76
ROH 101.25 107.51 92.28 108.09 88.93 109.55 98.36
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Non-Elective HSMR by day of the week - April 2013 to March 2014
Bury
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RI
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ROH ROH ROH ROH ROH ROH ROHNMGHNMGHNMGHNMGHNMGHNMGHNMGHBury Bury Bury Bury Bury Bury Bury
HSMR Observed Deaths (Non-Elective)- April to
December 2014
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4.6 SHMI
The graph below shows the quarterly SHMI trend for the last 3 years. The latest data available is Quarter 1 2014/15 which has decreased from Quarter 4 2013/14 to 100.77. Oldham has the highest SHMI for Trust as 119.57. There is a small improvement for Oldham from previous quarter. Pennine
FGH Oldham NMGH
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Pennine (yellow) has a lower confidence interval above 100 like the other ‘red’ Trusts. In the graph below actual in-hospital deaths in SHMI is 97.61 compared to 90.01 for HSMR. SHMI has over twice as many spells (127,916) as HSMR (60,626) due to the fact that HSMR only looks at 56 diagnosis groups.
On the graph below you can see how SHMI compares across sites. Oldham now has the highest SHMI at 116.9.
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4.7 Crude Mortality Rate
The graph below reflects the crude mortality rate for the Trust over the last rolling 24
months.
050100150200250300350
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Crude Mortality Rate - All Admissions
Crude Mortality rate (%) Deaths
A breakdown for the last 24 months by age shows the marked higher mortality rate
for patients 75+ who account for 70% of all deaths.
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5.0 Key Performance Indicators
5.1 Palliative Care Coding
Title Description/Rationale Metric Target/ Outcome
Palliative Care Coding
Compared to peers, our Palliative Care Coding remains around the median. We need to ensure that we are capturing all spells where Specialist Palliative Care is involved.
[Number of Spells with Z515 (Specialist Palliative Care)] / [Total Number of Spells]
This will be a dynamic target to continuously achieve the North West average. This will be realigned as rebased data is loaded into Dr. Foster
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5.2 Key Performance Indicators - Percentage of Spells with Palliative Care Coded
4.0%3.8%
2.7% 2.6% 2.6% 2.6% 2.5% 2.5% 2.4% 2.3% 2.3% 2.1% 2.1% 2.1% 2.0% 2.0% 1.9% 1.8% 1.8%1.5% 1.5%
0.6%
0.0%0.5%1.0%1.5%2.0%2.5%3.0%3.5%4.0%4.5%5.0%
% Spells with Specialist Palliative Care - April to December 2014
% Palliative NW Avge
4.1%
3.3%
2.6% 2.5% 2.5% 2.4% 2.3% 2.2% 2.2% 2.2% 2.2% 2.2% 2.2% 2.1% 2.1%1.9% 1.8% 1.8%
1.5% 1.5%1.2%
0.9%
0.0%0.5%1.0%1.5%2.0%2.5%3.0%3.5%4.0%4.5%
% Spells with Specialist Palliative Care - April 2013 to March 2014
% Palliative NW Avge
5.3 Actions & Ongoing work
The Trust remains slightly above the NW average but continues to be monitored.
A regular report is sent to the coding department of all Specialist Palliative Care visits for inpatients to assist in ensuring that the activity is captured correctly.
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5.4 Depth of Coding
Title Description/Rationale Metric Target/ Outcome
Depth of Coding
To ensure that appropriate relative risks are applied we need to ensure that all co-morbidities are captured by clinicians and then coded accordingly
Average number of co-morbidities per FCE (finished consultant episode)
National mean average from Trust Quality Dashboard = 4.51
5.5 Key Performance Indicators – Average Number of co-morbidities per FCE
1.0
3.0
5.0
Average co-morbities Non-Elec - March 2013 to February 2015
PAT Avge Co-morb. National Mean Q1 13/14
5.6 Actions & Ongoing work
Clinical Coding Specialty Leads work closely with the clinicians to improve the recording in the clinical documentation for co-morbidities.
Clinical Coding Co-morbidity Awareness Training has been provided to the clinical coders and will be refreshed annually.
5.7 Consultant review of Death Alerts prior to coding of episodes
Title Description/Rationale Metric Target/ Outcome
Consultant review of Case notes
Consultants will be asked to review all deaths before the casenote is sent to clinical coding.
[Number of cases reviewed by Consultant] / [Total number of deaths]
Arising from comments from a previous Trust Board, the target now needs to be agreed following the completion of the pilot for the Mortality Validation tool.
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5.8 Key Performance Indicators – Percentage of Deaths that have been reviewed
before being coded
Actions & Ongoing work
The Mortality Validation tool The Clinical coding team have had a new validation tool built to support the Trust in ensuring that the deaths are coded correctly before the data is submitted to SUS for Dr Foster. This is an electronic tool which allows a two way conversation between the coding team and the consultant who was responsible for the care of the patient at time of death. The consultant is asked to sign off the coding as correct or provide additional information through the tool to improve the accuracy of the coded data.
Version 1 of the Mortality Validation Tool is fully rolled out for use across the Trust.
Clinical coding speciality leads will now monitor Consultant compliance in using the tool.
The second version of the Tool will allow Consultants to carry out a clinical review at the same time as validating the coding. This is still in development with Woodward’s and is due for demonstration on the 14/5/15. An initial demonstration of the tool was shown to Dr Anton Sinniah, Dr Roger Prudham and Dr Jason Raw who all gave good and positive feedback regarding the next version and the ability to record clinical information regarding the death alongside the validation of the coding to assist in the analysis into hospital deaths.
Anton Sinniah Medical Director May 2015
Appendix 1
Glossary & Terms
Ref Explanation/Detail
HSMR Hospital Standardised Mortality Ratio
SHMI Summary Hospital-Level Mortality Indicator
FCE Finished Consultant Episode
RR Relative Risk
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Title of Report Medical Revalidation & Appraisal
Executive Summary
This report contains an update on Medical Revalidation & Appraisal
Actions requested
The Board is asked to note the report.
Corporate Objectives supported by this paper: Quality Improvement - patient safety, patient experience & clinical effectiveness Leadership & Personal Responsibility
Risks: Failure to meet statutory obligations Failure to revalidate the Doctors licences would have a negative impact on service.
Public and/or patient involvement: Each Doctor has a 360 degree patient feedback within a five year period
Resource implications: Admin & Clerical PA time for medics both appraisees and appraisers
Communication:
Have all implications been considered? YES NO N/A
Assurance
Contract
Equality and Diversity
Financial / Efficiency
HR
Information Governance Assurance
IM&T
Local Delivery Plan / Trust Objectives
National policy / legislation
Sustainability
Name Dr Anton Sinniah
Job Title Acting Executive Medical Director/Responsible Officer
Date April 2015
Email [email protected]
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THE PENNINE ACUTE HOSPITALS NHS TRUST
Medical Revalidation & Appraisal Report
Background 1. The Health Secretary introduced Revalidation of doctors in the UK with effect from 3 December 2012. Revalidation is the process that assures patients, the public, employers and other health care professionals that licensed doctors are up to date and fit to practise. 2. A rigorous appraisal process is needed to ensure that GMC requirements will be met. Revalidation will require annual appraisals to be completed, with 5 yearly cycles leading to personal recommendation of the individual medical practitioner by the Responsible Officer (RO) of the organisation, usually the Medical Director. This will be based on a summation of 5 summative annual appraisals, and supporting portfolio of evidence. The doctor must demonstrate fitness to practise in relation to each of the four domains of good medical care as defined by the GMC in “Good Medical Practice” 2013. The four domains are: knowledge, skill and performance; safety and quality; communication, partnership and teamwork and maintaining Trust. 3. The Trust uses the PremierIT Appraisal system and this has been used for all medical appraisals since April 2013. 4. The Trust has purchased licences for doctors to undertake their annual job plans on the PremierIT system. The Directorate Managers have all been invited to training on the system and the roll out has commenced. Purpose of the Paper 5. The purpose of this paper is to provide the Trust Board, members of the public, patients, employers and other health care professionals with the assurance that the Trust has the necessary resources and processes in place which will support the appraisal and ultimately the revalidation for all doctors not on a training scheme. Management of Appraisal & Revalidation 6. At the 1st April 2015 there were 531 doctors with a prescribed connection to the Trust on GMC Connect and active on PremierIT; of these doctors 100% had completed an annual appraisal in the 2014/15 appraisal cycle. Appendix A shows the breakdown of the appraisals for the 2014/15 cycle.
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7. Appendix B shows the details of all missed or incomplete appraisals during the 2014/2015 appraisal cycle. 8. Any Locums appointed by the Trust are treated, in relation to appraisal and revalidation, as a permanent member of staff and are appraised and revalidated according to Trust policies. The Trust are currently working with Locum agencies and work is underway to revise the service level agreement through the framework to ensure they track revalidation and appraisal of locums to improve the quality assurance and those figures are reported to the Revalidation Steering Group. 9. The Trust currently has 116 active trained appraisers. 10. The Revalidation Team found that having the Trust appraisal cycle run from 1st April to 28th February greatly assisted in ensuring that all doctors met the NHS England criteria of an appraisal in the cycle 1st April to 31st March and the Trust will continue to work with a shorter appraisal cycle as detailed above, this will ensure that any last minute unforeseen circumstances will not adversely affect the appraisal process. 11. Appendix C shows the appraisal statistics as at 12th May 2015. 12. Monthly updates on statistics are sent by email to all Exec Directors, Clinical Directors, Divisional Directors, Divisional Medical Directors and Directorate Managers. 13. The Responsible Officer has successfully recommended for revalidation 378 doctors to date, with a further 55 doctors being deferred, (of which 35 were consultants and 20 were other grades). The reason for deferral has been ‘insufficient evidence to support a recommendation’ and the cause of this has predominately been that the doctors are on sabbaticals, long term sick or maternity leave. Where a deferral has been made the Appraisal and Revalidation team work closely with the doctor to ensure that they are fully prepared for their new revalidation date to ensure the Responsible Officer can make a successful recommendation for revalidation. The audit of revalidation recommendations for the period 1 April 2014 to 31 March 2015 is shown at Appendix D. 14. To date the appraisal and revalidation team are currently working to prepare the revalidation folders for the doctors due to be revalidation in August/September/October 2015. These are presented to the Responsible Officer for review on a two weekly basis. 15. The Trust Board receives from HR an annual report which covers any doctors in difficulty and concerns raised. 16. A review of the revalidation & appraisal policy has been undertaken due to the evolving and changing environment for appraisal and revalidation and this is in the process of being ratified by the JLNC. 17. The PremierIT system has been aligned to the new directorate structures to include the directorate of Integrated and Community Structure and work will be
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carried out to realign the system again once the newly announced directorate changes/structures are known. Quality Assurance 18. The revalidation team have randomly selected 50 appraisers to have 1 appraisal reviewed by The Revalidation & Clinical Appraisal Lead and the Head of Medical Business and Professional Support (with the remit for Trust Appraisal & Revalidation Lead) for QA purposes and this is currently in progress. Any concerns will addressed via the appraisal team leaders and feeds into the performance review of appraisers, see paragraph 19 below. A summary of the findings of this audit will be included in the next Medical Revalidation & Appraisal Board paper submitted. Please see paragraphs 23-25 for details of some of the QA work the Appraisal Team Leaders are carrying out. 19. At the end of each appraisal the appraisee has to complete a feedback form on how they felt their appraiser conducted the appraisal. At the end of the appraisal cycle these reports are collated and the Trust Appraisal Team Leaders are each provided with a portfolio of results for them to discuss with their individual appointed appraisers. Any areas for improvement identified will be addressed at future training events. 20. In 2014 NHS England introduced a framework for quality assurance to provide assurance to patients, the public, the service and the profession that the systems and processes underpinning revalidation are in place and working effectively. This framework is known as the Annual Organisational Audit (AOA) and consists of mandatory returns and these are currently being reviewed by the Trust Revalidation & Appraisal Lead. 21. NHS England have now included in the 2015 AOA documentation the requirement for us to report on our internal process to ensure that Trusts are completing the transfer of information between Responsible Officers as part of their recruitment checks and this is being raised at the Revalidation Steering Group with the Executive Directors of HR and Executive Medical Director for our current systems to be amended to incorporate this element. 22. Internal Audit has conducted a second Internal Audit of the Appraisal Process with the only recommendation made around the performance of the speed of the appraisal system. IM&T are looking into this. Performance Review, Support & Development of Appraisers. 23. Five Appraisal Training events have been run during the year and these are planned to continue moving forward. In house appraisal training has been approved by the RO and the Revalidation & Clinical Appraisal Lead holds a minimum of two full day Appraiser training events per appraisal cycle for both new appraisers and those who are required to attend for their 3 yearly update.
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24. After attending the Appraisal Training all newly appointed appraisers have to have their first appraisal peer reviewed by an Appraisal Team Leader. If this is found to be conducted satisfactory then the appraiser is recorded as being qualified, if however, any issues are identified at this first appraisal then these will be discussed with the appraiser and appraisal team leader and further peer reviews may be undertaken before the appraiser is recorded as being qualified. 25. A number of Appraisal Training workshops are held during the appraisal cycle and all appraisers have to attend at least one workshop in an appraisal cycle to remain compliant with their training. Clinical Governance 26. A number of documents are uploaded to the PremierIT system for discussion at appraisal, examples of these include complaints received, consultant dashboard data, audit data, declaration of interests and job plans. Access, Security & Confidentiality 27. The PremierIT system provides a fully auditable log with access being restricted and controlled by the Appraisal & Revalidation Team. 28. All Information Governance protocols are followed at all times. Remediation 29. A review of the conduct and capability policy has been undertaken by HR and a new policy titled remediation, capability & conduct for medical staff has been introduced and is available on the Trust intranet. Conclusion 30. The Trust are currently revalidating all doctors in a timely and responsible manner. 31. The Trust are actively encouraging and engaging with doctors to ensure that annual appraisals are carried out and that these are of a higher quality than previously. 32. Where there is statistical evidence of specific divisions responding very late to requests for appraisals to be undertaken and then failing to meet the 100% requirements a discussion between the Revalidation & Clinical Appraisal Lead and the Divisional Manager will be arranged to see if there are any underlying contributing factors and/or assistance required to improve the compliance rate.
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Recommendations 33. The Board are asked to note the contents of this report. 34. To approve the ‘statement of compliance’ confirming that the Trust, as a designated body, is in compliance with the regulations. Statement of Compliance is attached at Appendix E. DR ANTON SINNIAH Acting Executive Medical Director/Responsible Officer May 2015
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APPENDIX A
Appraisals breakdown by Division
Completed Appraisals
Overall 487 Diagnostics 148 HR 4 Medicine 106 Women’s and Children’s 81 Surgery 132 Integrated & Community Services 16
Appraisals completed on another system Overall 4
Diagnostics 0 HR 0 Medicine 1 Women’s and Children’s 0 Surgery 3 Integrated & Community Services 0
Appraisals escalated to RO Overall 1
Diagnostics 0 Facilities 0 Medicine 1 Women’s and Children’s 0 Surgery 0
Integrated & Community Services 0 Missed Appraisals (Maternity leave & Sabbatical
leave)
Overall 9
Diagnostics 1
HR 0
Medicine 2
Women’s and Children’s 2
Surgery 3
Integrated & Community Services 1
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APPENDIX B
Audit of all missed or incomplete appraisals
Doctor factors (total) Number
Maternity leave during the majority of the ‘appraisal due window’ 4
Sickness absence during the majority of the ‘appraisal due
window’
1
Prolonged leave during the majority of the ‘appraisal due
window’
3
Suspension during the majority of the ‘appraisal due window’ 0
New starter within 3 month of appraisal due date 1
New starter more than 3 months from appraisal due date 0
Postponed due to incomplete portfolio/insufficient supporting
information
0
Appraisal outputs not signed off by doctor within 28 days 0
Lack of time of doctor 0
Lack of engagement of doctor 0
Other doctor factors (describe) 0
Appraiser Factors
Unplanned absence of appraiser 0
Appraisal outputs not signed off by appraiser within 28 days 0
Lack of time of appraiser 0
Other appraiser factors (describe) 0
Organisational Factors
Administration or management factors 0
Failure of electronic information systems 0
Insufficient numbers of trained appraisers 0
Other organisational factors (describe) 0
TOTAL 9
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APPENDIX C
These statistics are taken from the system on 12th May 2015.
Overall
Successfully completed appraisals
0
Appraisal progress within guidelines
526 (98%)
Appraisal progress not within guidelines
4 (1%)
Appraisal due date not defined
0
Appraisals closed prior to completion
0
A milestone for these appraisals has been missed 7 (1%)
Appraisals with escalations to RO
0
Total
537
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APPENDIX D Audit of revalidation recommendations
Revalidation recommendations between 1 April 2014 to 31 March 2015
Number Recommendations completed on time (within the GMC recommendation window) including the recommendation of deferral
207
Late recommendations (completed, but after the GMC recommendation window closed).
0
Missed recommendations (not completed)
0
TOTAL
207
Primary reason for all late/missed recommendations For any late or missed recommendations only one primary reason must be identified
No responsible officer in post
0
New starter/new prescribed connection established within 2 weeks of revalidation due date
0
New starter/new prescribed connection established more than 2 weeks from revalidation due date
0
Unaware the doctor had a prescribed connection
0
Unaware of the doctor’s revalidation due date
0
Administrative error
0
Responsible Officer error
0
Inadequate resources or support for the responsible officer role
0
Other (describe)
0
TOTAL 0
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A Framework of Quality Assurance for Responsible Officers and Revalidation
Annex E - Statement of Compliance Version 4, April 2014
APPENDIX E
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NHS England INFORMATION READER BOX
Directorate
Medical Operations Patients and Information
Nursing Policy Commissioning Development
Finance Human Resources
Publications Gateway Reference: 01142
Document Purpose Guidance
Document Name A Framework of Quality Assurance for Responsible Officers and Revalidation, Annex E - Statement of Compliance
Author NHS England, Medical Revalidation Programme
Publication Date 4 April 2014
Target Audience All Responsible Officers in England
Additional Circulation List
Foundation Trust CEs , NHS England Regional Directors, Medical Appraisal Leads, CEs of Designated Bodies in England, NHS England Area Directors, NHS Trust Board Chairs, Directors of HR, NHS Trust CEs, All NHS England Employees
Description The Framework of Quality Assurance (FQA) provides an overview of the elements defined in the Responsible Officer Regulations, along with a series of processes to support Responsible Officers and their Designated Bodies in providing the required assurance that they are discharging their respective statutory responsibilities.
Cross Reference The Medical Profession (Responsible Officers) Regulations, 2010 (as amended 2013) and the GMC (Licence to Practise and Revalidation) Regulations 2012
Superseded Docs
(if applicable)
Replaces the Revalidation Support Team (RST) Organisational Readiness Self-Assessment (ORSA) process
Action Required Designated Bodies to receive annual board reports on the implementation of revalidation and submit an annual statement of compliance to their higher level responsible officers (ROCR approval applied for).
Timings / Deadline From April 2014
Contact Details for further information
http:// www.england.nhs.net/revalidation/
Document Status
This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet
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Annex E – Statement of Compliance
Designated Body Statement of Compliance
The Trust Board – of the Pennine Acute Hospitals NHS Trust has carried out and submitted an annual organisational audit (AOA) of its compliance with The Medical Profession (Responsible Officers) Regulations 2010 (as amended in 2013) and can confirm that:
1. A licensed medical practitioner with appropriate training and suitable capacity
has been nominated or appointed as a responsible officer;
Comments: I can confirm that this is correct
2. An accurate record of all licensed medical practitioners with a prescribed
connection to the designated body is maintained;
Comments: I can confirm that this is correct
3. There are sufficient numbers of trained appraisers to carry out annual medical
appraisals for all licensed medical practitioners;
Comments: I can confirm that this is correct
4. Medical appraisers participate in ongoing performance review and training /
development activities, to include peer review and calibration of professional
judgements (Quality Assurance of Medical Appraisers or equivalent);
Comments: I can confirm that this is correct
5. All licensed medical practitioners1 either have an annual appraisal in keeping
with GMC requirements (MAG or equivalent) or, where this does not occur,
there is full understanding of the reasons why and suitable action taken;
Comments: I can confirm that this is correct
6. There are effective systems in place for monitoring the conduct and
performance of all licensed medical practitioners1, which includes [but is not
limited to] monitoring: in-house training, clinical outcomes data, significant
events, complaints, and feedback from patients and colleagues, ensuring that
information about these is provided for doctors to include at their appraisal;
Comments: I can confirm that this is correct
7. There is a process established for responding to concerns about any licensed
medical practitioners1 fitness to practise;
Comments: I can confirm that this is correct
1 Doctors with a prescribed connection to the designated body on the date of reporting.
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8. There is a process for obtaining and sharing information of note about any
licensed medical practitioners’ fitness to practise between this organisation’s
responsible officer and other responsible officers (or persons with appropriate
governance responsibility) in other places where licensed medical
practitioners work;
Comments: I can confirm that this is correct
9. The appropriate pre-employment background checks (including pre-
engagement for Locums) are carried out to ensure that all licenced medical
practitioners2 have qualifications and experience appropriate to the work
performed; and
Comments: The Trust has appropriate checks in place; however
weaknesses have been identified and are subject to ongoing discussions
between the Executive Director of HR and the Acting Medical
Director/Responsible Officer.
10. A development plan is in place that addresses any identified weaknesses or
gaps in compliance to the regulations.
Comments: An action plan is in place for improvements where required.
Signed on behalf of the designated body
Name: DR GILLIAN FAIRFIELD Signed: _ _ _ _ _ _ _ _ _ _
[chief executive or chairman a board member (or executive if no board exists)]
Date: _ _ _ _ _ _ _ _ _ _
2 Doctors with a prescribed connection to the designated body on the date of reporting.
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Title of Report Dr Kershaw’s Hospice
Executive Summary
The paper updates the Board on the review of the relationship between Hospice and the Trust
Actions requested
The Board is asked to note the report.
Corporate Objectives supported by this paper: 9. To be an influential organisation working in partnership with others across the health and social care system to improve the health of the population.
Risks: Financial –through employment issues
Public and/or patient involvement:
Resource implications:
Communication:
Have all implications been considered? YES NO N/A
Assurance X
Contract
Equality and Diversity X
Financial / Efficiency X
HR X
Information Governance Assurance X
IM&T X
Local Delivery Plan / Trust Objectives X
National policy / legislation X
Sustainability X
Name Mr J Wilkes
Job Title Director of Estates and Facilities
Date May 2015
Email [email protected]
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Dr Kershaw’s Hospice update
Introduction 1. This paper outlines the progress that has been made in reviewing the
relationships between the hospice and the Trust with the aim to ensure there are clear lines of accountability and responsibility and where needed formal service level agreements are in place.
Strategic context 2. As the board will recall there was a formal investigation into the
Hospice following a patient complaint. This led to Oldham CCG raising concerns with the Hospice about its over reliance on Trust policies and procedures.
Review 3. The Hospice has now reviewed all its clinical policies and procedures
and taken ownership of them. However, due to historical arrangements 56 staff currently working at the Hospice have been employed on Trust terms and conditions of service. Working together the aim is for the Trust to transfer the staff over to Dr Kershaw’s on 1st September 2015.
4. The Trust supported the Hospice during this period by seconding a
Matron to them to give them the clinical leadership it required. The Matron has now been recruited by the Hospice on a permanent basis.
5. A major barrier has been the NHS Pension scheme and getting the
hospice to apply for membership to the scheme to enable the transfer of the staff under the Transfer of Undertakings regulations (TUPE). This has now been actioned by the Hospice and supporting information from the Trust was sent back to the Pension agency at the beginning of May.
6. A task and finish group has been set up following agreement by the
hospice directors in February to ensure the transfer and supporting processes are delivered by the agreed timescale. The group is led by the Director of Governance and supported by Deputy Director of Workforce. Other trust officers will be included as and when needed for their expertise.
7. Besides the staffing issues the group is looking at Recruitment,
Occupational health, Training, Financial services, Nurse bank and I&MT.
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Conclusion 8. The Task and Finish group has been set up and the Director of Support
Services will be kept aware of progress. The Director has also met with the Hospice Secretary and Director, and agreed to meet with him on a quarterly basis.
Recommendations 9. The Board is asked to note the contents of the report. John Wilkes Director of Estates and Facilities May 2015
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Title of Report Trust Programmes Update
Executive Summary
This paper sets out progress with Programme arrangements for the Trust.
Actions Requested:
The Board is asked to:
Note the role of a Trust Programme Board
Note individual Programme progress
Note PMO structure and potential developments
Risks: 1) Failure to deliver programme management approach may lead to; 2) – failure to achieve service transformation 3) – failure to deliver CIPs 4) – failure to progress SLR 5) – failure to deliver safe services 6) – failure to develop a workforce fit for the future 7) – failure to achieve Foundation Trust status
Public and/or Patient Involvement: 8) Not applicable to this paper.
Resource Implications: 9) Funding to support PMO previously agreed.
Communication: Through normal Trust communication channels in due course. Progress of individual programmes will be via the Programme Board to the Board of Directors
Have all implications been considered? YES NO N/A
Assurance X
Contract X
Equality and Diversity X
Financial / Efficiency X
HR X
Information Governance Assurance X
IM&T X
Local Delivery Plan / Trust Objectives X
National policy / legislation X
Sustainability X
Name Sandra Good
Job Title Director of Strategy and Commercial Development
Month and Year May 2015
Email [email protected]
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Trust Programmes Update 1. Purpose This briefing sets out the progress with Trust Programme arrangements. 2. Background Following approval of revised Trust governance arrangements in June 2014, and introduction of the programme management approach, this paper provides an update from the December 2014 written briefing and March presentation update. 3. Overarching Programme Governance Framework Trust-wide Programmes Board (time limited committee) In order to support the main Trust business and operational delivery of services the Trust has established six core programmes of work. The Trust-wide Programmes Board provides assurance to the Trust Board in relation to the delivery of the activities of the Trust Programmes, ensuring programmes of work are appropriately governed, aligned with the Trust strategic goals and that interdependencies within programmes are managed effectively. There are six core programmes reporting into the Trust-wide Programmes Board:
Service Transformation Programme
Safety Programme
Workforce and Leadership Programme
CIP Programme
Service Line Reporting (SLR) Programme
Foundation Trust Programme 4. Programme Structure The Trust describes within its five year Integrated Business Plan (IBP) a significant transformation agenda, in order to improve quality whilst maintaining financial stability. The key delivery vehicle is the Programme Management approach. 4.1. Service Transformation Programme The Service Transformation Programme oversees the development and implementation of new service models ensuring that the programme realises the expected benefits to:
increase quality for the patient;
reduce cost in accordance with agreed 5 year CIP plans; and
ensure that the Trust remains clinically and financially sustainable. The outputs of this programme will be a five year service development strategy which is a central plank of the Trust IBP.
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4.21 Safety Programme The Safety Programme will:
Identify emerging themes and develop programmes of themed work through the review of SUIs, Complaints, Incidents, Disciplinaries and other quality indicators.
Examine in detail the safety implications of the transforming services agenda, assessing the risk and suggest monitoring arrangements.
4.3. Workforce and Leadership Programme The workforce and leadership programme will:
Create the future workforce to deliver transformed services in order to increase quality for the patient;
Develop leadership strategy and programmes for the Trust
Address key workforce metrics including sickness absence
Reduce cost in accordance with agreed 5 year CIP plans; and
Ensure that the Trust remains sustainable. 4.4. Cost Improvement Plan (CIP) Programme The Cost Improvement Plan (CIP) programme will:
Oversee, develop, initiate and discuss all activities associated with the delivery of the Cost Improvement Programme.
Problem-solve delivery issues so that any obstacles to success are managed and eliminated.
Ensure alignment and delivery against the associated five year plan. 4.5. Service Line Reporting (SLR) Programme The Service Line Reporting (SLR) Programme will:
Develop and implement robust service line reporting Trustwide
Provide assurance to the Trust-wide Programme Board that Service Line Reporting (SLR) programme is being managed effectively and is delivering.
4.6. Foundation Trust Programme The Foundation Trust Programme will:
Lead the Foundation Trust application, ensuring all actions collectively meet the needs of the organisation, TDA and Monitor to achieve FT status.
Ensure alignment between individual FT work streams and with other strategy, policy and operational need.
Manage strategic risk and issues relating to FT programme and strategic external dependencies.
5. Progress Since previous updates, progress has been made as follows:
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Substantive role of Foundation Trust Programme Director subsumed into role of Director of Strategy and Commercial Development 1st January 2015
Substantive Transformation Director commenced 1st February 2015. Secondee’s substantive post as Divisional Director of Diagnostics removed as part of recent Divisional restructuring.
PMO Administrator commenced 11th May 2015 as part of recent Divisional restructuring.
Project Manager posts filled. Start dates to be confirmed for 2 candidates.
Time limited interims will be reduced over time to reduce financial burden and increase long term commitment to the Trust. Planned end dates June 2015.
Transformation delivery Managers are being recruited to support Divisions with implementation of transformation and cost improvement plans (short delay due to conclusion of recent Divisional restructuring).
Key changes to Senior Responsible Officers operationalized –
- Jon Lenney, Director of Workforce and Organisational Development lead on Workforce and Leadership
- Dr Anton Sinniah, Acting Medical Director lead on Service Transformation
- Gill Harris, Chief Nurse lead on Safety Programme
Trust wide Programme Board operational
Service Transformation Programme. Progressing. Supported by 2 wte Project Managers and McKinsey.
Safety Programme. Progressing. Work streams identified as Sepsis, Diabetes, Failure to Rescue, Learning Lessons and Falls. Supported by 1.4 wte Project Managers.
Workforce and Leadership Programme. Early stages of development in terms of work streams now identified as modernisation, engagement, leadership and Health & Wellbeing. Interim legacy Project Manager in place.
Cost Improvement Programme. Board fully established. Supported by 2 wte Project Managers (1 appointed, 1 interim Project Manager in place) and Ernst & Young.
Service Line Reporting Programme. Board fully established. External input from Ernst & Young completed. Implementation focused going forwards. Project Manager appointed.
Foundation Trust Programme. Board fully established. FT Project Manager
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returned from long term sickness absence January 2015, graded basis – requested move to Corporate Governance from 1st June 2015 (agreed). No interim arrangements identified – for review.
6. Future Arrangements As a result of the convergence of the transformation and cost improvement work streams, discussions are planned for 8th June 2015 to consider a merger of the two Programme Boards. This will improve synergy and reduce the meetings commitments of participants and Divisional staff, particularly clinicians. This approach is supported by planned changes to external support. 7. Conclusion As a new approach for the Trust a variable start was anticipated, but the new financial year has demonstrated a renewed commitment to the approach driving progress forward across each of the Programme Boards to ensure delivery against key milestones and outcomes, and to provide the Board of Directors with the necessary assurance. Sandra Good Director of Strategy and Commercial Development 28th May 2015
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Page 1
Title of Report IM&T Strategy
Executive Summary
The purpose of this paper is to present the IM&T Strategy 2015 to 2018 to the Trust Board.
The Strategy was approved by the Senior Management Team on 11 May 2015, and noted by the Finance, Infrastructure and Business Development Committee on 26 May 2015.
The Strategy examines the Trust’s business and strategic drivers that will guide activities and prioritise investment in IM&T for the next 3 years. The Strategy describes the current IM&T capabilities and assesses progress against the previous Strategy identifying key gaps to be addressed.
Ten strategic objectives have been defined in support of the Trust’s transformation and quality agenda:
Supporting the Trust’s Transformation Map
Digitising patient records and clinical workflow
Integration across the care-continuum
Improving patient access to care and information
Providing high quality information and business intelligence
Flexible and innovative working
Enhancing IT infrastructure
Optimising existing technology
Efficient and effective IM&T service
Improving clinical engagement.
Delivery of the Strategy requires immediate additional revenue investment of £400k and capital investment of £7.3m in 2015/16, £10m in 2016/17 and £7.7m in 2017/18. There is an identified shortfall in the Trust’s capital plans in 2016/17 and 2017/18 to meet the IM&T funding requirements.
In principal the Strategy should deliver cash-releasing
benefits, but as a minimum be self-funding.
Actions requested
To approve the IM&T Strategy until 2018 and undertake annual review of progress against objectives
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Page 2
Corporate Objectives supported by this paper:
All
Risks:
Adequate capital and revenue funds are not made available to deliver the strategy and to provide a business as usual IT Service that supports the operational needs of the organisation
Sufficient project resources and management cannot be secured risking delays or abandonment of projects
Projects run late or over-budget, delaying delivery of benefits
Projects completed, but benefits not fully realised
Loss of efficiencies and disruption to organisation arising from out-of-date or redundant systems
Failure to attract and retain high quality staff leads to heightened risk of project failures and unreliable systems and processes
Failure to identify project and programme risks
IM&T are not involved early enough in hospital projects
Trust culture does not change to one of “IT is not optional, it is part of the day job”
Clinicians see IT as purely administration
Lack of flexibility and response to change
Increased demand for IT solutions as cost improvement enabler cannot be met by current IM&T resource establishment
IM&T strategy is impacted or delayed by Devolution of Manchester and/or other political changes in local area
Increased demands on the finite business as usual resources due to the expansion of IM&T systems delivered as part of the strategy
Public and/or patient involvement:
Not applicable
Have all implications been considered? YES NO N/A
Assurance √
Contract √
Equality and Diversity √
Financial / Efficiency √
HR √
IM&T √
Local Delivery Plan / Trust Objectives √
National policy / legislation √
Sustainability √
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Page 3
Name Brian Steven
Job Title Deputy Chief Executive / Finance Director
Date 28 May 2015
Email [email protected]
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Information Management and
Technology Strategy 2015-2018
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The Pennine Acute Hospitals NHS Trust IM&T Strategy 2015 – 2018
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Version Date Amendment
V1.0 01/04/15 Created
V1.1 15/05/15 Minor revisions further to comments from SMT
Approvals:
Name Lead Date of Review Date of sign-off
Version
Senior Management Team
Gillian Fairfield
11th May 2015
Trust Board John Jesky
28th May 2015
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Contents
1 EXECUTIVE SUMMARY ..............................................................................................4
2 INTRODUCTION ...........................................................................................................7
3 STRATEGIC CONTEXT ...............................................................................................9
3.1 NATIONAL CONTEXT ........................................................................................................ 9
3.2 SOCIAL CONTEXT........................................................................................................... 13
3.3 LOCAL CONTEXT ............................................................................................................ 14
3.3.1 The Pennine Acute Hospitals NHS Trust ........................................................... 14
3.3.2 Greater Manchester Devolution Agreement ...................................................... 16
3.3.3 North East Sector .................................................................................................. 17
3.3.4 Healthier Together ................................................................................................. 17
3.3.5 Living Longer, Living Better ................................................................................. 18
3.3.6 Greater Manchester Academic Health Science Network ................................ 18
3.3.7 CQUINs ................................................................................................................... 18
3.4 SUMMARY OF THE STRATEGIC ENVIRONMENT ............................................................ 20
3.5 STAKEHOLDER ANALYSIS .............................................................................................. 21
4 CURRENT IM&T ENVIRONMENT ............................................................................. 22
4.1 PROGRESS AGAINST PREVIOUS IM&T STRATEGY ....................................................... 22
4.2 STATUS OF CURRENT IM&T INFRASTRUCTURE AND SERVICES PROVISION ............... 22
4.3 CURRENT STATE OF CLINICAL SYSTEMS ....................................................................... 25
4.4 IM&T STAFFING ............................................................................................................. 28
4.5 DIGITAL RECORD MATURITY AND ADOPTION MODELS .................................................. 29
5 VISION AND STRATEGIC OBJECTIVES ................................................................. 30
5.1 VISION AND MISSION ..................................................................................................... 30
5.2 IM&T STRATEGIC OBJECTIVES ..................................................................................... 30
5.2.1 Supporting the Trust’s transformation ................................................................ 31
5.2.2 Digitising patient records and clinical workflows ............................................... 32
5.2.3 Integration across the care-continuum ............................................................... 35
5.2.4 Improving patient access to care and information ............................................ 36
5.2.5 Providing high quality information and business intelligence ......................... 37
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5.2.6 Flexible and innovative working .......................................................................... 39
5.2.7 Enhancing IT infrastructure .................................................................................. 42
5.2.8 Optimising existing technology ............................................................................ 43
5.2.9 Efficient and effective IM&T service ................................................................... 44
5.2.10 Improving clinical engagement ............................................................................ 44
6 ACTIONS AND IMPLEMENTATION PLAN .............................................................. 46
7 GOVERNANCE ........................................................................................................... 51
7.1 INFORMATION ASSURANCE FRAMEWORK - IM&T DEPARTMENT ................................ 51
7.2 CALDICOTT AND INFORMATION GOVERNANCE COMMITTEE - TERMS OF REFERENCE51
7.3 IM&T AND INFORMATION QUALITY ASSURANCE COMMITTEE - TERMS OF REFERENCE 51
7.4 CLINICAL STRATEGY GROUP – TERMS OF REFERENCE ............................................. 52
7.5 IM&T PROGRAMME / PROJECT FUNDING APPROVAL ................................................. 52
8 METHODOLOGIES AND BEST PRACTICE ............................................................. 53
8.1 PROGRAMME MANAGEMENT ......................................................................................... 53
8.2 PROJECT MANAGEMENT ................................................................................................ 53
8.3 SERVICE MANAGEMENT ................................................................................................. 53
8.4 SECURITY MANAGEMENT ............................................................................................... 53
9 BENEFITS ................................................................................................................... 55
10 RISKS .......................................................................................................................... 56
11 CONCLUSION ............................................................................................................ 59
12 GLOSSARY OF TERMS ............................................................................................ 60
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1 Executive Summary
The Trust’s previous Information Management and Technology (IM&T) strategy was presented to the Trust Board in June 2013. The strategy has been revised to reflect the priorities of the Trust under the leadership of its new Chief Executive and the planned ambitious clinical service transformation programme that is currently underway. It also reflects the opportunities presented to the Trust through healthcare integration activities with the North East Sector Consortium, the devolution of Greater Manchester health and social care, and advances in technology and innovation. The strategy emphasises the significant progress made against the previous strategy and describes the changes to the context and direction of approach.
IM&T supports and underpins the strategic direction of the Trust. It acts as a catalyst to enable more efficient processes and new and innovative ways of working. These will ultimately enhance the health of the North East Sector of Greater Manchester population and the working lives of Trust staff.
This document examines the Trust’s business and strategic drivers and identifies those objectives that will guide activities and prioritise investment in IM&T over the next three years. It describes the current IM&T capabilities and assesses progress against the previous strategy, identifying the key gaps that need to be addressed in order to achieve the strategic objectives.
The national strategic agenda focuses on engaging patients in their own care and providing them with information they need to make informed choices. There is currently a strong emphasis on preventative care and better integration of services across the care continuum and organisational boundaries. The NHS recognises the role information, technology and innovation can play to support quality and efficiency of services, improve patient access to care and combat the increasing national budgetary gap. This is highlighted in NHS England’s recently published report, the Five Year Forward View (FYFV).
The environment in which the Trust now exists requires it to operate as a competitive business and to take a lead in the local community. The specific needs of the local population will be addressed working alongside the North East Sector Consortium and within the context of the Greater Manchester devolution and the Healthier Together programme.
These forces drive The Pennine Acute Hospitals NHS Trust to improve efficiency and effectiveness of services at an ambitious but realistic rate. IM&T has a critical role to play in enabling the Trust to overcome these challenges through modernising business critical systems and transforming how information is shared with its partners and peers.
Since the last strategy was approved the IM&T Department has made significant progress in a number of areas. All clinical areas have wireless networking and a range of mobile devices have been deployed. Development and rollout of electronic prescribing (ePMA), order communications and results reporting (OCRR) and handover of care summaries are near full completion within the Trust inpatient areas. The Trust’s achievements have been recognised through NHS England’s
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Clinical Digital Maturity Index (CDMI), receiving a ranking of 24 out of 160 Trusts across the country, and improving significantly on its 2013 ranking of 77.
The Trust have recently approved the extension of the existing Electronic Patient Record (EPR) approach in light of the significant progress made, and on the basis of a cost benefit analysis of continuing the best of breed approach versus procuring a single vendor integrated EPR. In order to keep up with the accelerated pace of change the Department has set itself ambitious but realistic goals for the future.
The strategic vision for IM&T is:
Improving patient care through technology and innovation
The strategic mission for IM&T is:
To provide the Trust with IT systems, information and services to enable staff to deliver excellent and efficient patient care anytime, anywhere
The following IM&T strategic objectives have been developed to support the Trust’s transformation and quality agenda. The approach to each objective is explored in further detail.
1. Supporting the Trust’s transformation: create a robust and innovative IM&T foundation to underpin the Trust’s transformation of clinical services.
2. Digitising patient records and clinical workflows: extend the development and rollout of the Trust’s acute EPR and clinical portal with the aim of achieving a digitised patient record by 2018.
3. Integration across the care-continuum: lead development of a community wide, integrated patient record in collaboration with acute, primary care, community, mental health and social care partners to improve access to patient data.
4. Improving patient access to care and information: provide the structure and support to enhance patient’s access to their own records, to services and to safe healthcare.
5. Providing high quality information and business intelligence: deliver a high quality information service which supports the Trust’s clinical and business processes real-time, such as service line reporting and business intelligence dashboards.
6. Flexible and innovative working: improve productivity and access to care by leveraging technology and telecommunications.
7. Enhancing IT infrastructure: continue to update and improve the Trust’s infrastructure to form a robust foundation for future IM&T delivery.
8. Optimising existing technology: optimise and standardise use of existing IM&T software and devices to provide efficient clinical, corporate and back office systems.
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9. Efficient and effective IM&T service: review and strengthen the capacity and capabilities to improve the efficiency and effectiveness of the IT services provided to Trust personnel.
10. Improving clinical engagement: improve clinical engagement in Trust IM&T and transformation activities through strengthen clinical leadership to promote clinical innovation through the better utilisation of technology.
An action plan is set out in section six which outlines key developments over the next three years to deliver reliable and robust infrastructures, systems and processes.
In conclusion, this strategy aims to maximise the benefit from investment in IM&T by focusing on achieving the Trust’s strategic objectives and by supporting the goals of Greater Manchester in the most efficient, cost effective and collaborative way. It highlights the need to build on the solid capabilities already in place and the need to strengthen areas such as system optimisation, clinical engagement and service delivery.
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2 Introduction
The NHS environment is one of constant change driven by shifts in economic conditions, politics, society and technology. The ability for the NHS to prosper rests on how quickly it responds to these emerging market forces. Technology, in particular, advances at an increasingly rapid rate. The NHS must adequately plan for change as well as leverage such changes to its competitive advantage.
Advances in technology can improve access to healthcare information and our ability to predict, diagnose, treat and prevent illness. Individuals in today’s society are immersed in technology. Users have an expectation of immediate access to reliable information and systems, wherever and whenever they need it. This demand, by both staff and patients, is increasingly evident within healthcare.
In addition to these external forces, the NHS must respond to governing pressures which require it to provide the highest quality of care with increasing budgetary constraints. It is imperative that NHS organisations shift their focus to increasing quality of care and productivity gains through more streamlined and efficient services. These factors create an opportunity for IM&T departments to provide the most fitting technology to help their organisations meet these challenges.
To achieve this, NHS IM&T departments will need to create reliable and responsive services using affordable, dependable and up-to-date technology. At the same time they need to future proof implementations against evolving technology and ever changing landscapes. Systems need to provide information to support the organisation’s business needs including decision making, risk management and transformational activities.
Purpose of this document
The purpose of an IM&T Strategy is to help the organisation to achieve these end points by guiding them towards a coherent and integrated setting for delivering and managing technology services.
The Trust is committed to the effective use of informatics to support the delivery of excellent patient care, facilitate the work of our clinicians and deliver efficiency gains. This strategy sets out the roadmap to achieving these aims. It examines the Trust’s business and strategic drivers and derives relevant strategic objectives to guide the activities of the IM&T Department and prioritise investment in healthcare IT. It identifies the key gaps in the Department’s capability that will need to be addressed in order to achieve the vision. Finally, the strategy presents a pragmatic and achievable programme of work against which progress can be measured and the vision can be achieved.
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Process used for the development of this strategy
The process used for the development of this strategy is summarised in the diagram below:
Approvals
The document will be reviewed and approved by the Clinical IM&T Strategy Group, the Senior Management Team, the Finance Infrastructure and Business Development Committee and the Trust Board.
Determining the Strategic Environment
Analysing Stakeholder
Requirements
Future Vision for IM&T
Determining the Current IM&T Environment
IM&T Current Capability Statement
Strategic Gap
Strategic Choices
Actions and Implementation Planning, Prioritisation, Costing
Staffing Structures Standards Governance Policies
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3 Strategic Context
This section describes the context in which the Trust operates and identifies the key strategic drivers at a national and local level.
3.1 National Context
The national context for NHS organisations across the country is increasingly challenging. In October 2014, NHS England produced the NHS Five Year Forward View (FYFV) which aims to articulate why change is needed, what change might look like and how to achieve it. It indicates that the estimated £30 billion gap in NHS funding predicted to appear by 2020-21 could be closed completely if the health service receives additional funding to develop new, more efficient care models. The Five Year Forward View states that the biggest challenges for the NHS are:
1. Changes in patient health needs and personal preferences.
2. Changes in treatments, technology and care delivery and the need to provide
care that is genuinely co-ordinated around what people need and want.
3. Changes to funding/continued decline in funding growth.
The Five Year Forward View sets out a number of key themes that need to be addressed to overcome these challenges. The eight themes are captured and discussed below.
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1. Quality The events at Mid Staffordshire from 2008 onwards have led to an increased focus on quality, safety standards and governance within the NHS. The subsequent reports of Francis (2010, 2013), Keogh (2013), Cavendish (2013) and Berwick (2013) have all called for a change to a truly patient-focussed culture, greater transparency and more rigorous management of standards. The FYFV continues the focus on quality stating that NHS organisations must narrow the gap between the best and the worst whilst raising the bar for all. 2. Prevention Prevention is increasingly becoming the most important area of focus for healthcare providers. As populations are living longer with more chronic health conditions, communities must work towards reducing causes of preventable illness such as obesity and lifestyle risks. If organisations can successfully incentivise and support healthier behaviours then we can prevent ill health and increasing demands on healthcare. The FYFV focuses on targeted prevention, supporting a healthier workforce and working across healthcare partners to enable local, democratic leadership. 3. Patients and communities In 2012 The White Paper, Equity and Excellence: Liberating the NHS (2012) set out the Government’s vision of an NHS that puts patients and the public first, where “no decision about me, without me” is the norm. The FYFV builds on this stating that patients must have more access to their healthcare information and must have increased control over the care that is provided to them supporting them to manage their own health in a way that is suitable for them. However, the paper also expands on this stating that the wider community, including carers, third sector and general citizens, also play a vital role and must be engaged in new ways to support the challenges ahead and work together for healthier futures. 4. New models of care Over the next five years and beyond the NHS will increasingly need to flex its traditional care boundaries to support truly integrated, patient centred care. The FYFV takes a radical approach by defining its own view of what healthcare should look like over the next five years and introduces new organisational types/care models including;
Multi-specialty Community Providers
Primary and Acute Care Systems
The document also focuses on how smaller hospitals can remain viable, how specialised care can be provided into a wider array of providers, modern maternity services and enhanced healthcare in care homes. It has long been understood that in order to meet the rising demand on resources while actively achieving financial savings and high quality care, providers will need to come together to deliver truly integrated care but the focus on this as a solution is definitely intensifying with the FYFV.
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5. Leadership and workforce No change, let alone radical change, can be achieved without leadership and people to make the changes happen. However, change in the NHS will always be a constant and so greater support is needed to help mobilise leaders and workforces to work differently, develop the newly needed skills, values, behaviours and numbers to deliver the improvements required. The FYFV also states it will work to better align national leadership.
6. Efficiency and productivity In 2009, the NHS set out plans for providers and commissioners to prepare to operate in more austere times than many had experienced before. By 2015, the NHS needs to make savings of £20 billion with an additional £30 billion required by 2021. It has been estimated that funding growth will remain at 1.2% per annum, which will be half of what is needed to fund future services. With the Better Care Fund shifting a significant amount of NHS funding to Social care in 2015/16, the financial future of the NHS is increasingly challenging. Greater efficiency and productivity continues to be key to delivering the NHS vision for the future as demand increases and funding decreases. 7. Information and technology The FYFV focuses heavily on the importance of information and technology in achieving the required changes the NHS has to make. It talks of a national focus on key systems that will provide the ‘electronic glue’ to enable different parts of the NHS to work better together. During the summer of 2015 the National Information Board (NIB) will publish a set of ‘road maps’ to set out who will do what to transform digital care. Key elements will include:
comprehensive transparency of performance data
expanding set of NHS accredited health apps to support digital inclusion
fully interoperable electronic health records continuing the move towards
paperless
family doctor appointments and prescriptions online, everywhere
better audit data
increased focus on technology including smart phones
support to help build capacity and help those unwilling or unable to use
technology.
8. Health innovation Finally, the FYFV focuses on the need for health innovation in relation to research, personalised care, accelerated innovation in ways of delivering clinical care and the unexploited opportunity to combine different technology such as mobile apps and telemedicine. The National Information Board (NIB) proposes to make England a leading digital health economy with new resources to support research and maximise the benefits of new medicines and treatments. This would include genomic science to combat long-term conditions and tackling infectious diseases.
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Implementing the Five Year Forward View
The National Information Board (NIB) has subsequently published a framework outlining proposals to transform outcomes for patients and the wider population. The National Information Board plans to issue a set of road maps and standards which will provide a more detailed approach to transforming digital care. Key milestones include:
• from March 2015, all citizens will have online access to their GP records
• by 2017, 100,000 individual genomes will have been sequenced
• by 2018, clinicians in primary care, urgent and emergency care and other key
transitions of care contexts will be operating without the use of paper records
• by 2020, all care records will be digital real-time and interoperable.
The Health and Social Care Information Centre (HSCIC) have published a draft strategy for 2015-2020 which further emphasise these goals and outlines ways in which HSCIC will support organisations to achieve them.
NHS England’s Business Plan for 2015-2016, Building the NHS of the Five Year Forward View, demonstrates how information and technology will provide the foundations for improvement. Priorities for the next two years will include: harnessing the information revolution, and developing capability and infrastructure for transformational change.
In addition to this, the Health Secretary, Jeremy Hunt, has set out how the Government intends to implement the Five Year Forward View. During his statement to the House of Commons on 1 December, 2014, he announced four “pillars” of work:
• Pillar one: strong economy – £1.95 billion for frontline care was confirmed,
and the establishment announced of the Genomics England Clinical
Interpretation Partnership to stimulate development of diagnostics, treatments
and therapies for rarer diseases and cancers.
• Pillar two: new models of care – to address demographic changes and the
need for greater emphasis on prevention and improved out of hospital care.
• Pillar three: innovation and efficiency – to access the additional funding
hospitals will need to show plans about how they will be more efficient and
sustainable and deliver their commitment to a paperless NHS by 2018.
• Pillar four: culture – the Government will announce work culture initiatives
such as new measures to improve safety training for clinical staff, and a
campaign to reduce sepsis.
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3.2 Social Context
Technology is dramatically changing how we run our day-to-day lives. Mobile and social technology is becoming more and more accessible to all and, as a result, is revolutionising how we interact with businesses and services.
The NHS is already seeing how social technology can positively impact the lives of staff and customers, and is beginning to understand how IM&T could support the challenges the NHS faces. Key to its success will be ease of use for staff and patients alike.
In 2013, the King’s Fund published their view of the key social trends that will affect how health and social care is delivered in the next 20 years. The key messages from an information technology perspective are as follows:
THE KINGS FUND: FUTURE OF HEALTH AND SOCIAL CARE 2013-2033
Our use of the internet continues to grow
Four out of five people in the UK can currently access the internet at home
and three out of ten use a smart phone to do so. It is expected that by
2023, everyone will have access to the internet.
Computing power and data is increasing exponentially
The increase in computing power, new devices, sensors and screens
combined with improving access to ever-expanding quantities of data will
support the shift to what is known as ‘ubiquitous computing’. In health and
social care there will be new opportunities to capture, relay and interpret vital
signs and other health information, both in the home and in other care
settings.
Social media will grow rapidly in importance
The impact of social media on health and social care can be expected to
grow, particularly alongside increased public availability of information.
Patients and doctors are already using social media such as Twitter and
Facebook to post medical problems and seek help finding diagnoses.
The rise of the app
Apps have a wide array of uses in health and social care, including providing
information about conditions and supporting self-diagnosis.
Changing the relationships between professionals and service users
Information technology is changing the way in which professionals manage
and make use of their knowledge. This is likely to drive changes in the
relationship between professionals, and between professionals and service
users.
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3.3 Local Context
3.3.1 The Pennine Acute Hospitals NHS Trust
The Pennine Acute Hospitals NHS Trust serves the communities of North Manchester, Bury, Rochdale and Oldham, along with the surrounding towns and villages. This area is collectively known as the North-East Sector of Greater Manchester and has a population of around 820,000. It is a large Trust with a total operating budget of £560m. The main commissioners are NHS Bury CCG, NHS Heywood, Middleton and Rochdale CCG, NHS Oldham CCG and NHS Manchester CCG.
NATIONAL CONTEXT – IMPLICATIONS FOR IM&T
IM&T that is flexible and agile to adapt, change and integrate services.
Systems that provide the ability to capture, monitor and audit clinical information to support safe, high quality care.
IM&T that is smart, real-time and accessible to support right care at the right time in the right location.
Systems and information that support people, processes, timely communication and learning.
Digital records that provide direct access to data by staff, patients and public, and communicated across organisational boundaries such as primary care and social services.
A strategic approach to IM&T that provides rigorous structure and governance to the required change as well as a culture of innovation.
Information that is complete, accurate and transparent to enable the public to become involved in decisions about how services are provided.
IM&T that allows organisations to identify, diagnose, treat, manage and prevent illness within their community.
Strategies that enable patients to take control of their information and make informed choices about their care and treatment options, including research and clinical trials.
IM&T infrastructures which can enable innovative healthcare models and promote a culture of innovation amongst patients and clinicians.
Innovative and effective informatics to support the Trust in making quality and productivity gains in line with the national agendas such as the Five Year Forward View.
Interoperability and healthcare standards to enable integration with local and national systems.
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The Trust provides a range of elective, emergency, district general services and specialist services operating within the community and from five sites.
Fairfield General Hospital
North Manchester General Hospital
Royal Oldham Hospital
Rochdale Infirmary
Floyd Unit
The values that underpin the Trust’s mission statement determine how the Trust works and the promises made to patients, their families, the public and staff. The Trust’s values are:
Quality Driven
Responsible
Compassionate
The Trust’s corporate priorities for 2015/16 align to its mission:
1. To provide high quality, evidence based, safe services delivered in a personal
and compassionate way
2. To be a financially and clinically sustainable organisation
3. To modernise, transform and integrate services across our sites
4. To improve productivity and reduce variation
5. To engage and support patients, carers, volunteers, staff, public and
communities in our work
6. To drive up quality and performance, reaching all our targets
7. To develop and embed leadership and personal responsibility across the
Trust
8. To create an environment so staff choose to work with us, sickness absence
is reduced and morale increased
9. To be an influential organisation working in partnership with others across the
health and social care system to improve the health of the population
10. To progress Foundation Trust status.
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3.3.2 Greater Manchester Devolution Agreement
The recent devolution agreement between the government and Greater Manchester (“Devo Manc”) emphasises the urgency of reform that is required to meet budgetary, health and social pressures as outlined in the Five Year Forward View.
As a result of the agreement, a Memorandum of Understanding (MoU) has been drafted between all local authority members of the Association of Greater Manchester Authorities (AGMA), all Greater Manchester CCGs and NHS England.
The purpose of the MoU is to ensure the “greatest and fastest possible improvement to the health and wellbeing of the 2.8 million citizens of Greater Manchester (GM)”. It sets out a more integrated approach to utilising the £6bn of health and care resources allocated for 2015/16. It also highlights the transformation changes and collaborative working that will be required to deliver services across the city.
The MoU recognises that integrated health and social care services; along with a digitally-integrated health economy is vital to improving efficiencies and health of the GM population.
GREATER MANCHESTER HEALTH AND SOCIAL CARE DEVOLUTION MOU
Shared objectives:
To improve the health and wellbeing of all of the residents of Greater
Manchester (GM) from early age to the elderly, recognising that this will
only be achieved with a focus on prevention of ill health and the promotion
of wellbeing. We want to move from having some of the worst health
outcomes to having some of the best.
To close the health inequalities gap within GM and between GM and the
rest of the UK faster.
To deliver effective integrated health and social care across GM.
To continue to redress the balance of care to move it closer to home
where possible.
To strengthen the focus on wellbeing, including greater focus on
prevention and public health.
To contribute to growth and to connect people to growth, e.g. supporting
employment and early years’ services.
To forge a partnership between the NHS, social care, universities and
science and knowledge industries for the benefit of the population.
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3.3.3 North East Sector
More than ever, there is an emphasis placed on integrating care across the Trust’s local healthcare community. To this end the North East Sector Health and Social Care Leadership Group has been established and, in support of this Group, the Trust has set up an IM&T sub-group with local NHS and non-NHS representatives to address the IT requirements of this programme. The stakeholder consortium comprises Pennine Acute, Pennine Care (Community and Mental Health), CCGs, Local Authorities and out-of-hours GP services.
The Consortium is in the process of seeking funding and actively developing a final business case to support an integrated care portal. The portal is a critical piece in the integration of services across the healthcare community. The first implementation phase will provide a view only summary of a patient’s record which incorporates primary care, acute, mental health and social care information to authorised users. The second implementation phase will provide write back and alerts to the authorised users.
3.3.4 Healthier Together
Healthier Together is a review of health and care in Greater Manchester. The Association of Greater Manchester Authorities (AGMA) Executive has challenged all partners to work together to deliver new models of integrated care. This includes primary, community and hospital services and the impact on social care. It is led by NHS Greater Manchester on behalf of the area’s twelve Clinical Commissioning Groups (CCGs).
The Healthier Together outline model of care aims to develop integrated care services that will help the NHS and other care providers provide quality services that are safe, accessible and sustainable. It will provide enhanced levels of specialist, senior medical and nursing staffing creating ‘champions’ across organisations.
A number of options have been proposed all based on the need to significantly improve primary care and community based services with a particular emphasis on the delivery of integrated services and the innovative use of technology. The Royal Oldham Hospital is proposed as one of the four or five key specialist hospitals in the region. The other Trust sites will continue to operate as local hospitals and retain the current emergency department profile. This plan will help shape future priorities of the IM&T deployment across the Trust.
At the time of writing this report the Healthier Together programme had completed its public consultation phase. Healthier Together has welcomed the Government’s recently proposed new partnership for health and social care. It clearly aligns with the Healthier Together proposals, as they share the same principles and goals.
Integrated, efficient IM&T services are required to enable ‘joined up’ care across Greater Manchester. The Trust’s IM&T capabilities will be key to delivering successful outcomes from the programme.
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3.3.5 Living Longer, Living Better
The ‘Living Longer, Living Better’ initiative for integrated healthcare across Greater Manchester is the basis for a collaborative working platform where patients as individuals are placed at the centre of care. The programme is an integrated care blueprint for Manchester led by Manchester City Council. Integrated care has been led by the three health and social care systems in North, Central and South Manchester. The joint programmes of work cross the boundaries of the CCGs, acute and community sector, primary care, mental health, social care and other agencies. The initiative focuses on service delivery and the integration of care to provide holistic care pathways that encompass diagnostics, treatment and therapeutic aspects of care.
With the aspirations of the ‘Living Longer, Living Better’ initiative it is important that each participating Trust maintains a high level of digital maturity with an emphasis on integration, interoperability and mobility to achieve their goals.
3.3.6 Greater Manchester Academic Health Science Network
The Pennine Acute Hospitals NHS Trust is one of 16 NHS provider members of the Greater Manchester Academic Health Science Network (AHSN). The AHSN covers Greater Manchester, East Lancashire and East Cheshire and is a collaborative network of NHS organisations, higher education institutes and industry. It aims to deliver a change in health outcomes, to integrate the health ecosystem, and leverage health spending and expertise for the benefit of local community through innovative health initiatives.
3.3.7 CQUINs
The Trust’s CQUINs for 2015/16 will reflect the Trust, Greater Manchester (GM) and National Information Board (NIB) goals for transformative information and technology. A GM CQUIN has been proposed that will run alongside local arrangements, focussing on the aims of the Five Year Forward View and GM Strategic Plans. A key CQUIN for GM providers will be provision of a plan to achieve the NIB’s 2020 Vision.
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LOCAL CONTEXT – IMPLICATIONS FOR IM&T
Systems and solutions that enable real time data capture, feedback and reporting to drive accurate business decisions.
An infrastructure that enables integration and sharing of data between departments, other Trusts and community healthcare providers and social care including opportunities for collaboration on population health and preventative care.
Systems and connectivity to provide remote working across acute and community locations.
Supporting the achievement of Foundation Trust status.
Actively leading local collaborations such as the North East Sector Health and Social Leadership Group and establishing initiatives in support of its agenda to integrate care across the healthcare community.
Making contributions to the Trust Cost Improvement Plan.
Providing reliable and flexible IM&T services and infrastructure that are responsive to partnership requirements.
Assisting the business in its financial recovery plan through the optimisation of systems and solutions leading to full recognition of both qualitative and financial benefits.
Providing IT solutions and support that can be marketed to the Trust’s partners providing the business with revenue potential.
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3.4 Summary of the Strategic Environment
The strategic drivers were analysed using a PESTLE analysis, looking at the political, economic, social, technological, legal and environmental factors in the strategic environment. The results are shown below:
Political
Political complexity re: multiple authorities / MPs/ unitary and non-unitary authorities make it difficult to get consensus
Differing priorities at local government level
Political and hospital boundaries are not co-terminus
General election May 2015 – health policy may change again
Political desire to foster more private competition
Global political instability – impact on financial markets/costs
Public health remit transferring to LAs
National policy re clinical commissioning
Impact of health bill
Influence of a range of campaign groups
Economic
Potential introduction of Personal health budgets
Private sector investment in NHS
Public sector spending cuts, CCG finances/ decommissioning intentions
Costs increasing (power, utilities, drugs, NHS inflation, etc.)
Imposition of CIPS
Changes to tariff
Changes in land values
Changes to public sector pensions
Deprivation in local area
Social
Deprivation and impact on health
Ageing/growing population
Ethnic diversity, immigration and impact on specific needs
Health inequalities both nationally and locally
Desire for more community based services
Strong local identities
Decline of nuclear families in some areas
Access to transport both public and private
Public’s changing expectations of what a healthcare provider should do
Increasing consumerist approach to health
Wider view of the role of a hospital as a part of the community
Role of media on lookout for “news”
Employment patterns / impact of unemployment on health
Technological
Influence of social networking
Information available on the internet
Patient opinion/rating sites
Use of social media to mobilise opinion/ objections
New treatments / drugs / techniques
Growth in home monitoring
Increasing professionalism of roles
Increasing subspecialisation
Technology creep : the expectation that healthcare should use technology because it is available
Legal
Increasing litigious society
Cost of settlements
Increasing levels of regulation and scrutiny
The need to be seen to act immediately in event of a “crisis”
Right to die / euthanasia debate
Consent / mental capacity debate
Francis report
European working time directive (EWTD)
Environmental
Carbon footprint
Local transport links
Local transport policies
Town planning : where will new estates be built
Global warming : impact on energy consumption
Scarcity of resources pushing up prices
Changing weather patterns – colder winters? Hotter summers? Floods? Drought? Impact of these on health
Source: Business Development Team @ PAHNT
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3.5 Stakeholder Analysis
Stakeholder engagement interviews and workshops were held with the following Trust groups and individuals during the development of the strategy. These themes and ideas have been incorporated into the current document and revisited with particular groups of stakeholders.
the patient forum
medical staff
nursing staff
community and allied health professionals (AHPs)
GPs
corporate teams
providers of core solutions
commissioners
senior management
IM&T staff.
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4 Current IM&T Environment
This section describes progress made to date against the previous IM&T strategy and describes the current status of IM&T capabilities.
4.1 Progress against previous IM&T strategy
The IM&T Department has made good progress against the previous strategy. The installation of resilient and standardised infrastructure within the Data Centre has improved systems availability.
The single sign on virtualised environment will be fully rolled out to clinical areas by August 2015, significantly improving and accelerating access to key clinical systems.
Rollout of electronic prescribing (ePMA), order communications and results reporting (OCRR) and handover of care communications (formerly referred to as discharge summaries) are complete within the Trust inpatient areas. Outpatient requesting will follow before the end of 2015. IM&T are currently engaging with clinicians and pharmacy to prepare for rollout of emergency prescribing.
There is a keen focus on integrated care solutions across the Trust, community and wider sector partnerships. Progress has been made in a number of key areas which are highlighted below.
4.2 Status of current IM&T infrastructure and services provision
Infrastructure
The Trust has developed its infrastructure significantly over the past three years. Wireless networking is now in place in all clinical areas and suitable mobile technology is made available on the wards including tablets and laptops-on-wheels. Further work to understand what the right tools are for each environment is continuing.
Virtual desktops have recently been rolled out to support flexible ways of working. Minimising the need to travel is a key objective of this initiative that is yet to be fully achieved.
Data is one of the most valuable assets of the Trust. To facilitate the sharing of data, the IM&T Department has consolidated its storage resources centrally using Storage Area Network technology. This allows for an efficient use of storage so servers can access the same pool to remove waste by unused storage and significantly reduce operating costs. To further secure the integrity of Trust data and improve its resilience, 150 of approximately 340 servers have now been moved to a new facility with minimum disruption to clinical services. The remainder of the migration will be complete by July 2015. As well as improving the Trust’s ‘green’ footprint, the programme has secured the capacity and security necessary to support the Trust’s strategic direction.
The Trust has invested in a number of other infrastructure initiatives which support the need for flexible and scalable technology, such as upgrading the remote area network thus improving accessibility for clinicians working away from the Trust.
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Increased use of wireless technology infrastructure is being deployed to support the Electronic Document and Record Management System (EDRMS) and other solutions. These initiatives have improved resilience, performance and availability of operational systems within the Trust, and will also help to deliver the medium to longer term strategic IM&T objectives.
Two varieties of the Connect Anywhere solution have been developed and are being deployed to acute, community and non-clinical locations. Connect Anywhere (plus) is a virtual desktop solution that enables a user to access their unique desktop within 15 seconds at any location. The solution includes single sign on and provides availability of applications and information at any device. Connect Anywhere (standard) is a non-virtual desktop solution that allows access to the same services with a significantly faster log-on speed than previously provided.
The Connect Anywhere solution is managed in a highly centralised manner with a thin app deployment for all services. It allows changes and new services to be provisioned rapidly to meet user needs at all times, at lower operational cost and high reliability and performance.
The solution can be accessed regardless of location, for example on the ward, in community settings or the back office. This ensures services can be accessed by users at all times allowing patient care to be provided at any location. Connect Anywhere allows services to be accessed on a mobile basis using both online and offline clients, providing portable and accessible information and services.
Service management
The current hardware estate of the IM&T Department has grown considerably and developed as technology has been deployed throughout the Trust. As the Trust has grown and harnessed the benefits of technology, the reliance on a robust support function has also increased. This is an area that requires significant focus. Work has begun to reconfigure and streamline processes and procedures within the IT Helpdesk function with an emphasis on automation and self-service. Computer password self-service will be fully implemented to give end users responsibility for managing their computer accounts, along with automated workflows for computer account and system access management, creating time efficiencies within the Helpdesk.
An IT support portal has been rejuvenated enabling the organisation to self-serve incidents and requests and review and update those requests throughout their lifecycle. A major service improvement program is currently underway, with the primary aim of improving response times and ensuring that the majority of incidents are fixed first time. On an ongoing basis this will include delivery of a new ITIL orientated helpdesk tool. This tool will provide workflow automation and management for non-clinical services outside of IM&T. An example of this is the recent improvements realised in portering services.
In 2014 the Estate Help Desk management was reassigned to IM&T. During 2015 work will be undertaken to provide a single help desk function for IM&T and Estates to ensure that a more efficient service is provided, particularly at peak times.
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The Trust will continue to identify ways to support service management staff by growing capacity and capability.
Integration
The Trust’s Integration Engine (TIE) is a critical system that provides the interoperability for sharing information across systems. This sharing of information extends beyond the Trust’s boundaries into areas such as GP practices, clinical portals and remote-hosted systems such as Radiology.
The Ensemble integration tool was procured and implemented as the new TIE, and all interfaces residing on the legacy TIE were successfully migrated by 30 March 2014, as planned.
Information provision
InView is the Trust’s new management information system that provides a single source of clinical, operational, financial and management information. In addition to replacing the existing data content, InView includes planned support for further datasets such as pathology, radiology, theatre, maternity and pharmacy. It is the Trust’s chosen solution to support all its information provision needs for the term of this strategy.
The Trust has been using the Qlikview dashboard development software for the last two years to support the reporting of Trust financial, activity and performance information. Use of dashboards has been extended across all Trust services. Dashboards developed include:
Consultant Performance
Speciality Performance
Trust-wide Activity Monitoring
Surgical Division Performance
Medical Division Performance
Women and Children Division Performance
Diagnostics Division Performance
Service Line Reporting (SLR)
Patient Safety
Safety Thermometer
Unscheduled Care (A&E)
Cancer Two Week Waits
Clinical Letters / Automated Letter System (inc Discharge Summaries)
Clinical Coding
Dashboard Usage Report
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Evolve (Record Scanning)
ePMA (Electronic Prescribing)
G2 (Clinical Dictations)
Information Governance
Nursing and Midwifery
Paediatric Pathway
Trauma Tracker
Various Finance Dashboards.
Communications and web services
Comprehensive condition-specific information is available to patients via the Trust website and the Trust is a certified member of The Information Standard.
The Trust-hosted intranet and public facing website had been developed in-house over time and had become very dated. A business case was approved for the replacement of the content management system (CMS) to provide a new and modern Intranet, Internet and Extranet (allows controlled access for non-Trust users such as GPs, Local Councils, etc.). All supporting IM&T infrastructure and software for this project has been delivered. The first phase of the project is complete and the Trust launched its new public-facing website in 2014. The second phase to replace the intranet is currently in development being managed by the Trust Communications team.
The Trust currently has a social media presence on Twitter, a social networking site. It is used to share news, events and information about the Trust. The Trust uses YouTube as a platform for hosting short promotional videos produced by the Trust. This is an effective method of sharing video content internally and externally which the Trust plans to invest in and expand.
The Trust is currently utilising crowdsourcing techniques to obtain contributions from staff for needed services, ideas and content.
4.3 Current state of clinical systems
Good progress has been made across a number of clinical areas, greatly improving the local environment.
Patient Administration System (PAS)
PAS infrastructure was upgraded in 2011 to provide a more resilient foundation. PatientCentre was rolled out in inpatient areas prior to the EPR clinical system implementations to improve the quality and timeliness of admission, discharge and transfer information. Enhanced bed management functionality and reporting provides the Trust with the ability to identify occupied or available beds.
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PatientCentre and Clinicom undergo regular upgrades and were last upgraded in August 2014 to support CDS 6.2.
Options to replace PAS have been appraised. However, since the options appraisal there has been a commitment from the PAS supplier to support PatientCentre and Clinicom for the next nine years. This provides the Trust with a tangible option going forward and allows the Trust to focus on clinical systems as priority.
Unified communications
Digital dictation is now fully rolled out across the Trust enabling restructuring of administrative support services. A pilot of speech recognition has recently begun. The Trust will be developing a strategy to contract with a single VoIP telecommunication supplier.
Electronic Patient Record (EPR) programme
Accelerated by a Technology Fund Award, Phase 1 of the Electronic Prescribing rollout (Adult Medicine and Surgical Inpatients, Theatres and Critical Care) was completed in Q2 2014. A fully integrated handover of care communications has been rolled out alongside electronic prescribing. Work has been completed to refine handover of care workflows and templates to enable the Trust to attain CQUIN targets.
The rollout to complex prescribing areas was completed in February 2015 when Paediatrics went live with ePMA. 99% of Trust inpatients now have an electronic prescription. Neonatal units at Royal Oldham Hospital and North Manchester do not yet prescribe electronically. Deployment has been deferred with clinical agreement until 3 decimal place weight prescribing is available. Revised milestones have been negotiated and completed with NHS England in view of this. An upgrade which includes infusions and iPad support is planned in 2015.
The next release of Medchart, which goes live early summer 2015, allows Phase 3, a pilot of A&E prescribing, to be undertaken at Royal Oldham. If the pilot is successful clinically and operationally, a business cases for Trust wide rollout in A&E will be raised. Phase 4, a pilot in Outpatients, has been deferred until 2016, due to supplier roadmap delays.
There are a number of other specialist clinical systems in constant use across the Trust’s wards and departments, some standalone, causing duplication of effort and frustration to Clinicians. IM&T has started to make some in-roads to resolve this by integrating the electronic prescribing system with Healthviews, along with the automated letters look up system, PACS and the electronic handover of care communications, which itself includes integrated clinical data from a variety of systems. The Trust is now the leading sender of electronic handover of care communications across Greater Manchester, reaching 152 practices in the region. The Evolve electronic casenote can be launched under Healthviews or as a standalone module. Healthviews invocation will be replaced by the Trust’s clinical portal due to be deployed in 2015/2016 – the key building block in the Trust’s EPR strategy.
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A programme of work to start replacing paper began in 2013, as the Ophthalmology Outpatient Clinic at The Royal Oldham Hospital went digital. This was followed by the introduction of the electronic dementia assessment form. The programme has not been without its problems, as it was the first of type for the Trust. A small number of tactical electronic form solutions have been developed in Healthviews. Electronic forms will be introduced in Evolve from Q2 2015/16 to replace paper Trust wide. The approach, approved by the Forms Steering Group, is to focus on generic forms and strategic pipeline developments initially. Initial priorities are:
Generic Nursing Forms (the main assessment, mandatory risk assessments
and generic care plan).
Outpatient and Elective Documents to reduce forward scanning and clinic
preparation (paediatric growth charts, clinical history sheets, clinic outcome
forms and questionnaires, elective booking and pre-operative assessments).
Strategic pipeline focusing on 15/16 CQUINS, Doctor’s Handover and
Clerking, End of Life and Social Work Referrals.
The rollout of radiology and pathology orders and results is now complete in inpatient areas and theatres. Rollout to outpatients and A&E is due to complete before April 2016 facilitated by the deployment of a major software release in May 2015, which adds blood transfusion results, microbiology and cellular pathology ordering.
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EPR Programme Roadmap
Other clinical systems
A business critical theatre system was procured to help drive improvements in theatre utilisation and improve productivity and efficiency within the Surgical Division. The system is now live in all theatres across all four sites. Risks associated with the support and maintenance of the previous system have also been mitigated. Reports to assist with performance and efficiency are being developed and phase two to implement stock-taking is being planned.
The IM&T Department has been successful in having a number of business cases approved since the last strategy was published. These will enhance the clinical systems estate and include major upgrades of the pharmacy system, A&E system, maternity modules and a diabetes system. In addition to this, a number of other specialist clinical systems have been regularly upgraded.
The challenge for the IM&T Department is now to build on what has already been achieved by ensuring future systems meet the changing needs of the organisation. They need to be timely, agile in their development, flexible in their capabilities, and scalable as the Trust moves towards supporting integrated services across the North East Sector and Greater Manchester.
4.4 IM&T staffing
Capability of the department is reviewed on a regular basis to ensure it is responsive and adaptive to business requirements and can support the IM&T strategy. The last review took place early 2015.
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4.5 Digital record maturity and adoption models
There are two key healthcare digital maturity or adoption models currently in use within the UK. The first, the Clinical Digital Maturity Index (CDMI) was developed by EHI Intelligence in partnership with NHS England specifically for NHS Trusts. The second, HIMSS Electronic Medical Record Adoption Model (EMRAM) model is used widely across the globe but has only recently been used by UK organisations.
CDMI is a benchmarking tool which aims to provide NHS Trusts with a better understanding of how investing in, and using information technology can provide benefits. The index is based on a nine-level electronic patient record rating. Trusts are divided into quartiles to make an effective benchmarking tool against which to gauge progress with the Government’s objectives for paper-free digital patient records. At their most recent CDMI review in 2014 the Trust achieved a strong ranking of 24 out of 160 acute NHS Trusts, placing them in the first quartile and showing significant progress since 2013 when they were ranked 77/160. Data has recently been submitted to obtain the current status.
HIMSS Analytics Europe has developed a European EMR Adoption Model (EMRAM) based on the model established across the U.S. and Canada. It aims to identify the levels of electronic medical record (EMR) capabilities ranging from basic departmental systems through to a paperless EMR environment. The methodology and algorithms automatically score hospitals based on their IT enabled clinical transformation status.
During the course of this strategy the Trust will investigate the use of HIMMS to benchmark its progress in achieving digital adoption and transformation, as well as using it to assist in strategic decision making.
Summary of actions arising
In summary, IM&T needs to perform the follow actions:
Complete implementation of EPR projects such as ePMA, clinical portal, electronic case notes and electronic forms.
Introduce new IT solutions when business cases have been approved.
Improve IT support focussing on responsiveness and resolving incidents first time.
Embedding a culture of self-service and self-help within the organisation by the automation of processes, systems and implementation of workflow.
Continue to refresh and improve client services to achieve best practice.
Improve the provision of information, data quality, service line reporting and BI dashboards.
Undertake options appraisals for proposed solutions and infrastructure.
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5 Vision and Strategic Objectives
This section aims to describe the vision for IM&T across the Trust, and to identify the key strategic objectives for the IM&T Department to achieve their vision.
5.1 Vision and Mission
The strategic vision for IM&T is:
Improving patient care through technology and innovation
The strategic mission for IM&T is:
To provide the Trust with IT systems, information and services to enable staff to deliver excellent and efficient patient care anytime, anywhere
5.2 IM&T Strategic Objectives
The following set of objectives for IM&T support the Trust’s transformation agenda. The primary aspects of this strategy which set it apart from previous strategies are its focus on integrated services across the care community and patient engagement.
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5.2.1 Supporting the Trust’s transformation
Fundamental to this IM&T Strategy is the need to provide the infrastructure, information and technology to underpin the Trust’s ambitious transformation plans. Specifically, IM&T will support the following areas of work from the Trust’s transformation agenda:
Transformation of services
IM&T will provide robust, flexible and adaptable infrastructure and devices that supports users moving across sites and locations of care. The implementation of
IM&T STRATEGIC OBJECTIVES 2015-18
1. Supporting the Trust’s transformation: create a robust and innovative IM&T foundation to underpin the Trust’s transformation of clinical services.
2. Digitising patient records and clinical workflows: extend the development and rollout of the Trust’s acute EPR and clinical portal with the aim of achieving a digitised patient record by 2018.
3. Integration across the care-continuum: lead development of a community wide, integrated patient record in collaboration with acute, primary care, community, mental health and social care partners to improve access to patient data.
4. Improving patient access to care and information: provide the structure and support to enhance patient’s access to their own records, to services and to safe healthcare.
5. Providing high quality information and business intelligence: deliver a high quality information service which supports the Trust’s clinical and business processes real-time, such as service line reporting and business intelligence dashboards.
6. Flexible and innovative working: improve productivity and access to care by leveraging technology and telecommunications.
7. Enhancing IT infrastructure: continue to update and improve the Trust’s infrastructure to form a robust foundation for future IM&T delivery.
8. Optimising existing technology: optimise and standardise use of existing IM&T software and devices to provide efficient clinical, corporate and back office systems.
9. Efficient and effective IM&T service: review and strengthen the capacity and capabilities to improve the efficiency and effectiveness of the IT services provided to Trust personnel.
10. Improving clinical engagement: improve clinical engagement in Trust IM&T and transformation activities through strengthen clinical leadership to promote clinical innovation through the better utilisation of technology.
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virtual desktops and mobile devices means that clinicians will be able to access information and provide care regardless of location.
The Business Intelligence team will provide data for service line reporting and business intelligence tools that will enable the Trust to monitor performance and measure benefits of service transformation.
Partnerships The integrated care platform will improve patient pathways across Greater Manchester. It will facilitate the evolving delivery models such as shared care, Devo Manc and Healthier Together initiatives. As part of this Strategy the IM&T Department will initiate approaches to support the anticipated health and social care integration within Greater Manchester.
People
The IM&T Department will help the Trust strengthen relationships with staff through optimising technology such as virtual desktops, remote working and e-rostering to improve the working lives of staff.
Premises and facilities
Technology and infrastructure will provide a foundation for the Trust’s substantial capital investment in clinical services over the next four to five years.
Quality, governance and performance
IM&T will continue to contribute to improving quality of care, and clinical transformation projects by digitising patient records and clinical processes to improve quality and accessibility of data.
Trust management and executives will be supported in their transformation goals through the provision of Integrated Performance Dashboards and Service Line Reporting. Information will assure performance on targets and continuing compliance with external bodies such as CQC, Monitor and the TDA.
Finance and systems
The revision of this IM&T strategy is integral to the transformation of the Trust’s systems. How this is achieved is outlined in the strategic objectives below.
5.2.2 Digitising patient records and clinical workflows
EPR
Over the next three years the Trust will continue to build upon the capabilities and momentum within its existing EPR programme. This progress is reflected in the Trust’s CDMI rating which shows substantial progress in a shortened timeframe when compared to other NHS Trusts nationwide and against its own baseline data.
The Trust has decided to continue with the existing best of breed approach for extending the functional scope and rollout acute electronic patient records. An options paper was presented to the Clinical IM&T Strategy Group, the Senior Management Team and the Trust Board providing a cost benefit analysis of continuing the best of breed approach versus procuring a single vendor integrated
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EPR. The risks and benefits of each approach were highlighted and it was agreed that continuing along the current trajectory is the most appropriate approach at this juncture. EPR options will be reappraised at the end of year three of this strategy.
Over the next three years the IM&T Department plans to extend existing acute EPR functionally to additional roles such as nurses, AHPs and community healthcare workers. Other priorities for the next three years include:
Complete rollout of the Evolve casenote solution.
Accelerated replacement of paper with electronic workflow and workflow in
Evolve.
Configuration of a Trust-wide, clinical portal to further enhance the
experience for patients and clinicians.
Procurement of eObservations and patient flow solution to better alert its staff
to change in patient conditions.
Initiation of an Electronic Referral Management Solution.
Community systems to support the goal of the new Community Division.
Improved integration between the EPR and Symphony.
Rollout of order communication and result reporting in Outpatients and
Emergency.
Rollout of ePMA in emergency departments.
Initiate replacement of Healthviews with an alternative handover of care
communication document and ordering solution due to sun setting of the
solutions.
Community Services System
The Trust provides an increasing number of services delivered in a community setting, including domiciliary visits. Current systems are largely paper-based or managed using disparate databases. To support the aims of the new Division of Integrated and Community Services, a common EPR and care activity management system is required, which will provide flexible remote and mobile working
Evolve casenotes
The rollout of the Evolve casenotes is proceeding to plan at a pace and completes in autumn 2015. This is a significant milestone on the Trust’s EPR programme and is a key enabler for the Trust achieving a paper-light status, and being able to achieve its clinical service transformation plans. The Evolve eforms toolkit will be used to develop electronic forms and workflow to replace paper Trust-wide. Paper replacement is expected to start with generic nursing assessment documents and outpatient and elective forms which reduce the forward scanning bills.
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functionality, and will integrate with other Trust systems for information sharing and reporting.
The system will ensure that community nursing staff are able to work more efficiently and effectively by having direct access to up-to-date patient information at point of care; avoid duplication of effort between recording information in both paper and electronic systems which will also improve data quality; reduce time spent travelling which in turn will provide opportunities for increased patient contact.
Many community services are delivered under contract to the area CCG. A common system will enable service performance statistical reporting and activity returns to be generated more efficiently and accurately.
In the longer term, deployment of an integrated Community Services System will also support the achievement of the national objective to allow patients greater access to their care record.
Requirements analysis and options appraisal of suitable systems is currently underway with the intention to go to procurement by mid-2015.
eReferral Management
A key component of digitising clinical and administrative workflows will be implementation of an electronic referral system. The Trust will redesign their outpatient referral process to improve quality and patient care and implement a fully electronic referral system as part of a wider strategy to become paper-light.
The goals of the implementation are to improve referral processing times, relieve the pressure of referral to treatment targets and improve utilisation off outpatient services. Through streamlining and standardising referral processes the Trust aim to decrease administrative effort, improve patient and GP experience and reduce cancellations of appointments. The Trust will benefit from improved reporting, tracking and auditability of referrals as a by-product of digitising the system.
The eReferral system will capture referrals through a variety of means including scanning, faxing, electronic transfer and Choose and Book. It will build on existing
Clinical portal
Intersystems have been approved as preferred supplier of the Clinical Portal. The business case is expected to be approved in May 2015 and a pilot deployment to at least one staff group will take place in 2015/16. The portal will be used by clinicians and other health professionals to consolidate vital information from the 148 clinical information systems currently in use within the Trust, with a single sign-on. It will allow them to record patient information pertinent to the care setting used and has built in alerting capabilities. The portal will improve efficiency, facilitate sharing of information and give users rapid access to patient information with the aim of improving productivity and quality of care. It will also provide the flexibility to evolve with the Trust’s needs and enable the Trust to transition to an integrated EPR over time.
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hub and electronic document transfers to integrate with local GP practices within the area and beyond.
eObservation and early warning system
Inpatients will be monitored through a combination of electronic documentation of vital signs and early warning decision support based on national guidance and criteria. Staff will be alerted real-time, either on-site or remotely through mobile devices. Patients at risk of infection, or deteriorating conditions will be managed earlier and more effectively, leading to more efficient use of high dependency resources and improved patient outcomes.
Standards
As part of this strategy the IM&T Department will be reviewing the necessary regulatory and interoperability standards for achieving their vision of a digitised environment. This will include GS1 and interoperability standards outlined within NIB and HSCIC roadmaps. Where needed these will be included in the action plan and the Trust will work with suppliers to ensure standards are met within published timeframes.
5.2.3 Integration across the care-continuum
Achieving a single patient record across their entire health and care community is a key goal for the Trust. This objective aims to improve coordination of care, prevent illness and manage care across all care settings including the home and community. A consortium of ten local organisations led by The Pennine Acute Hospitals NHS Trust has fully supported this initiative and is currently seeking funding to achieve this goal.
A proof of concept will take place over summer 2015 with the Trust, Bury CCG and the local council using the InterSystems integration solution. This proof of concept will cover a small subset of patients with an end of life pathway, and aims to give GPs the confidence in the project to support a business case for further funding.
The costs of providing a single portal are being assessed on behalf of the North East Sector consortium. The first phase of the portal will bring together and make available read-only data from all the stakeholder organisations, to enhance efficiency and reduce the costs of discharge planning, end-of-life care and support services. The intention is to proceed beyond acceptance of the business case to full implementation of the service, to be hosted by Pennine Acute. Services using the portal will include out of hours services, primary care, secondary care, mental health and local councils which will, amongst other benefits, minimise the patient’s stay in hospital and improve end of life care.
It is anticipated that the underlying architecture of this Integrated Care Record is a federated database contributed to, and accessed by authorised health and care professionals via a portal. With funding in place, implementation of the integrated
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care record will begin in the first year of this strategy and integration activities will continue into the second year.
This initiative aligns directly with the Greater Manchester Devolution and national imperatives for the development of new models of care, integration of services, and the personalisation of care.
5.2.4 Improving patient access to care and information
IM&T will provide the infrastructure and IT solutions to offer patients access to their own records, and safe healthcare services.
Improving patient engagement with and access to healthcare is a central goal of NHS England. By achieving this, patients will build up their experience and capabilities to help manage their own care and symptoms. Enabling citizens to interact directly with healthcare services can improve convenience, satisfaction and lead to earlier, more cost effective interventions.
Within the NIB’s framework, Personalised Health and Care 2020, a milestone has been set to provide all citizens with online access to their GP record from March 2015 and this will extend to other care providers, including acute, by 2018.
NHS England’s goal is for individuals to create and manage their own personal care record. The patient engagement roadmap will be published by June 2015 and will include aspects such as booking appointments and online repeat prescriptions for all care services. It will leverage mobile technology and smart phone apps to maximise engagement.
The Trust will evaluate the published roadmap to determine implications for Trust systems and interoperability standards. It will also examine how it can use existing and future capabilities to optimise the healthcare of the local population. A patient portal is planned for year 3 of this strategy and government roadmaps will inform development of this initiative.
Patient Portal
In year three of this strategy the portal will be extended to patients with a focus on resource intensive, and high cost conditions such as HIV which are suitable for management in the home. It is essential that Trust strategies and infrastructure are sufficiently robust to support such access. The Patient Portal will promote patient engagement and self-care through a self-service approach. Ideas at this stage include access to the patient record, scheduling and management of appointments and patient forums. Self-care could be extended for use in clinical processes such as performing investigations, and is discussed in more detail below.
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5.2.5 Providing high quality information and business intelligence
As noted, the IM&T Department has made significant progress over the past year by providing business intelligence dashboards and migrating to a new data warehouse. They will continue improving the quality of information with bespoke and operational reporting to support Service Line Reporting (SLR), commissioning data, and monitoring of targets, standards and priorities. A comprehensive set of dashboards has been developed and work is in progress to extend this to cover external benchmarking information such as Dr Foster.
Service Line Reporting and Patient Level Costing
A key area of focus for the Trust is improvement to their Service Line Reporting (SLR) and Patient Level Costing (PLICS). An external review was undertaken which found that these reporting mechanisms could be optimised through greater automation, integration of new data sources and better governance through improving accessibility and ownership of data. These aspects are being addressed by the Business Intelligence team in the development of dashboards outlined below. The development will align with Trust’s overall SLR/PLICS strategy.
Business Intelligence
The Information Department has developed a number of BI dashboards for the purpose of providing performance, efficiency and productivity data in a visual format. The focus over the next few years will be on automation, accessibility and quality of data. This includes:
Integrated Performance Dashboards – accessible, automated dashboards for
performance monitoring are currently in development and will provide high
quality, timely data to support decision making and benchmark performance.
Dashboards will provide executives and managers with clear oversight of
corporate performance indicators such as quality or financial targets. Users
will be able to drill down to understand where performance has improved or
where attention should be focussed. The dashboards will also allow staff to
self-monitor their own metrics and compliance. Dashboards will target
different tiers of the organisational groups – strategic, divisional,
operational/service and personal level.
Self-service - The BI team will improve accessibility by automating report
generation through self-service. Clinicians, managers and executives will be
provided with an interactive, personal dashboard capability. Users will
configure settings based on a predefined set of favourites. For example,
consultants will be interested in viewing data such as training, activity data,
average length of stays and readmissions. Users will be able to filter
information and drill down to a level of detail which meets their needs as they
arise.
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Remote and mobile access - Another means of improving accessibility is to
provide remote and mobile access to data. The personalised dashboards will
initially be available on any thin client device across the organisation as
defined by the user’s personal settings. Over time this will be extended to
cover mobile devices such as tablets and smart phones.
Other key goals over the next two years include:
collaborating with the Finance and HR Departments to support Service Line
Reporting (SLR) from a single access point
supporting benchmarking and audit data such as Dr Foster
provision of mandatory and operational reporting for Community Services
working with the data quality team to identify where data quality can be
improved
production of real-time reports and dashboards
extending the number of data sources to feed the data warehouse.
Longer term goals will build on these foundations and further explore areas such as:
forecasting and modelling to provide more analytical and predictive data
mechanisms for reporting data across care settings and patient pathways to
align with the Trust’s integrated care initiatives.
In order to achieve these goals the Departments will need to update their BI tools. An assessment of the latest BI software will be undertaken with the aim of providing intuitive, interactive and functionally rich solutions that will work across multiple data sources and mobile devices.
The Trust is also establishing a new team of information analysts based within the Divisions. Their aim will be to help the Trust achieve the top quartile for outcomes (e.g. mortality rates, lengths of stay, readmissions) and tariffs.
Coding and data quality
Changes to Coding Department processes are currently underway which include a reduction of coding deadline targets while maintaining the same level of coding staff. This will have implications for the coding workflows to ensure that the most efficient and accurate processes are in place.
In order to meet Trust financial objectives there is a greater need for coded activity to be available sooner. This will enable financial reporting to the Board to be made earlier in the month with robust coded and costed activity providing early indications of the true financial position of the Trust. In order to achieve this in 2015/16 a formal options appraisal will be undertaken with clear plans of how this will be achieved including resilience at times of absence. The plan for the Coding Department is to code 95% of discharges by the third working day which will be implemented during 2015.
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The Department has a number of projects planned to improve turnaround times and data quality including:
Electronic coding of co-morbidities by clinicians. This is expected to improve
audit capabilities and quality of coding significantly as clinicians adapt to the
system. Coders will use the electronic handover of care component as a real
time summary of the patient episode to assist coding, rather than rely on
paper notes. This is expected to commence in Q1 2015/16 and be completed
by the end of 2015.
A new coding dashboard will be built during 2015/16 with the aim of improving
quality of coding providing specific tools and techniques which will deliver a
richness and depth in audit quality. Ad hoc audits will allow management to
drill down and identify specific individuals or specialties where improvement
may be required (for example, HRG by specialty). These areas can then be
acted on expediently before affecting performance ratings or commissioning;
Use of a live audit tool for a six month pilot.
A mortality validation tool that was rolled out across the Trust in 2014/15 will
continue to be monitored via ongoing review and support as part of the
Improvement Programme.
There is a dedicated Data Quality team within the IM&T Department who work
to an annual programme of audits agreed by the governing IM&T and
Information Quality Assurance Committee. These structures help to meet
overarching governance and auditing requirements such as Information
Governance Toolkit, as well as addressing accuracy for day to day business
and clinical purposes.
5.2.6 Flexible and innovative working
The IM&T Department will improve the ways clinicians access technology to support safe and effective care of patients, whenever and wherever it is required. This in turn will increase efficiency, productivity and satisfaction of Trust staff. Likewise, patient satisfaction and access to care will also be improved by providing more flexible care delivery options.
The Trust will improve access to care delivery, data and systems through four innovative mechanisms:
1. Remote working
2. Mobile devices
3. Telehealth and telemedicine initiatives
4. Patient self-service.
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Remote working
There are currently three workstreams of IM&T activity occurring within the Trust: acute, community and integrated care. While remote working is a central requirement for community and integrated care, these needs will primarily be addressed through other strategies. Strategies for all these areas will be developed in collaboration and be compatible in their recommendations to ensure the Trust’s integration goals are fully met. The strategy will address the needs of Trust clinicians accessing the acute patient record from anywhere within the organisation or from home.
The Trust has begun to meet this need through Connect Anywhere. This initiative aims to address the increasing costs of ownership, administration, support and management arrangements of the desktop estate across the Trust. The infrastructure strategy must ensure that departments will not be able to purchase software unless it can run on a virtual desktop.
Connect Anywhere will be the strategic solution for supporting end user device provision into the future including support of home working. Throughout the life of this strategy defined users will be allowed to access almost any service at home, this facilitates flexible working patterns and will improve productivity. Other initiatives include proximity card access, which is currently being piloted, and unified communications that will deliver voice, instant messaging, presence and video.
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The diagram below illustrates the key deliverables of the initiative:
Community workers will be able to access acute clinical solutions using Connect Anywhere over the telecoms network. Offline capability is also supported through Connect Anywhere’s ‘briefcase’ functionality.
Analysis of requirements to enable more efficient working specifically for community midwives is also underway to minimise travel time and avoid duplication of manual and electronic system updates, by providing remote mobile or offline access to the maternity system from the mother’s home or community clinic location. This includes review of system functionality and provision of mobile technology to support this objective.
The remote working plans align with the Trust’s thin client strategy which allows users to access their own personal settings on any thin client desktop across the organisation; the IM&T Department will continue rolling this out across the hospital in year one of the strategy.
Mobility
The current mobile platform (Good) provides smart phone access to administrative tools such as email and calendars. There is currently limited access to clinical information. However, this will be extended to provide access to clinical information wherever and whenever it is required.
A Bring Your Own Device (BYOD) strategy has been adopted to enable clinicians to access administrative systems. It is anticipated that this will not be extended to clinical access due to the need for greater control over access to patient data and management of devices. Consultants will be provided with their own iPad tablets during 2015.
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The Trust will determine a schedule for rolling out further mobile devices, based on staff role and benefits derived. Certain roles will benefit more from greater mobile access than others, for example, access to electronic information at the bedside for nurses and access from multiple different locations for bed managers or Allied Health Professionals (AHPs).
Telehealth and telemedicine
The Trust will leverage advances in telecommunication and introduce telehealth and telemedicine initiatives into their roadmap in year two of the strategy. Plans are currently in early stages but enthusiasm has recently increased. A number of potential projects have been identified by clinicians to ensure that the Trust and patients benefit from advances in technology. Current proposals include:
Remote monitoring of patients – in an effort to prevent hospital visits and
promote self-care the Trust will investigate introducing telehealth initiatives
such as home monitoring of physiological observations.
Remote visits and consultations – Clinicians at the Trust will derive great
benefit in using telehealth and telemedicine technology to review patients or
provide consultations to patients with chronic conditions. This can be
undertaken remotely from community-based clinics, nursing homes or in the
patient’s home. Restructured models of care will be highly dependent on
clear, agreed, evidence based pathways and protocols. The Trust plan to
pilot such an approach initially with an agreed care pathway for managing a
single condition.
Patient self-service
Departments such as A&E will be equipped with kiosks to check in at reception and guide patients to where they need to be. The Trust will also work in collaboration with Greater Manchester initiatives to develop a means for patients to become more engaged with their healthcare and encourage self-care and self-service tools. Other self-service initiatives will be explored, for example, kiosk technology could be extended for use of providing samples and receiving test results.
To take this concept further the Trust have identified groups of patients who are suitable candidates to undertake appropriate routine tests themselves and record the results within the patient record. This will not only empower these patients with the ability to monitor and manage their own conditions, but will also present cost savings for the NHS for conditions that are expensive to manage through traditional means.
5.2.7 Enhancing IT infrastructure
The IM&T Department has made progress with IT infrastructure improvements but recognises there is further progress to be made. They aim to provide an infrastructure which:
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is service-orientated, flexible and responsive to users’ needs
is efficient, green and effective
provides opportunities for generating income
improves the user experience of IT
reduces cost and risk related to IT services.
Investment in hardware and underlying infrastructure is crucial for the Trust to achieve fundamental goals such as integrating services and improving access to information. The IT infrastructure underpins the Trust’s transformation activities. The Trust has a complex legacy environment that will require ongoing strategic revision to replace its aging technology. In the early stages of this strategy an options appraisal will be performed to determine the relative benefits and cost of available options.
Following the options appraisal, the IM&T Department will produce a detailed strategy to bring together all aspects of infrastructure planning including networks, telecommunications, hardware, and devices. The strategy will ensure that performance and availability issues are addressed through proactive monitoring and remote servicing using a blend of in-house and third party services.
The options appraisal will also include an assessment of Voice over Internet Protocol (VoIP) telephony options. VoIP has the benefit of potentially reducing costs for both the Trust and its patients, as well as enabling integrated video calls and data transfer. This allows doctors and nurses to be contacted and provide care wherever and whenever needed. It is envisaged that specialists will be contracted to perform the installation to ensure a fast, secure and high quality service.
As outlined above, significant progress has already been achieved against the previous strategy with data centres, remote working and rollout of Connect Anywhere. However, the Trust needs to continue to develop its approach to meet the rate of technological change and the changing operational requirements of its users.
5.2.8 Optimising existing technology
The IM&T Department plans to optimise and standardise use of existing software and devices to provide more efficient clinical, corporate and back office systems. IM&T will implement processes to ensure existing systems are best utilised wherever they are suitable for use.
Solutions will be assessed to understand where savings and efficiencies can be made. It is important to ensure they fit in with and align to the IM&T and Trust strategy. This assessment will take into account emerging infrastructure and technology, including the NHS’s interoperability standards framework and roadmaps.
The Trust will redesign workflows to transform corporate and back office systems bringing in elements of e-service and self-service as appropriate. Workflow will be streamlined and more efficient through the introduction of:
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e-requisitioning
e-procurement
self-service HR.
5.2.9 Efficient and effective IM&T service
The Department will review its capacity and capabilities to improve the effectiveness of the service provided to the Trust on a regular basis. Plans will reach across the Department and include all personnel and include:
support for attainment of professional qualifications
embedding best practice such as PRINCE2 and ISO standards
roll-out of up-to-date training to support new technology
achieving the ISO 27001 standard
implementing ITIL Best Practice
appropriate succession planning
undertaking a full options appraisal to examine IT Service Models
development and publication of a service catalogue
updating its methodology for the management of projects.
5.2.10 Improving clinical engagement
The success of a clinical system implementation is largely dependent on engagement from clinicians and productive relationships with the relevant Trust services. IM&T is an enabler and catalyst for improvement - not an end in itself. It is therefore crucial that clinical engagement drives the transformation activities that underpin IM&T implementations.
As the Trust widens its adoption of their IM&T solutions it is clear that further strengthening of relationships with stakeholders will be beneficial. A number of approaches will be taken to optimise clinical stakeholder engagement;
Active leadership - leadership, direction and effective relationships built within the Trust and with its partnership organisations. Top down support and direction from leadership will provide encouragement and governance to adopt new policies and procedures which capitalise on IM&T initiatives. Plans need to ensure the correct governance and structures are put in place to leverage the benefits. The Trust currently has clinicians on its Project Boards but this will be strengthened further to include the recently appointed lead physician and nursing roles for each of the Divisions.
Clinical champions - clinical leaders who champion transformation activities within the workplace. This approach has already been applied through the formation of the Clinical IM&T Strategy Group. The Trust will
Item
9a
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consolidate the role of clinical leaders in their implementation plans and review how this can further drive adoption and clinical transformation.
Innovation - The IM&T Department will use the appeal of innovation and new technology to leverage further engagement from clinicians. Innovation will not only support efficiencies but also encourage a culture of creative thinking and incentivise adoption of IM&T. Now more than ever there is an interest from clinicians in using technology. This trend can be harnessed to develop innovative solutions to problems as well as improve the likelihood of success by ensuring there is clinical buy-in from the outset. For example, the development of BI dashboards is identified as one area where both users and developers will benefit from clinical involvement.
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6 Actions and Implementation Plan
Key areas of focus for 2015/16
The IM&T Department is continuing to build on the progress made against the previous strategy with priority areas of focus for 2015/16:
Complete the Trustwide rollout of EPR projects for ePMA, OCRR and
Evolve
Broaden the scope of electronic communications to GPs and patients
to eliminate paper
Commence deployment of the Trust clinical portal solution
Procure e-Observations / Patient flow system
Procure a centralised diagnostic and alerting system for Maternity
Identify a solution to support Community Services
Continue deployment of core infrastructure enhancement, including
back end server upgrades, client refresh and additional mobile
equipment on wards, Connect Anywhere rollout and improved network
connectivity to community locations
Further develop business intelligence dashboards and reporting
capability
Improve governance of and compliance with project management
methodology
The planned timetable for these and other projects to support achievement of the strategy over the next three years is provided in the table below:
Item
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IDH
igh
-lev
el A
ctiv
ity
1.1
Iden
tify
indi
cato
rs a
nd m
etri
cs f
or m
easu
ring
obj
ecti
ve
1.2
Dev
elop
com
mun
icat
ion
plan
for
com
mun
icat
ing
prog
ress
1.3
Mea
sure
and
com
mun
icat
e pr
ogre
ss e
very
6 m
onth
s
1.4
Adj
ust
stra
tegy
eve
ry 6
mon
ths
to r
efle
ct p
rogr
ess
and
cha
nges
IDH
igh
-lev
el A
ctiv
ity
2.1
Com
plet
e ro
llout
of
the
Evol
ve c
asen
ote
solu
tion
2.2
Dep
loy
Trus
t-w
ide,
clin
ical
por
tal
2.3
Proc
urem
ent
of e
Obs
erva
tion
s/Pa
tien
t fl
ow
2.4
Dep
loy
eObs
/Pat
ien
t fl
ow
2.5
Impl
emen
tati
on o
f El
ectr
onic
Ref
erra
l Man
agem
ent
Solu
tion
TB
D
2.6
Com
mun
ity
syst
ems
2.7
Impr
oved
inte
grat
ion
betw
een
the
EPR
and
Sym
phon
y
2.8
Rol
lout
of
orde
r co
ms
in O
P an
d ER
2.9
Rol
lout
of
EPM
A in
em
erge
ncy
dep
artm
ents
2.10
Rep
lace
Hea
lthv
iew
s fo
r ha
ndov
er o
f ca
re a
nd o
rder
com
ms
2.11
Stre
ngt
hen
Bus
ines
s as
Usu
al (
BA
U)
proc
ess
2.12
Rev
iew
reg
ulat
ory
and
inte
rope
rabi
lity
stan
dard
s (e
.g. G
S1)
2.13
Prod
uce
revi
sed
EPR
opt
ions
app
rais
al e
nd
of 2
017/
18
1.
Su
pp
ort
ing
th
e Tr
ust
’s t
ran
sfo
rma
tio
n -
cre
ate
a r
ob
ust
an
d in
no
vati
ve IM
&T
fou
nd
atio
n t
o u
nd
erp
in t
he
Tru
st’s
tra
nsf
orm
atio
n o
f cl
inic
al s
erv
ice
s
2.
D
igit
isin
g p
ati
ent
reco
rds
an
d c
lin
ica
l wo
rkfl
ow
s: e
xte
nd
th
e d
eve
lop
me
nt
and
ro
llo
ut
and
of
the
Tru
st’s
acu
te E
PR
an
d c
lin
ical
po
rtal
wit
h t
he
aim
of
ach
ievi
ng
a d
igit
ise
d p
atie
nt
reco
rd b
y 20
20
2015
/16
2017
/18
2016
/17
2015
/16
2016
/17
2017
/18
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ity
3.1
Hea
lthc
are
com
mun
ity
inte
grat
ion
port
al p
ilot
3.2
Subm
it b
usin
ess
case
for
fun
ding
3.3
Init
iate
and
hos
t he
alth
care
com
mun
ity
inte
grat
ion
port
al p
roje
ct
IDH
igh
-lev
el A
ctiv
ity
4.1
Eval
uate
HSC
IC a
nd N
IB r
oadm
aps/
spec
ific
atio
ns
4.2
Eval
uate
loca
l hea
lthc
are
econ
omy
need
s
4.3
Eval
uate
sup
plie
r ca
pabi
litie
s to
mee
t ne
eds
and
asse
ss g
aps
4.4
Dev
elop
str
ateg
y fo
r im
prov
ing
pati
ent
acce
ss
IDH
igh
-lev
el A
ctiv
ity
5.1
Sing
le d
ata
war
ehou
se t
o be
use
d t
o fe
ed r
epor
ting
5.2
All
data
to
be m
oved
to
new
vir
tual
ser
ver
envi
ronm
ent
5.3
Cha
nge
SLR
qua
rter
ly t
o m
onth
ly a
nd n
ew d
ashb
oard
for
clin
icia
ns/m
anag
ers
5.4
All
lega
cy d
ashb
oard
s to
be
rep
lace
d w
ith
a ne
w c
omm
on t
hem
e
5.5
Incl
ude
self
-ser
vice
dat
a fo
r PA
S an
d A
&E
sour
ces
5.6
Dr
Fost
er b
ench
mar
k da
ta a
dded
to
cons
ulta
nt-l
evel
das
hboa
rds
and
rep
orts
5.7
Rea
l-ti
me
dash
boar
ds t
o be
rel
ease
d f
or k
ey in
form
atio
n
5.8
All
dash
boar
ds t
o ha
ve s
elf-
serv
ice
data
ext
ract
s av
aila
ble
for
end-
user
s
5.9
Rad
iolo
gy, P
harm
acy,
Pat
holo
gy, m
ater
nity
dat
a to
be
adde
d t
o da
ta w
areh
ouse
5.10
All
BI r
epor
ting
to
be a
vaila
ble
on m
obile
dev
ices
5.11
Fore
cast
ing
and
mo
de
llin
g to
pro
vid
e m
ore
an
alyt
ical
an
d p
red
icti
ve d
ata
5.12
Mec
hani
sms
for
rep
orti
ng d
ata
acro
ss c
are
sett
ings
and
pat
ien
t pa
thw
ays
5.13
Ass
ess
and
upda
te B
I too
ls
5.14
Dep
loy
codi
ng d
ashb
oard
5.15
Dep
loy
mor
talit
y va
lidat
ion
tool
5.16
e-Le
arni
ng t
ool f
or ju
nior
doc
tors
2015
/16
2016
/17
2017
/18
4.
Im
pro
vin
g p
ati
ent
acc
ess
to c
are
an
d in
form
ati
on
: pro
vid
e t
he
str
uct
ure
an
d s
up
po
rt t
o e
nh
ance
pat
ien
t’s
acce
ss t
o t
he
ir o
wn
re
cord
s, t
o s
erv
ice
s, a
nd
to
saf
e h
eal
thca
re.
2015
/16
2016
/17
2017
/18
3.
In
teg
rati
on
acr
oss
th
e ca
re-c
on
tin
uu
m:
lead
de
velo
pm
en
t o
f a
com
mu
nit
y w
ide
, in
tegr
ate
d p
atie
nt
reco
rd in
co
llab
ora
tio
n w
ith
acu
te, p
rim
ary
care
, co
mm
un
ity,
me
nta
l he
alth
an
d
soci
al c
are
par
tne
rs t
o im
pro
ve a
cce
ss t
o d
ata
2015
/16
2016
/17
2017
/18
5.
P
rovi
din
g h
igh
qu
ali
ty in
form
ati
on
an
d b
usi
nes
s in
tell
igen
ce:
de
live
r a
hig
h q
ual
ity
info
rmat
ion
se
rvic
e w
hic
h s
up
po
rts
the
Tru
st’s
cli
nic
al a
nd
bu
sin
ess
pro
cess
es
real
-tim
e s
uch
as
serv
ice
lin
e r
ep
ort
ing
and
BI d
ash
bo
ard
s
Item
9a
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IDH
igh
-lev
el A
ctiv
ity
6.1
Com
plet
e ro
llout
of
Con
nect
rem
ote
wor
king
6.2
Rol
lout
Goo
d m
obile
pla
tfor
m f
or a
cces
sing
clin
ical
app
licat
ions
6.3
Dev
elop
long
er t
erm
str
ateg
y fo
r m
obile
acc
ess
6.4
Ass
ess
tele
hea
lth/
tele
med
icin
e op
port
unit
ies
6.5
Dev
elop
tel
ehea
lth/
tele
med
icin
e st
rate
gy
6.6
Rol
lout
A&
E ki
osk
func
tion
alit
y
6.7
Ase
ss o
ther
pat
ien
t se
lf-s
ervi
ce o
ppor
tuni
ties
acr
oss
inte
grat
ed c
are
netw
orks
IDH
igh
-lev
el A
ctiv
ity
7.1
7.2
7.3
7.4
7.5
IDH
igh
-lev
el A
ctiv
ity
8.1
Iden
tify
exi
stin
g Tr
ust
syst
ems
whi
ch a
re u
nder
utili
zed
8.2
Iden
tify
sys
tem
s w
hich
do
not
alig
n w
ith
Trus
t IM
&T
stra
tegy
or
road
map
8.3
Prod
uce
road
map
to
mig
rate
, ext
end,
impl
emen
t or
dec
omm
issi
on e
xist
ing
syst
ems
8.4
Red
esig
n pr
oces
ses
usin
g e-
req
uesi
stiio
ning
, e-p
rocu
rem
ent
and
self
ser
vice
7.
En
ha
nci
ng
IT in
fra
stru
ctu
re:
con
tin
ue
to
up
dat
e a
nd
imp
rove
th
e T
rust
’s in
fras
tru
ctu
re t
o f
orm
a r
ob
ust
fo
un
dat
ion
fo
r fu
ture
IM&
T d
eli
very
8.
O
pti
mis
ing
exi
stin
g t
ech
no
log
y: o
pti
mis
e a
nd
sta
nd
ard
ise
use
of
exi
stin
g IM
&T
soft
war
e a
nd
de
vice
s to
pro
vid
e e
ffic
ien
t cl
inic
al, c
orp
ora
te a
nd
bac
k o
ffic
e s
yste
ms
2015
/16
2016
/17
2017
/18
2015
/16
2016
/17
2017
/18
2015
/16
2016
/17
2017
/18
6.
Fl
exib
le a
nd
inn
ova
tive
wo
rkin
g:
imp
rove
pro
du
ctiv
ity
and
acc
ess
to
car
e b
y le
vera
gin
g te
chn
olo
gy a
nd
te
leco
mm
un
icat
ion
s
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&T
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ate
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igh
-lev
el A
ctiv
ity
9.1
Supp
ort
for
atta
inm
ent
of p
rofe
ssio
nal q
ualif
icat
ions
9.2
Embe
d b
est
prac
tice
- P
rinc
e 2
9.2
Embe
d b
est
prac
tice
- I
SO s
tand
ards
9.3
Rol
l-ou
t of
up-
to-d
ate
trai
ning
to
supp
ort
new
tec
hnol
ogy
9.4
Ach
ieve
the
ISO
270
01 s
tand
ard
9.5
Impl
emen
t IT
IL B
est
Prac
tice
9.6
App
ropr
iate
suc
cess
ion
plan
ning
9.7
Und
erta
ke a
ful
l opt
ions
app
rais
al t
o ex
amin
e IT
Ser
vice
Mod
els
9.8
Dev
elop
men
t an
d pu
blic
atio
n of
a s
ervi
ce c
atal
ogue
9.9
Upd
ated
met
hodo
logy
and
han
dboo
k fo
r th
e m
anag
emen
t of
pro
ject
s
IDH
igh
-lev
el A
ctiv
ity
10.1
Enga
ge e
ach
Div
isio
nal P
hysi
cian
and
Nur
sig
lead
in I
M&
T in
itia
tive
s
10.2
Wor
k w
ith
Div
isio
nal l
eads
to
deve
lop
clin
ical
cha
mpi
ons
10.3
Iden
tify
opp
ortu
niti
es f
or c
linic
ians
to
enga
ge in
IM
&T
inno
vati
on
10.4
Dev
elop
str
ateg
y fo
r lo
nger
ter
m c
linic
al e
nga
gem
ent
to s
uppo
rt f
utur
e EP
R p
lans
2015
/16
2016
/17
2017
/18
2015
/16
2016
/17
2017
/18
10.
Im
pro
vin
g c
lin
ica
l en
ga
gem
ent:
imp
rove
cli
nic
al e
nga
gem
en
t in
Tru
st IM
&T
and
tra
nsf
orm
atio
n a
ctiv
itie
s th
rou
gh le
ade
rsh
ip a
nd
inn
ova
tio
n t
o p
rom
ote
ad
op
tio
n o
f te
chn
olo
gy.
9.
Ef
fici
ent
an
d e
ffec
tive
IM&
T se
rvic
e: r
evi
sio
n o
f th
e IM
&T
serv
ice
te
am’s
str
uct
ure
, cap
acit
y an
d c
apab
ilit
ies
to im
pro
ve t
he
eff
icie
ncy
an
d e
ffe
ctiv
en
ess
of
the
se
rvic
es
to T
rust
pe
rso
nn
el
Item
9a
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7 Governance
This section sets out the governance arrangements for the implementation of this strategy.
7.1 Information Assurance Framework - IM&T Department
7.2 Caldicott and Information Governance Committee - Terms of Reference
Purpose
Ensures integrated information governance as the primary performance review committee for the Trust
Ensures assurance of the effective management of information governance risk across the Trust
Ensure compliance with law, best practice, governance and regulatory standards.
7.3 IM&T and Information Quality Assurance Committee - Terms of Reference
Purpose
The IM&T and Information Quality Assurance Committee will monitor the implementation of the Trust’s IM&T Strategy focusing on the wider local IM&T programme.
It will monitor the operational IM&T service and support the management of IM&T within the Trust.
It will support the development of initiatives to promote a culture of Information Quality Assurance across the Trust, and to further promote
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consistent practice in the area of activity classification and its application.
7.4 Clinical Strategy Group – Terms of Reference
Purpose
The IM&T Clinical Strategy Group will direct the Trust’s IM&T Strategy focusing on the use of IM&T systems in operational clinical settings
It will monitor the delivery of the IM&T Strategy, the EPR Programme and other clinical projects
It will provide clinical advice IM&T related issues which impact clinical users.
It will act as the Project Board for key projects that affect clinical staff globally, specifically the Clinical Portal.
7.5 IM&T Programme / Project Funding Approval
Programmes and projects have been included in the IM&T capital programme five year plan for funding in principle. The plan is reviewed on an annual basis to agree the priorities for a detailed programme of work.
Detailed business cases will be presented to the relevant approval authority based on investment needs for each of the major projects, to ensure that value for money and return on investment is demonstrated using a cost / benefit analysis.
In principle, projects should deliver cash-releasing benefits, but as a minimum be self-funding for impact on service revenue.
Item
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8 Methodologies and Best Practice
The IM&T Department will adopt best practice and methodologies in order to manage this ambitious programme of work effectively. This section sets out the standard methodologies to be adopted by IM&T.
8.1 Programme management
Managing Successful Programmes (MSP) is a structured, flexible framework that allows the management and control of all activities involved in managing a programme. MSP is the de facto standard used for managing programmes in the NHS. Senior Staff within the IM&T Department responsible for managing programmes are expected to follow the MSP methodology as part of the IM&T Department’s drive to improve its services.
8.2 Project management
PRINCE2 is the de facto standard used for managing projects in the NHS. It is a generic, tailorable project management methodology, covering how to organise, manage and control projects. PRINCE2 has been adopted as the in-house standard for project management and key staff receive training and mentoring in project management techniques. All projects have a Project Board with a sponsor and clinical engagement. A recent audit confirmed that this implementation is robust.
To provide further governance and auditability of compliance with the methodology, a project portfolio management system is being implemented to allow consolidation of project and progress reporting.
8.3 Service management
ITIL is the most widely accepted approach to IT service management in the world. ITIL provides a cohesive set of best practice, drawn from the public and private sectors internationally.
As part of the IM&T Department’s structure review a capability and training review scheme will be introduced to ensure ITIL best practice is fully implemented and adhered to.
8.4 Security management
The ISO/IEC 27000 series consists of information security standards published by the International Standards Organisation (ISO) and the International Electrotechnical Commission (IEC). The series is designed to give best practice recommendations on information security management including risks and controls within the context of an overall Information Security Management System (ISMS).
The Trust intends to gain certification to the ISO/IEC 27001 standard in order to achieve:
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better management of information security risks, now and in the future
increased access to new customers and business partners
demonstration of legal and regulatory compliance
potential for reduced public liability insurance costs
enhanced status and competitive advantage
overall cost savings (reduced errors and re-work).
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9 Benefits
The overarching aim of the IM&T Strategy is to support the objectives of national, local and Trust goals to improve patient care through technology and innovation by delivering the following benefits:
Real time information available and accessible at the point of care
Reduction in time accessing multiple systems and searching for patient
information through further system integration and consolidation, and
use of portal technology
Eliminate duplication of entering information across disparate systems
thereby improving patient safety and use of clinicians’ time
Availability of complete and accurate comprehensive information for
clinicians to support care management and decision making which
could impact length of stay or increased readmissions
Reduce the amount of time patients spend avoidably in hospital
through better and more integrated care in the community
Faster management of the patient journey to recovery through
improved communication and sharing of information between patients,
clinicians and other care providers
Enhance continuity of care with provision of timely electronic
communications to GPs and other care providers
Efficiency improvements in clinical practices as the Trust progresses
with the move to electronic records and removal of paper
Increase positive patient experience of both inpatient care and care
outside the hospital
Enable harm-free care and avoidance of financial penalties through
comprehensive monitoring and reporting systems to support service
improvement initiatives
Improved data quality and reporting to maximise income generation
Demonstrate consistent working practices across the Trust’s services
and departments
Use business intelligence reporting and dashboards to enable service
improvement strategies and develop enhanced models of care to
support delivery of cost improvement plans
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10 Risks
The IM&T programme is large and complex and there is significant risk of delay and over spend which would constitute a threat to the delivery of benefits and achievement of the Trust’s objectives. Additionally, failure to support the complex configuration of live systems would have a serious effect upon the ability to achieve organisational goals.
The main areas of risk are summarised below:
No Risk Probability (H/M/L)
Severity (H/M/L)
Mitigation
1 Sufficient project resources and management cannot be secured risking delays or abandonment of projects.
H H Agree PAHT funding through this strategy.
Agree external funding with Commissioners; prepare bids to apply for other strategic funding offered by the Government.
Prepare contingency plans for resourcing shortfalls.
2 Project run late or over-budget, delaying delivery of benefits.
M H Use ‘best practice’ project management methods (PRINCE 2).
Adopt a development methodology to ensure projects and developments are managed in a quality controlled and consistent manner.
3 Projects completed, but benefits not fully realised.
M M Prepare and monitor Benefits Realisation plans for all major projects.
Appoint Business Change owners within Services to ensure benefits realised.
4 Loss of efficiencies and disruption to organisation arising from out of date or redundant systems.
M H Undertake regular upgrade and system reviews as ongoing business and usual.
Monitor via System Manager meetings
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No Risk Probability (H/M/L)
Severity (H/M/L)
Mitigation
5 Failure to attract and retain high quality staff leads to heightened risk of project failures and unreliable systems and processes.
M H Develop IM&T managers with strong focus on leadership and people management skills.
Ensure effective communications at all levels of IM&T staff.
Ensure staff qualifications are updated to meet industry standards and best practice.
6 Failure to identify project and programme risks.
M H Ensure MSP & PRINCE 2 methodologies are followed.
Implementation of Project in A Box to consolidate project and portfolio risks.
7 IM&T are not involved early enough in hospital projects.
M M Continually educate or reinforce that the business MUST involve IM&T from the outset.
Divisional pipeline process implemented as precursor to capital planning.
8 Trust culture does not change to one of “IT is not optional, it is part of the day job”.
M M Recent significant rollout of Clinical IT systems but requires Senior Clinical leadership.
Greater alignment of clinical strategy group and project leadership with changes in Trust Divisional structures.
Switch off old ways of working.
Appoint Business Analysts and Clinical Trainers to ensure IT is fully utilised and business processes are changed.
9 Clinicians see IT as purely administration.
L L Secure Senior Clinical leadership to address shortfall in uptake on clinical systems.
Enforce new ways of working by changing JDs, judge as part of PDR process.
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No Risk Probability (H/M/L)
Severity (H/M/L)
Mitigation
10 Lack of flexibility and response to change.
M M Continued review of IM&T Strategy in line with national and organisational strategies including Trust transformation map.
11 Increased demand for IT systems as cost improvement enabler (e.g. electronic forms and workflow and complex pathway solutions with associated interfacing) cannot be met by current IM&T resource establishment.
H M Additional resource requirements built into business cases and revenue to support ongoing strategy.
12 IM&T strategy is impacted or delayed by Devolution of Manchester and other political changes in local area
H H Proactive participation of Trust and IM&T in local and national initiatives.
Harnessing of opportunities arising from change.
13 Increased demands on the finite business as usual resources due to the expansion of IM&T systems delivered as part of strategy
H H Additional resource requirements built into business cases and revenue to support ongoing strategy.
Service review, monitoring and improvement
These risks, and associated action plans, will be managed and monitored through a combination of project risk logs, a programme risk log and the departmental risk register.
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11 Conclusion
This strategy has assessed the Trust’s current IM&T provision and identified the challenges and opportunities to come. The Trust has made considerable progress with its current best of breed EPR and has decided to continue building on this capability over the life of this strategy. The overarching goal of the strategy is to support the Trust in meeting its ambitious transformation plans by providing robust and agile IM&T services. The strategic objectives laid out in the strategy highlight the opportunities for the Trust, staff and patients by achieving fully digital patient records and clinical workflows. It identifies the strong lead role the Trust can play by supporting Greater Manchester in its aims for truly integrated pathways within the wider health community, including GPs, community health, social care and patients. It also provides a path to delivering efficiencies through the latest innovation and technology, and making them accessible to patients and staff alike. Over the next three years the IM&T Department should build on the solid capabilities already in place, and strengthen areas such as system optimisation, clinical engagement and service delivery. By focusing on these areas over the life of this strategy the Trust will be better prepared to manage future possibilities, such as migrating to a single integrated EPR.
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12 Glossary of Terms
AGMA Association of Greater Manchester Authorities
AHP Allied Health Professionals
AHSN Allied Health Science Network
BI Business Intelligence
BYOD Bring Your Own Device
CCG Clinical Commissioning Group
CDMI Clinical Digital Maturity Index
DoH Department of Health
EDRMS Electronic Document Record Management System
ePMA Electronic Prescribing and Medicines Administration
EPR Electronic Patient Record
FYFV Five Year Forward View
HRG Healthcare Resource Group
HSCIC Health and Social Care Information Centre
IM&T Information Management and Technology
IT Information Technology
ITIL Information Technology Infrastructure Library
MoU Memorandum of Understanding
NIB National Information Board
OCRR Order Communications and Results Reporting
PAS Patient Administration System
PLICS Patient Level Information and Costing System
SAN Storage Area Network
SLR Service Level Reporting
TDA Trust Development Authority
TIE Trust Integration Engine
VoIP Voice Over Internet Protocol
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Title of Report Audit Committee Minute – 7 April 2015
Executive Summary
The minute of the Audit Committee meeting held on 7 April 2015 is attached. The Committee:
Noted the interim External Audit Report for 2014/15
Reviewed the Internal Audit Progress Report
Received the interim Internal Audit Opinion for 2014/15
Reviewed the draft Internal Audit Plan for 2015/16
Noted the arrangements for producing the annual accounts and annual report for 2014/15
Noted the draft Annual Governance Statement
Received the Counter Fraud Update
Approved the Counter Fraud Plan for 2015/16
Received the Information Governance Audit.
Actions Requested:
The Board is asked to note the contents of the minute.
Corporate objectives supported by this paper: The Audit Committee supports all corporate objectives of the Trust.
Risks: Not relevant for this paper.
Public and/or Patient Involvement: Not relevant for this paper.
Resource Implications: Not relevant for this paper.
Communication: Not relevant for this paper.
Have all implications been considered? YES NO N/A
Assurance X
Contract X
Equality and Diversity X
Financial / Efficiency X
HR X
Information Governance Assurance X
IM&T X
Local Delivery Plan / Trust Objectives X
National policy / legislation X
Sustainability X
Name Riaz Ahmad
Job Title Non-Executive Director
Month and Year May 2015
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Minute
Audit Committee Executive Directors’ Meeting Room, Trust HQ
7 April 2015 1.30pm – 3.15pm
Owner Timescale
Present Mr R Ahmad, Non Executive Director (Chair) Mrs W Cardiff, Non Executive Director Mrs C Guereca, Non Executive Director In Attendance Mr G Barclay, Assistant Chief Executive Mr T Cutler, KPMG Ms S Flaherty, Corporate Governance Manager Miss W Jones, Deputy Director of Finance Ms R Ghelani, KPMG Mrs D Pullen, Head of Corporate Governance Mrs L Squires, MIAA Mrs K Wheatcroft, MIAA Apologies Mrs U Martin, Director of Clinical Governance Mr A Smith, KPMG Mr B Steven, Deputy Chief Executive/Director of Finance
19/15 Introductions Mr Ahmad led the introductions and apologies
20/15 Declarations of Interest There were no interests declared.
21/15
Minutes of Meeting held on 10 February 2015 The Minutes of the meeting were submitted. Mr Cutler stated that in respect of agenda item 11/15, KPMG had been appointed as auditors for 2015/16 and 2016/17. With this clarification, the minutes were approved.
22/15
Matters Arising Mr Ahmad referred to the brought forward action log. 08/15 Audit Plan The Audit Plan had been discussed with Mr Barclay and other key individuals in the Trust. Mr Barclay would ensure that a copy of the Audit Plan was submitted to SMT for consideration.
GB
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13/15 Counter Fraud – Whistleblowing The whistleblowing case discussed at the last meeting was included on the log which had been submitted to the Trust Board. 17/15 The Terms of Reference of the Finance, Infrastructure and Business Development Committee These still needed to be ratified by the Trust Board. The other actions had been updated on the brought forward actions log and were noted.
GB
23/15 Chairman’s Remarks Mr Ahmad had no specific comments to make.
24/15
External Audit – Interim Audit Report 2014/15 Ms Ghelani spoke to the report and provided the committee with the key highlights. In relation to the controls over key financial systems, it was reported that the controls were generally sound. One best practice recommendation around journals had been identified in relation to segregation of duties and timeliness. Work continued in relation to purchase order data analytics. Internal Audit work was not relied upon during the interim testing, however dialogue continued with Internal Audit to avoid duplication and to use the highlights of their work to aid a focused approach. Good progress was noted in relation to the accounts production for the year and there was confidence that the un-audited accounts would be submitted on time. Work was completed on the high level review of the financial management processes which had been found to be robust. It was also reported that the Trust had posted a deficit of £1.9m at Month 11, representing an improvement due to the £9m non-recurring funding received from NHS England to cover the initial deficit position of £10.9m. The report was noted.
25/15 External Audit - Technical Update The content of the technical update report was received. The report was noted.
26/15 Internal Audit – Progress Report Mrs Squires presented the internal audit progress report covering the period April 2014 to March 2015. The report contained findings and recommendations from the monitoring work undertaken by internal audit and provided details of the Trust’s progress in implementing agreed
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recommendations. In relation to the Assurance Framework, this was designed and operated to meet the requirements of the Annual Governance Statement and provided reasonable assurance that there was an effective system of internal control. Mrs Squires took the Committee through the completed audits as follows:
Data Quality: Referral to Treatment – DNA – limited assurance
Recruitment Process – limited assurance
Absence Management – limited assurance
E-procurement – significant assurance
Information Governance – significant assurance
IT Service Continuity – significant assurance
Mortality Reduction Project – significant assurance Mrs Squires then took the committee through the specific areas of concern for the limited assurance reports, as detailed in the papers, and described the actions being taken to address the limited assurance. Mrs Squires said good progress was being made in relation to follow up recommendations, commenting that the majority of the recommendations were due to be cleared by July 2015. Mrs Squires provided an update on the critical and high level risk action plans, stating that she was content with the actions being taken. The report also provided an update on progress against the plan, an overview of the output delivery, upcoming events and a summary of the MIAA events and conferences. Members of the committee asked various questions in relation to the limited assurance reports. In response, Mrs Squires confirmed that Dr Sinniah was the lead executive for the Data Quality: Referral to Treatment – DNA – limited assurance audit. Mr Ahmad sought assurance that everything possible was being done to rectify this limited assurance review which had an impact on patients and that time was of the essence to improve compliance. It was agreed that Mr Mullen and Dr Sinniah would be approached to provide a written update to members. In addition, Mrs Squires would forward confirmation that 6 out of the 9 recommendations had already been completed. In relation to response notice for appointments, Mrs Squires said that staff had been working to 3 weeks, rather
DP LS
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than 2 weeks as per policy but this had since been rectified. Concerning with the Recruitment Audit, the audit sample was from the current year; all positions had been authorised prior to advert. Insufficient ID documentation was being addressed. In relation to Absence Management, Mrs Squires said the key failures were in relation to staff not attending Occupational Health and then managers not always following this up. Confirmation was given that as this was a limited assurance audit, it would be detailed in the follow up section of a future report to the committee. The report was noted.
27/15 Internal Audit Briefing Notes The briefing notes had been included for information purposes. The report was noted.
28/15 Internal Audit – Interim Opinion Statement Mrs Wheatcroft advised that the purpose of the Director of Internal Audit Opinion was to contribute to assurance available to the Accountable Officer and the Board which underpinned the Board’s own assessment of the effectiveness of the system of internal control and to assist in completion of the Annual Governance Statement. The overall opinion was that significant assurance could be given that there was a generally sound system of internal control designed to meet the organisation’s objectives and that controls are generally being applied consistently. Some weaknesses in the design or inconsistent application of the controls put the achievement of a particular objective at risk. The opinion had been formed by review of the Assurance Framework, assurance across the critical business systems and contribution to governance, risk management and internal control enhancements. Mrs Cardiff sought to understand the where the Trust was positioned from a benchmarking perspective. Mrs Wheatcroft advised that during the year, MIAA may have 1-2 clients whose opinion statement was limited. Mrs Wheatcroft further stated that she considered the balance of the Trust’s internal audit reports and their scope of coverage was good on the basis that there was a mixture of significant assurance and limited assurance audits. The report was noted.
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29/15 Internal Audit Draft Plan – 2015/16 Mrs Squires presented the draft plan which was based on their local risk assessment and demonstrated how their work was aligned with the Trust’s Strategic Risk Assessment. The plan included the 3 year audit strategy and a detailed operational plan for 2015/16. It was noted that whilst this had been developed with key individuals in the Trust, Mr Steven was yet to provide comments so it may still alter. Members of the committee asked questions in relation the plan which included potential audits for 2016/17. In response, it was confirmed that bank, agency and locum spend had been pulled forward into 2014/15 from 2015/16 due to its importance. Discussion followed in relation to vacancy management; members expressed the view that this should be brought forward into 2015/16. Additionally, it was expressed that bank, agency and locum spend should also be brought forward into 2015/16 in order that the impact of the recommendations from the 2014/15 could be monitored. Linkage with the areas to be assessed by the Chief Inspector of Hospitals visit expected by the end of the calendar year was raised. After discussion, it was agreed that the draft plan would be considered in its entirety by the Executive Team for an overall discussion. The report was noted.
GB
30/15 Arrangements for Annual Accounts and Annual Report Mr Barclay spoke to the report which set out the process for finalising and approving the statutory annual accounts and annual report for the Trust. The Quality Accounts had been tabled at the last Trust Board and was now subject to consultation. The Annual Report was being drafted and the Annual Accounts were underway. The report was noted.
31/15 Audit Committee Terms of Reference Annual Review The Terms of Reference were discussed and reference to the Audit Commission was to be removed and replaced with “independently appointed”. The changes would be made and thereafter submitted to the Trust Board for ratification. The report was noted.
DP/GB
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32/15 Review of Assurance Statements: Quality & Performance Committee and the Finance, Infrastructure & Business Development Committee Both Annual Assurance Statements were considered by the committee. Mr Barclay asked whether the committee had assurance that the two sub-committees of the Board had fulfilled their terms of reference. Mrs Cardiff said that she felt both committees had made progress since they were established particularly in relation to attendance and contributions. Mrs Guereca, who was a member of the Quality and Performance Committee, commented on the large and complex agenda, stating that the committee was now more effective and was turning its attention to seeking assurance rather than reassurance. Mrs Cardiff said that she would like to see more triangulation of issues across the sub-committees and requested that this be drawn to the Board’s attention. The Annual Assurance Statements were noted.
GB
33/15 Annual Governance Statement Mr Barclay spoke to the Annual Governance Statement, advising the committee that it reflected new guidance issued by the TDA and also the significant amount of change around governance processes and restructuring of committees which had occurred in the year. Mr Barclay took the committee through each section of the document. In relation to the risks contained within the document, Mr Cutler said that he found this to be particularly detailed and helpful. After discussion, it was suggested that the assurance against the controls in place in relation to the risks could be removed and reference to the Board Assurance Framework, which was in the public domain, could be inserted into the statement. Mr Barclay said that he had not yet discussed the detail of the statement with the Chief Executive and discussion followed in relation to whether any specific quality issue should be included within the end of the statement. Mr Cutler suggested that the Trust Board considered what was reflected within the Board Assurance Framework. Mr Cutler summarised that he was very happy with the content of the statement but suggested that further to the discussion in the earlier agenda item, reference was included in the statement to the embeddedness of the committees. He also felt that reference to the Corporate Governance Code was helpful but suggested “shareholders” be changed to “stakeholders”.
DP/GB GB DP/GB
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Mr Cutler agreed with the significant issue included in the statement but queried whether the Strategic Risk Register risk number 3 was broad enough, referencing reputation and going concern elements. The draft Annual Assurance Statement was noted.
34/15 Draft Audit Committee Annual Report – 2014/15 The report was included for comment. Members were asked to provide updates of their resumes for inclusion together with any relevant training for section 5. Mr Barclay said that within section 2, the Audit Committee did not oversee the work of the sub-committees and this should be changed to “reviews and seeks assurance of…”. Dates also needed to be amended in section 5. The updated Terms of Reference discussed earlier would also need to be appended to the Annual Report. In relation to the section referring to approval of the report and accounts, Mr Cutler said that within this section a paragraph should be included to explain the main risks, discussions and challenges around the approval: it was noted that this could only be updated following the May 2015 meeting.
NEDs DP GB
35/15 Counter Fraud Progress Report Mr Gordon attended the meeting at this point and provided the committee with an update on progress against plan and key issues. Underachievement on plan was due to the retirement of the former LCFS. Mr Gordon said that the committee could be assured that the Counter Fraud status was “green”. During the period before Mr Gordon came into post, the service was being managed by the Deputy Director of Finance with assistance from the NHS Protect Specialist. Mr Gordon requested and received approval of the interim Counter Fraud Policy changes until 31 July 2015, by which time Mr Gordon would have completed a further review and update. Discussion followed in relation to Overseas Visitors, Pride in Pennine comments around working whilst off sick and Mr Gordon’s intention to work with HR to fraud-proof the Sickness Absence Policy. Mr Gordon then took the committee through the ongoing cases report. The report was noted.
36/15 Counter Fraud Annual Plan – 2015/16 Mr Gordon spoke to the plan, reporting that it mirrored the
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NHS Protect standards for provider requirements. The plan included 200 days in total, which was the same as the previous year, split by strategic governance (39), inform and involve (33), prevent and deter (48) and hold to account (80). Mr Gordon informed the committee that overseas visitors would be a particular focus in the year ahead, commenting about the reward scheme which had been introduced whereby if the Trust was able to identify overseas visitors but was unable to recover the money, 50% of the costs would still be recouped. This was noted by the committee to be an important piece of work with financial benefits. The plan was approved. Mr Gordon then left the meeting
37/15 Waivers to Trust Standing Financial Instructions It was noted that the report had been amended to include the name of the supplier, following a request at the last meeting. Mrs Cardiff said that there had been significant challenge at the Procurement Committee in relation to software support for IT solutions as this was felt to be an area where costs could escalate once an IT solution was in place. The report was noted.
38/15 Minutes of other Board Sub-Committees The minutes of the Quality and Performance Committee from January and February, together with the highlight report, were received and noted. Mrs Guereca said that the highlight report demonstrated clearly the issues which had been escalated to the Board, for which there had been extensive discussion and challenge at the Quality & Performance Committee. The minutes of the January and February Finance, Infrastructure & Business Development Committee were received and noted. Mrs Cardiff had no specific comments to draw to the committee’s attention upon items discussed at the meetings.
39/15 Information Governance Audit Paper The committee received and noted the paper which had been approved by the Caldicott & Information Governance Committee. It noted that the Information Governance Toolkit required Confidentiality Audits to be undertaken. The report was noted.
40/15 Any Other Business – Quality Accounts Mr Barclay said that the Trust was no longer required to use the existing External Auditors to audit the Quality
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Accounts but rather could chose. A quote had been received from KPMG which was discussed and approved.
41/15 Any Other Business – Committee Administration Mr Ahmad said that it was Mrs Pullen’s last Audit Committee and expressed appreciation for her assistance.
42/15 Date & Time of Next Meeting The next meeting would be held on Tuesday 26 May 2015 at the earlier time of 9.30 am in the Executive Directors’ meeting room, Second Floor, Trust HQ, NMGH.
There was no private meeting between the NEDS and Internal Audit.
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Title of Report Trust Programmes Board – 24 March 2015
Executive Summary
The minutes from the Trust Programmes Board held on 24 March 2015 are attached.
Actions Requested:
The Board is asked to note the minutes.
Corporate objectives supported by this paper: The Trust Programmes Board oversees the six programmes which in turn drive the corporate objectives of the Trust. The programmes are:
Service Line Reporting
Cost Improvement Programme
Foundation Trust
Clinical Service Transformation
Safety
Workforce and Leadership
Risks: Noted in the relevant section of the minutes
Public and/or Patient Involvement: Not relevant for this paper
Resource Implications: Noted in the relevant section of the minutes
Communication: Details of progress communicated through the line management structure.
Have all implications been considered? YES NO N/A
Assurance X
Contract X
Equality and Diversity X
Financial / Efficiency X
HR X
Information Governance Assurance X
IM&T X
Local Delivery Plan / Trust Objectives X
National policy / legislation X
Sustainability X
Name Ms S Good
Job Title Director of Strategy and Commercial Development
Month and Year May 2015
Email [email protected]
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Notes of Trust Programme Board
Executive Directors’ Meeting Room, Trust HQ 24th March 2015 4pm – 5.30pm
Owner & Timescale
Present S Good, Director of Strategy and Commercial Development (Chair) H Mullen, Director of Operations J Lenney, Director of Workforce and OD J Wilkes, Director of Estates C Sleight, Director of Transformation A Ennis, Head of PMO C Mayer, Non-Executive Directors (NED). M Ollerenshaw, Non-Executive Directors (NED).
In Attendance Nicola Rhodes, Programme Office Project Manager
1) Apologies Dr G Fairfield, Chief Executive B Steven, Deputy Chief Executive / Director of Finance K Salmon-Jamieson, Acting Chief Nurse
2)
Minute The notes of the last meeting were agreed as a true and accurate record.
3)
Matters Arising None
4) a)
Programme Progress Update The Trust Programme report was reviewed by the board and the summary report presented by A Ennis. Trust Programmes board Report attached for information. CIP Programme AE advised the board that the CIP Programme is on track to deliver the £22.5 million target. At month 11 the forecast out-turn position was £22.4m, the final month is reliant upon the cost control measures delivering as expected, and remaining schemes detailed on delivery tracker to deliver within month 12. Cost controls are expected to remain in place entering 15/16. There are currently £8 million of 15/16 CIP schemes with Project Initiation Documents in place; aiming to achieve 100% of the proposed CIP schemes by the end of March 2015.
20150324 Trust Programme Board v1.pptx
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b) c)
JL asked for clarification as to the process for approving CIP schemes. The board were advised that the PMO approves all CIP schemes which then reports to the Medical Director and Chief Nurse for QIA sign off. These are then reported to the CIP Programme Board. There are currently 220 CIP schemes within the pipeline tracker for 15/16. A schedule of approved CIP approved schemes is produced on a weekly basis and reported to the CIP Programme Board. It was agreed that this report will in future include QIA approved schemes and will be included within future CIP Programme Board & Trust Board Reports. Action: Nicola Rhodes to ensure that the PID & QIA schedule is included within the next Trust Programme Board Report. SG raised concerns regarding the commissioner discussions regarding the QIA Process and the approved schemes. Action: CS to meet with commissioners to understand the agreed process and organise necessary meetings to provide assurance. It was suggested that in September the systems and processes for CIP schemes should be reviewed. Service Transformation Programme CS advised the board that the Phase 1 modelling is now coming to an end, and that the 4 specialities (Cardiology, Obstetrics, ID & Orthopaedics) have developed more detailed Transformation plans using a “bottom up” approach. A stakeholder event including input by commissioners is organised for 25th March to discuss and further shape ideas for the proposed models. Work is scheduled to commence on Phase 2 which focuses on A&E, Acute Medicine, Paediatrics and General Surgery. Work will now begin on the development of the Strategic Outline Business Case (SOC) for Transformation. This will be led by Steve Brooks. SG advised the Board that recruitment within the Commercial Development Team would be accelerated to support this. JL sought clarification as to activities within Phase 1. An approach to shape the workforce plans has been discussed with Harsh Choudhry (McKinseys) however the board were asked to note that a lot of work within the workforce plan will be required. AE advised the board that there is a need to correlate the workforce plan with CIP. Safety Programme AE advised the Board that Key Milestones have been identified for 6 areas to develop to Safety Improvement Plan. The areas for safety improvement include:
Prevention of Perinatal harm & deaths
Diabetes
Sepsis
Failure to Rescue
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d) e) f)
Falls
Lessons Learned
Bids have been submitted to NHSLA / Sign up to Safety Programme to fund the safety improvement work. The outcome of the bid is yet unknown. SLR Programme AE advised the board that the SLR dashboard was presented within the work-stream meeting that allows divisions to view their SLR position at specialty level. It was acknowledged that there is a gap in delivery resource, which is proving a challenge. A meeting is scheduled to discuss SLR and the approach to SLR. G Fairfield has advised that she would like to take a lead on this work-stream. Workforce and Leadership Programme JL advised the board that the Workforce and Leadership Terms of Reference (ToR) and membership has been amended. The Board received and formally approved these Terms of Reference. (The ToR approved are attached for information ) JL raised concerns with regards to resource issues in relation to Workforce & Leadership programme. Action: JL, SG and CS to discuss resource for the Workforce and Leadership Programme Board Foundation Trust Programme SG advised the Board that work continues on the Foundation Trust Application. The constitution has been reviewed by the legal team. The desktop exercise with the TDA is going ahead however the Board to Board preparation has been deferred to June 2015. The Membership strategy has been agreed and work continues on this, plans are being developed with a focus on meaningful and active engagement. Work continues on the IBP. The assumptions within Workforce chapter will need to be revisited. The IBP is scheduled for submission in October 2015.
Workforce and Leadership PB Terms of Reference (230614).doc
5)
PMO Support to Trust Programmes – Update CS advised the board that the PMO structure currently contained 8 project manager positions supporting the six work streams. There are currently two interim project managers (occupying the 2 of the 6 Project Manager posts). The previous recruitment drive was successful in appointing one Senior Project Manager. A second round of interviews has taken place this week and 3 successful appointments were offered and accepted, the next step is to
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assign the Project Managers to work streams. SG advised the board that an agreement has been reached to introduce Transformation Support Managers. The Job Description and Person Specification are in draft format. The associated cost of the additional posts still needs finalisation. SG advised the board that a review of the effectiveness of the PMO would take place after it had been fully staffed for 6 months. Ernest Young have had their contract extended until the end of May. A further specification for external support has been tendered. At the end of the term of engagement it is expected that the PMO will self-sustaining. The tender will be released on Monday 30th March. JL suggested that General Management Training schemes for graduates could be considered as further support.
6) Priorities and Main Effort for the Next Period To finalise the Transformation Delivery Managers Job Description & Person Specification. HM asked any advertisements were held until consultation had completed on the divisional restructure work. This was agreed acknowledging this placed risk on the necessity for prolonged external support to the Programmes.
7) Date and Time of Next Meeting The next meeting is scheduled to meet on Tuesday 21st April 2015,
4.00-5.00pm in the Executive Meeting Room
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Title of Report Trust Programmes Board – 21 April 2015
Executive Summary
The minutes from the Trust Programmes Board held on 21 April 2015 are attached.
Actions Requested:
The Board is asked to note the minutes.
Corporate objectives supported by this paper: The Trust Programmes Board oversees the six programmes which in turn drive the corporate objectives of the Trust. The programmes are:
Service Line Reporting
Cost Improvement Programme
Foundation Trust
Clinical Service Transformation
Safety
Workforce and Leadership
Risks: Noted in the relevant section of the minutes
Public and/or Patient Involvement: Not relevant for this paper
Resource Implications: Noted in the relevant section of the minutes
Communication: Details of progress communicated through the line management structure.
Have all implications been considered? YES NO N/A
Assurance X
Contract X
Equality and Diversity X
Financial / Efficiency X
HR X
Information Governance Assurance X
IM&T X
Local Delivery Plan / Trust Objectives X
National policy / legislation X
Sustainability X
Name Ms S Good
Job Title Director of Strategy and Commercial Development
Month and Year May 2015
Email [email protected]
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Notes of Trust Programme Board
Executive Directors’ Meeting Room, Trust HQ 21st April 2015 4pm – 5.30pm
Owner & Timescale
Present S Good, Director of Strategy and Commercial Development (Chair) J Lenney, Director of Workforce and OD C Sleight, Director of Transformation B Steven, Deputy Chief Executive / Director of Finance Dr A Sinniah, Acting Medical Director Dr M Moonan, Director of Service Improvement
In Attendance Nicola Rhodes, Programme Office Project Manager
1) Apologies Dr G Fairfield, Chief Executive G Harris, Chief Nurse Dr R Prudham, Deputy Medical Director H Mullen, Director of Operations J Wilkes, Director of Estates
2)
Minutes of Previous Meeting The notes of the 24th March 2015 meeting were agreed as a true and accurate record.
3)
Matters Arising CS advised the board that Job Descriptions and Person Specifications were completed for the Transformation Delivery Managers. These positions will be offered on a secondment basis at existing grades. JL advised that the Job Description would need to go through banding process. CS to speak to Nick Hayes.
CS
4) a)
Programme Progress Update The April Trust Programme report (distributed on the agenda) was reviewed by the board and the summary report presented by CS. Cost Improvement Programme (CIP) CS advised the board that CIP Delivery for month 12 is £21,583. The current forecast CIP delivery position is £22.95 million, £563k of this is cost avoidance, with an additional £210k expected forecast within month and £599k of extreme measures. The final figures for cost controls are yet to be finalised and will published in the CIP Programme Board on Monday 24th April 2015. Work continues on the development of 2015/16 CIP schemes. The Trust is required to deliver a minimum CIP target of £27.5m in 2015/16.
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2
This is based upon a £20.76m efficiency target and a £6.78m decommissioning target. In addition the Trust needs to deliver £6m of non-recurrent savings. There are currently £14.7 million of CIP schemes identified. £9.9 million PIDs have been completed with an additional £4.8 million of schemes have been PMO accepted and QIA approved. A discussion took place regarding the requirement to finalise the CIP phasing by the end of April for submission in the final version of the Trusts Annual Plan. Concerns were expressed on CIP delivery in M1 and M2. It was agreed that the phasing would be reviewed and agreed at the next CIP Programme Board. BS raised concerns regarding the 2015/16 schemes advising the group that there is currently £19m of 2015/16 CIP schemes in place against a target of £28.5 million; a discussion took place on the best methods to bridge the gap. It was agreed that there may a need to change the approach to CIP delivery and that a large engagement event focussing on innovation would be a sensible option. Concerns were raised that previous engagement events lacked consultant and nurse leadership, and that the engagement was required with the whole clinical workforce. Action: H Mullen, G Harris, Dr A Sinniah & Dr M Moonan to explore this further and feedback at the next event. BS suggested that focus groups be considered to explore specific topics, i.e. Agency spend. JL agreed that this would be the biggest opportunity within the Workforce CIP Schemes as the Trust currently has 10% temporary staffing levels, the national average is 6%. BS noted that the Royal College paper on the reduction of clinical waste had been received by SMG and JLNC but hasn’t been progressed any further, it was agreed that this could be included within one of the workstreams. Action: J Lenney to consider the reduction of clinical waste within the Workforce Transformation Programme. CS suggested that the work emerging from the Clinical Services Transformation programme needed to be reviewed by divisions to establish if there were any schemes that could be progressed without consultation. This has already been identified as a CIP target but as yet there are no schemes firmly identified. This need for consultation needs clarity. SG reminded the Board there was a stakeholder event on 11th May where this could be discussed further. CS advised the board that there is a need to ensure that everyone is aware of the process for CIP schemes. There is a schedule of engagement events planned throughout April and May. The CIP PID & QIA schedules were reviewed. BS asked that scheme values be included at the next meeting. Action: Nicola Rhodes to ensure that future iterations of the PID & QIA schedule include values against the schemes.
HM/GH/AS/MM JL SG CS/NR NR
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3
b) c)
Clinical Service Transformation Programme Work has commenced on Phase 2 which focuses on A&E, Acute Medicine, Paediatrics and General Surgery and is progressing at pace. Two Senior Project Managers (Reyhana Khan and Julie Owen) have been assigned to this Clinical Services Transformation Programme, working with McKinsey. Clinical Leads for next phase are yet to be identified. Urgent Action: CS and SG to discuss the identification of Clinical Leads with Dr Roger Prudham. Concerns were raised regarding the support required to hit the end of June deadline. The activity and financial modelling team led by Imtiaz Bala were suggested as additional resource, as well as the four Information Managers that have been recently appointed within the divisions. CS to speak to Christine Walters to ascertain if these posts could provide support to the Clinical Services Transformation modelling. JL raised concerns that intelligence regarding assumptions may be lost when McKinsey complete their assignment at PAHT. It was agreed that the assumptions need to be more explicit and understood in more detail. JL to discuss workforce assumptions with McKinsey and Imtiaz Bala. CS to approach McKinsey to ensure all assumptions are articulated. It was suggested that a session with the executive team to explore the assumptions further be organised. CS to discuss this with G Barclay to see if it was possible to utilise a Board Development session. It was agreed that it was essential that once were the assumptions were understood that the directorate management teams would need to buy into the options and understand the degree of difficulties, complexities, risks and implications involved within the Transformation programme. A Stakeholder event took place on Wednesday 25th of March where the options were presented. A second event is being organised for Wednesday 24th of June. Work has begun on the development of the Strategic Outline Business Case (SOC) for Transformation. This will be led by Steve Brooks. SLR Programme BS advised the board that an appointment had been made into the Director Performance and Contracting post who would be joining the Trust in May 2015. Work continues on the development of the SLR Dashboard. The programme board did not meet in April. A meeting is scheduled to discuss SLR and the approach to SLR. It was acknowledged that there is a gap in delivery resource, which is proving a challenge. It was suggested that the SLR Project Manager could be shared with another a workstream.
CS/SG CS JL CS CS CS
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d) e)
Workforce and Leadership Programme JL advised the board that the Workforce and Leadership Terms of Reference (ToR) and membership has been amended. The Workforce & Leadership Programme Board did not meet in April. The next meeting has been scheduled for 14th of May however this will need to be rearranged. It is hoped that the next meeting will take place on 21st May. JL advised the board that there is an opportunity to develop an internal Graduate Training Programme as a joint venture with Central Manchester to help develop capacity and capability. Foundation Trust Programme SG advised the Board that work continues on the Foundation Trust Application. The constitution has been reviewed by the legal team. The consultation has been put on hold until after the Chief Inspector visit which is expected in the Autumn. SG provided feedback on the IBP chapters, detailed below: Chapter 2
The background information requires continuous updating
Agreement of cut off dates for information to be included in this
chapter
Chapter 3
Requires a stronger link between our values, corporate priorities,
transformation map etc.
TDA noted our ten corporate objectives will take more than a
year to deliver and therefore we need to explain how we will
achieve these over time.
TDA commented on the language used; we advised that we are
already reflecting on this but that is reflects staff input
Chapter 4
It was felt that we did not articulate strongly enough the
complexity of the landscape in which we operate and therefore
how we will respond/are responding.
Chapter 5
Need to articulate detailed response to how we intend to deliver
our services and what they will look like in view of the complex
position we are working with, i.e. DevoManc, Heathier Together.
Chapter 6
Advised that financial information required should be the current
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5
year and the previous two financial years.
Chapter 7
This section should identify top 10 risks
TDA stressed that the level of detail regarding the risks is
important but that mitigation is key, and also needs to line up with
our strategy
Chapter 8
This needs be better linked to our service development and
strategy development
Chapter 9
Noted that it was based on structure of Monitor guidance,
however TDA requested that we bring forward the structure of the
Board and how it fits in with the Strategy
Need to ensure Risk section reflects what is noted in Chapter 7
It was noted that the TDA re-iterated that they have not put anyone forward for approval without a breakeven financial position in the year they will be progressing, and therefore this is something the Trust will need to work hard on. Action S Good and S Statom
SG
5)
PMO Support to Trust Programmes – Update CS advised the board that the PMO structure currently contained 8 senior project manager positions supporting the six work streams. One substantive Senior Project Manager is now in post and has been assigned to the Clinical Services Transformation Programme. A further Senior Project Manager starts in post on Monday 27th of April and will be assigned to the Safety Programme. Two other applicants have now received unconditional offers of employment, start dates to be determined. Two other positions filled by internal secondments (Julie Owen – Clinical Services Transformation; and Su Statom – Foundation Trust Programme/Safety (Falls) work-stream). A discussion took place regarding the funding for Transformation Delivery Managers. This will need to be considered further. CS to progress the job description in the meantime (as item 3).
CS
7) Date and time of the next meeting: Tuesday 26th May at 4 pm in the Executive Meeting Room
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Title of Report Quality & Performance Committee Minute – 24 March 2015
Executive Summary
The minutes of the Quality & Performance Committee held on 24 March 2015 are attached. Items for escalation to the Trust Board were:-
Sickness and Absence rates
Resource and capability issues
Maternity Service Staffing Levels
Birthrate Plus
Bowel Cancer Progress
GI Bleed Rota
Level of Clinical Leadership and Decision Making
Actions Requested:
The Board is asked to note the content of the minutes
Corporate objectives supported by this paper: All Corporate Objectives are supported by the work of the Quality & Performance Committee
Risks: Any risks identified at the meeting are referred to the relevant manager for possible inclusion on the relevant part of the risk register.
Public and/or Patient Involvement: Not relevant for this paper
Resource Implications: Not relevant for this paper
Communication: The Quality & Performance Committee communicates its work through the Trust Board and the Divisional Quality & Performance Committees.
Have all implications been considered? YES NO N/A
Assurance √
Contract √
Equality and Diversity √
Financial / Efficiency √
HR √
Information Governance Assurance √
IM&T √
Local Delivery Plan / Trust Objectives √
National policy / legislation √
Sustainability √
Name Shauna Dixon
Job Title Non-Executive Director
Month and Year May 2015
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Minute
Quality and Performance Committee Room 237, Second Floor, Trust HQ
24 March 2015 9am – 12 noon
Owner
Timescale
Present Mrs S Dixon, Non-Executive Director (Chair) Mrs D Ashton, Divisional Director, Surgery Mr G Barclay, Assistant Chief Executive/Board Secretary Dr I Conyon, Performance Manager Mr V Crumbleholme, Divisional Nurse Director, Surgery Mrs C Guereca, Non-Executive Director Ms P Jones, Chief Pharmacist Mrs S Jones, Head of Clinical Professions Mrs U Martin, Director of Clinical Governance Mrs C Mayer, Non-Executive Director Mrs J Moore, Divisional Director, Medicine Mr H Mullen, Director of Operations Mrs K Salmon-Jamieson, Acting Chief Nurse Dr A Sinniah, Acting Medical Director Mrs C Trinick, Director of Midwifery Mr J Wilkes, Director of Estates & Facilities
In Attendance Mrs B Cook, Programme Manager Mrs A Dalton, Interim Turnaround Manager, RTT & Cancer Ms S Flaherty, Corporate Governance Manager Dr J Moise, Divisional Medical Director, Women & Children Mrs C Parker, Lead Nurse, Patient Experience Mrs D Pullen, Head of Corporate Governance
Apologies Dr G Ahmad, Divisional Director, Women & Children Mrs A Barker, Acting Divisional Director, Diagnostics Mrs J Keogh, Divisional Director, Women & Children Dr R Prudham, Deputy Medical Director (Quality) Mr B Steven, Deputy Chief Executive/Director of Finance Mr S Taylor, Divisional Director, Integrated & Community Care Dr S Woby, Director of Research and Development
Procedural Business
80/15 Welcome and Apologies Mrs Dixon welcomed everybody to the meeting, commenting that there was no triumvirate representative from the Diagnostics Division. Ms P Jones said that she would answer questions and would refer any further points back to the Division.
81/15 Declarations of Interest There were no declarations of interest relevant to items on the agenda.
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82/15 Chairman’s Remarks Mrs Dixon said that it was a long agenda and asked that when reports and items were presented that attendees concentrated on assurance, impact and outcomes for patients as the role of the committee was to provide assurance to the Trust Board. Mrs Dixon asked that everyone thought about quality, outcomes and impact on patients during the agenda items.
83/15 Minutes of the Previous Meeting The minute of the meeting held on 24 February 2015 was accepted as a true record with the addition under 40/15, Mrs Dixon had asked that “everyone thought about quality, outcomes and its impact on patients during the agenda items”.
84/15 Review of Action Checklist/Matters Arising From the Previous Meeting Mrs Dixon took the committee through the action checklist and spoke to the updates provided therein. It was noted that many of the items were included as a separate agenda item or updates were included in the highlight reports submitted to the committee. 21/14 D&T Review as Sub Structure of Quality & Performance Committee Ms Jones said that the review would not be ready for the April meeting. This item was deferred until May 2015. 33/15 Diagnostics Highlight Report It was noted that the updated version of the January highlight report had not yet been received or circulated to members. In Alex Barker’s absence, this item was deferred until April 2015. New Items added to the Action Checklist Vascular Mr Mullen said that this item was linked to specialist commissioning: a hybrid theatre would be available from mid-April. It was agreed that an update on “Vascular” would come back to the Committee in April 2015. HpB Pathology Services It was noted that Dr Benatar had agreed a SLA with CMFT and it was agreed that Ms P Jones would follow this up on behalf of the Division with Dr Benatar and thereafter provide an update.
PJ AB DA PJ
May 15 April 15 April 15 April 15
85/15 Quality & Performance Committee Chart Mr Barclay spoke to the updated chart which included one amendment of the Non Clinical Records Management Committee as a sub-committee of the Caldicott and Information Governance Committee. He said that there was one outstanding action to confirm the parent committee for the Safeguarding Committee. The reporting arrangements for the Performance Management Group would be discussed by the Executive team. Mr Barclay said that he and Mrs Martin were going to be working to realign and remove duplication in the structures and committee reports and would report back next month.
GB
April 15
86/15 Annual Assurance Statement – Various Committees Mrs Pullen advised that at the February meeting the majority of the annual assurance statements had been received and noted. Included in the pack were the remaining annual assurance
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statements which combined had led to the production of the annual assurance statement for the Quality & Performance Committee which was the next Agenda item. In relation to the Clinical Audit and Effectiveness Committee, Mrs Salmon-Jamieson said she would liaise with Gill Harris as to her view on nursing representation at that committee. Mrs Guereca raised the level of attendance at some of the committees and asked whether there was a minimum criteria for attendance and then escalation if that was not met. Discussion then followed as to the minimum criteria and it was agreed that Mr Barclay and Mrs Martin would look at this and come back with an attendance figure to the April meeting. A couple of other minor points were noted against the submitted annual assurance statements. Mrs Dixon commented that there was lots of reassurance within the statements submitted and felt there was the need for an increased focus on upward assurance to the Trust Board. Mrs Dixon commended the detail of the annual assurance statement for the division of Community and Integrated Services, particularly as this division had only recently been established.
KSJ GB
April 15 April 15
87/15 Annual Assurance Statement – Quality & Performance Committee Mrs Dixon noted the annual assurance statement provided assurance that the committee had effectively discharged its responsibilities since its inception in September 2014. The annual assurance statement was approved and would be submitted to the Audit Committee.
DP
April 15
Safety
88/15 External Review – Maternity Service – Report and Action Plan Both Dr Moise and Mrs Trinick were present at the committee and presented the overview of the external independent review into 9 serious incidents within Maternity Services at the Trust. The report included the paper to be considered by the Board of Directors on 26 March 2015, the terms of reference, the independent report, draft improvement plan and draft Internal Serious Incident Management Group Terms of Reference. The Trust’s draft improvement plan also took into account the recommendations from the report into Morecambe Bay FT which had been published in February 2015. The following points were noted during discussion, questions and answers:-
One further case would be added to the review and lessons learnt would be included in the action plan.
A monthly update in relation to the improvement plan would be submitted to the committee.
Assurance would be provided by the internal incident management group which would provide assurance internally to the Q&P Committee and externally to CCGs, TDA and NHS England.
Arising from the Morecambe Bay review, a National Enquiry into maternal deaths may take place.
CT
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Further work was needed on leadership and this would be taken forward with the Director of Workforce.
Timely decision making was a key theme. The Royal College of Gynaecologists had developed a toolkit to support this.
Bespoke leadership training would be considered and SMT would look at decision making processes.
Mr Mullen noted that there were some imminent completion dates within the improvement plan and he asked whether these would be delivered. It was agreed that the committee needed assurance that the improvement plan was on track post. Mrs Salmon-Jamieson said that the initial external report had been limited to a case note review and there were other elements of the original terms of reference which still needed to be completed. In addition one further case, which was being heard by the Coroner that day, needed to be added to the review. Mrs Salmon-Jamieson said that the recommendations from the review highlighted a number of issues related to process and risk and the RCA process and action planning. Mrs Martin said that she felt that the improvement plan needed further actions on staffing. Mr Wilkes queried whether there were any issues related to organisational culture which needed to be included. Mrs Salmon-Jamieson said such matters would be covered by the leadership programme. Work streams would be established to implement the improvement plan. Mrs Dixon asked that the divisional quality and performance committee monitor the improvement plan and to report to this Committee. Mrs Mayer said that the report implied that safety was compromised due to staffing levels being insufficient. She asked how that would be addressed. Mrs Salmon-Jamieson replied that in advance of the outcome of the review being known a separate review of midwifery staffing, known as Birthrate plus, had been carried out. This review had indicated that while the Trust currently met that national recommended ratio of one midwife for every 28 births, the acuity, case mix and staffing skill mix in the Trust’s hospitals meant that additional staff would be required. Mr Mullen said that while the Trust had 134 hours of consultant cover per week on the labour wards (24/7 cover would be 168 hours) and that this was one of the highest ratios in the country for the type of unit, further improvements were required. Mrs Dixon suggested that the Trust volunteer for any forthcoming national review of maternity services. Mr Mullen said that the Board could discuss this later in the week. In relation to the Serious Incident Management Group Terms of Reference, Mrs Salmon-Jamieson said she would take any comments from the Committee to the Trust Board and then to the first meeting of the group. In conclusion it was agreed that more actions would be included in the improvement plan relating to staffing levels and the work streams being implemented to deliver the plan. It was noted that additional resource capacity had been requested to support delivery
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of the plan and this item would remain an agenda item at the Committee until completed. Maternity staffing levels (Midwifes and Obstetricians) was an area that needed to be considered by the Senior Management Team and the Trust Board.
89/15 National Bowel Cancer Audit – progress on actions Dr Sinniah spoke to the update which had been previously circulated by email from Dr Prudham on 23/03/15 in relation to the 18 month stoma reversal and 2 year mortality data. Dr Sinniah said that the Royal College of Surgeons review was expected to complete in September 2015. The Committee noted that actions were now in place for unification of the MDT process from June 2015. A PTL for stoma reversal within 12 months was now in place. Mrs Mayer asked about the variation between individual consultants and Mrs Ashton responded. Mrs Dixon asked about confidence in the measures in place to ensure safe service provision. Dr Sinniah described various changes which had been put in place and said that he felt assured that the service was safe and actions had been taken which would improve this further. Mrs Dixon asked for the action plan to be written up and shared with the Royal College of Surgeons. Mrs Mayer said that the Trust needed unequivocal assurance from the Royal College of Surgeons review.
AS/ RP
April 15
90/15 SUI Report Mrs Martin spoke to the report which included confirmation of the base line assessment of serious incidents and red incidents. As a component of moving forward to a new policy and process in relation to serious incidents and incident management, Mrs Martin said a review needed to be undertaken regarding outstanding investigations and actions. This would involve transparent governance processes, shared with commissioners. After discussion the committee supported the actions to finalise current investigations and requested an update for the June meeting. It was agreed to escalate to the Trust Board the level of resource currently available to divisions in order to finalise all current investigations. Mrs Martin said that once in post, the Head of Patient Safety would work with divisions. Work to close all current investigations would be undertaken within the next 2 months and then agreement would be reached on the timescale to ensure that all actions arising had been consolidated and actioned appropriately.
UM SD
June 15
91/15 GI Bleed – Patient Impact Report Mr Crumbleholme presented the report which contained information on the impact on patients and staff arising from lack of a dedicated GI bleed rota. Mrs Dixon said that the Trust still had a high level of risk. Mrs Moore updated the Committee on the current situation with consultation on establishing a dedicated GI bleed rota. Establishment of a dedicated GI bleed rota would also require changes to the General Medical rota and the establishment of a stroke rota. Mrs Moore said that the stroke rota would be implemented from 1 April 2015 and the GI rota had a likely implementation date of 1 June 2015. The Senior Management Team had asked Mrs Moore whether an interim GI rota could be established in advance of the formal rota. Dr Sinniah said that Mrs
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Moore had explored all options and an interim solution was not feasible. Mrs Guereca asked whether GI bleed patients could be treated in other hospitals until a GI bleed rota was established. Mr Mullen said this was not practical as it was not usually known that a patient had a GI bleed until they had been admitted and undergone some investigations. The only way to prevent admitting GI bleed patients would be to close to all surgical admissions, and this was not practical and would create a much greater risk. Mr Mullen said that by establishing a separate GI bleed rota the Trust would be putting in place a service which was of a much higher standard than in most hospitals across the country as very few hospitals had separate GI bleed rotas. Mrs Mayer said that she was disappointed that a period of consultation was required and that an interim solution could not be found. She asked whether individual consultants had seen the impact report and had given thought to the implications for their own and the Trust’s reputation. Mrs Mayer was keen that a new rota was put in place as soon as possible. Dr Sinniah said that progress was being made as quickly as possible but that it was essential that staff were brought on board with the new arrangements. Mrs Dixon commended the work being undertaken and urged resolution as quickly as possible.
92/15 Nursing Metrics Assurance Process Reports Mrs Salmon-Jamieson spoke to the overview report which detailed the process within Medicine and Surgery to meet compliance against the nursing metrics. Only one ward (at TROH) had been red for two consecutive months. Mr Crumbleholme described the detailed review undertaken which would report back to the committee and was linked to leadership on that ward. A further eight wards which had been amber for more than two consecutive months. In relation to T3 ward. In response to a question from Mrs Guereca, Mrs Salmon-Jamieson confirmed that an escalation plan was in place, monitoring arrangements were being revised and would be considered by the Nursing & Midwifery Board meeting later in the day. Mrs Salmon-Jamieson then went on to describe ward accreditation which would be very closely linked to the CQCs new fundamental standards which would be developed after discussion with Gill Harris. Confirmation was given that actions were in place and being tracked and an escalation process for rapid review was in place. Progress was noted.
93/15 NHS England – Peer Review of Colorectal & Upper GI MDTs As mentioned earlier in the meeting, Mr Mullen said that the Trust was working to a date of June 2015 for a unified MDT.
94/15 Safety Committee Highlight Report Dr Sinniah spoke to the report drawing the Committee’s attention to C Diff being over trajectory and another issue in relation to downgrading of wrong blood in tube incidents to orange which would be reclassified as red incidents.
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Clinical Effectiveness
95/15 NICE: Specialty Level Report – Non Compliance Mrs Martin spoke to the report stating that a review of all NICE guidelines was undertaken with each of the directorate / specialties required to review the relevant guidance and complete the appropriate baseline assessment tool. Currently there were 41 NICE guidelines under review of which 17 (41%) required immediate completion as they were outside the allocated timeframe for completion. Mrs Martin asked that divisions clarified their timescales and plan for ensuring that all NICE guidance documents had been reviewed and actions identified for any areas of partial non-compliance. Discussion then followed in relation to the need for more clinical leadership and increased resources to deal with such matters. It was agreed that within 6 months the divisions would complete all the work required.
UM
Sept 15
96/15 Clinical Audit Forward Programme 2015/16 Mrs Martin spoke to the report which provided an overview of the development of the Clinical Audit Forward Programme for 2015/18. Mr Mullen noted reference to readmissions within the clinical audit programme at directorate level. Mrs Mayer asked whether maternity and infection were appropriately covered within the plan, to which Mrs Martin said yes but that these would need to be built into the scope for future items.
Patient Experience
97/15 Highlight report and the minutes were not due yet.
Quality Accounts
98/15 Quality Accounts Highlight Report The report was noted.
99/15 Quality Account Minutes There had been no meeting since the last Q&P.
100/15 Draft Quality Priorities 2015/16 Mr Barclay tabled the Quality Accounts report for 2014/15 which included quality priorities for 2015/16. These consisted of 9 priorities (3 patient safety, 3 clinical effectiveness and 3 patient experience). Mrs Martin said that the proposed priority regarding ward accreditation needed more discussion as whilst there was real value in terms of preparing for the Chief Inspector of Hospitals visit, there were resource requirements. Mr Barclay said that the draft quality account was being considered by the Trust Board later in the week and then would be sent to stakeholders for comment on the overall content. Any comments were welcomed and should be forwarded to Andrew Lynn as the author of the document.
ALL
Research & Development
101/15 The highlight report and minutes are not due this month.
Caldicott & Health Informatics
102/15 Caldicott & Health Informatics Committee Highlight Report The highlight report was received and noted.
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103/15 Caldicott & Health Informatics Committee – 23 Jan 2015 The highlight report was received and noted.
Medicines Management
104/15 Medicines Management Quarterly Report The quarterly report was received and noted.
105/15 Medicines Management – Omitted Medication Audit Report Ms Jones said the summary report had been received and compared with the last audit. The use of EPMA had made improvements due to more information now being available on why doses were missed. Ms Jones said that the missed dose figure was 12% which related to drug unavailability or clinical reasons. In relation to missed doses due to drug unavailability, Ms Jones said that 65% of the doses were actually available as ward stock in another area or via pharmacy’s emergency stock. In summary Miss Jones said that this was generally moving in the right direction. In response to a question from Mrs Dixon, Ms Jones said that she currently only had site level information and ward level would follow and be shared.
PJ
May 15
External Performance Monitoring and Reports
106/15 External Reviews – Horizon Scanning Mrs Martin said that in relation to the PHSO, 2 of the Trust’s complaints which had been referred to the PHSO would be featured in the report published that week. In addition, in relation to the Health and Safety Executive, a Notice of Contravention report had been received for non-compliance with EU Directive on safer sharps. It was noted that there had been investment agreed to be compliant and a plan in place which would be rolled out in high risk areas first: Infectious diseases and A&E. Mrs Martin suggested that the Horizon scanning agenda item be merged with the external visits log. It was discussed that there was a peer review underway in pathology and also a trauma review. It was agreed that the external visits log would come back to the Committee in April.
GB
April 15
Policies
107/15 Document Management Highlight Report The document management highlight report was received and noted.
Performance
108/15 Monthly Integrated Performance Report Dr Conyon spoke to the report highlighting initially that there were new National ward staffing RAG rated scoring systems being introduced for 2015/16 and included in the report was the Trust’s performance in shadow format, for which the Trust had an overall rating of blue (OK) because all of the KPIs were within their expected ranges. In relation to the 6 domains reported monthly on the summary integrated scorecard, all were stable with the exception of finance which had improved due to the allocation of support funding from the TDA. In respect of business capability, there had been a slight improvement in the specialties which earned sufficient income to
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cover their direct and indirect costs. Activity performance versus plan deteriorated in February and remained behind plan for Elective and Day Case. In relation to quality, C. Diff had exceeded the annual plan with 1 month remaining in 2014/15 at a rate of 67 cases against a plan of 62. In addition, one never event would be reported during March which was an incident from 2008. A root cause analysis was being undertaken as a priority. In relation to operational performance, the 4 hour standard was achieved in Q1 and Q2 but was not achieved in Q3, February and Q4. Pressure remained high with demand above plan. Mrs Moore said that from mid-February it was evident that the Trust statistically would not achieve the year end target as a Trust and pressures continued well into March. North Manchester had recovered and achieved every day and that site would achieve for the year, being 1 of only 3 sites in the North West to do so. Mrs Moore described the unprecedented number of attendees with 1012 attendees the day before. Monday’s were described as being very high for the number of attendances and Mrs Moore described her concern around the TROH site and gave an example of 54 patients arriving in 1 hour. Mrs Moore also described the succession plan issues for general medical doctors at the TROH site. Mrs Mayer acknowledged the significant work undertaken in the Trust in relation to both the RTT and the 4-hour targets. She noted that infections and pressure care continued to be issues. Mrs Salmon-Jamieson discussed the “don’t wait, isolate” infection control initiative and described the further work which would be undertaken at divisional level. In relation to finance, the Trust had recently received non-recurrent deficit funding from NHS England for 2014/15 and as such the Trust had revised its forecast outturn to achieve its statutory duty to break even. The year to date continuity of service rating had improved to 4 due to the TDA funding with a forecast year-end continuity of service risk rating of 3.5 which was above the level of an aspirant FT Trust of 3. In relation to workforce, sickness absence decreased at 6.05% missing the 4.2% trajectory every month and therefore missed the 2014/15 target. Bank and Agency spend had decreased but remained above target. Action was being taken to alleviate vacancies, backfill sickness absence to support safe nursing and midwifery staffing levels and support achievement of access targets. The National Staff Survey in relation to Staff Friends and Family test were below target for both indicators. In relation to CQUINs and particularly the NHS Safety Thermometer/Prevalence of Pressure sores, Mrs Salmon-Jamieson described work which was underway which could take 3-6 months for the full impact to be noted.
109/15 Cancer Performance Mrs Dalton attended the committee and presented her paper which provided assurance on the improvement in the delivery of the 62 day cancer waiting time standard by sharing an analysis of breaches of the 62 day standard, articulating improvements made internally to systems and processes and detailed the findings and recommendations of a GM wide review of pathways. Mrs Dalton
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went through the tracking practices and improvements to systems which included daily exception reporting and significantly enhanced cancer patient target lists resulting in improved efficiency of the tracking process, ability to escalate delays in between events and developing a prompt delivery approach to booking and scheduling of appointments. In January 2015, all cancer waiting time standards with the exception of 62 days were achieved and Mrs Dalton explained that the majority of pathways were 2 and 3 centre pathways so were complex and as such had been incorporated within the cancer improvement action plan which was monitored weekly. The development of a GM wide cancer access policy was a significant step in improving performance across the conurbation and Mrs Dalton said that the cancer commissioning lead was supportive of such an approach and a timescale set for completion was Q1 in 2015/16. Mrs Dixon commended Mrs Dalton for her improvement work. Mr Mullen described the need for commissioners to buy the right level of activity to enable the Trust to guarantee compliance for Q1.
110/15 Handover of Care Performance – Outpatients Mrs Cook attended the Committee and confirmed that the compliance report in relation to inpatient discharge summaries, as discussed last month, was included in the pack for information. Mrs Cook then took the committee through the report. In relation to outpatient letters first attendances, these needed to be sent to patients’ GPs within 10 working days of all first attendances. Mrs Cook went through the report and confirmed that there was now a more stable IT solution for dictation and described the Trust’s exclusion criteria which was the largest challenge as not all clinics should be included in the performance target. Mr Mullen said that the report showed significant progress in non-elective performance and hopes that the combined figure for February and March was 95%. It was noted that the errors due to poor communication between primary and secondary care were reducing.
112/15 Performance Management Group Highlight Report The report was for noting as the items had already been discussed.
113/15 Performance Management Group Minutes – Feb 15 The minutes were noted.
Reports from Divisional Quality and Performance Committee
114/15 Surgery Q&P Highlight Report Mrs Ashton said that Mrs Martin had observed their last meeting which had been useful. Mrs Martin said that she had asked that directorate managers talk to their own incidents and complaints at the divisional Q&P meetings in order to ensure ownership. Mrs Martin asked that this be replicated across all the divisions.
DDs
115/15 Diagnostics & Clinical Support The report was noted.
116/15 Medicine
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Mrs Moore said that there were a high number of nursing vacancies and staff sickness was at 7%. The division had a number of complaints and incidents to close down: it was at this point that clinical governance resource capacity relating to all divisions ability clear complaints, incidents and ensure compliance with NICE guidelines, update Trust policies, guidelines and patient group directives as well as delivering on quality, performance and finances was discussed.
117/15 Integrated & Community Services Mrs Dixon noted the good progress which was being made with this relatively new division.
118/15 Women & Children’s Division Mrs Trinick said that the Morecambe Bay Report had been received and would be included within the Trust’s internal improvement plan. It had been shared within the multidisciplinary team.
119/15 Divisional Quality & Performance Minutes The divisional Q&P committee minutes from the Division of Medicine’s meeting on 11 March 2015 were submitted and noted. Mrs Pullen requested that copies of all divisional Q&P committees be provided to her for inclusion in future agendas together with the highlight reports. It was acknowledged that the highlight report each month was for the divisional Q&P committee held that month with a month's time lag for provision of the minutes.
DDs
Monthly
Risk
120/15 Issues for Escalation to the Trust Board The immediate items noted for escalation to the Trust Board were:
Sickness and Absence rates
Resource and capability issues
Maternity Service Staffing Levels
Birthrate Plus
Bowel Cancer Progress
GI Bleed Rota
Level of Clinical Leadership and Decision Making Mrs Mayer asked in relation to the mortality report whether this would be coming back to the Q&P committee. Mrs Martin said that a detailed mortality report was received by the Safety Committee which was a subcommittee of Q&P. It was agreed that all reports would be mapped out in the work to take place between Mr Barclay and Mrs Martin.
GB/ UM
121/15 Date of Next Meeting The next meeting would be held on the Tuesday 28 April 2015 at 9:00-12:00 in room 237.
Review of Meeting Roundtable Feedback
Lots covered, better discussion
Open discussion
Helpful steer
Learning from Maternity Improvement Plan – all divisions
Understanding complexity of agenda items, balanced with timeframes
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Welcome support from Mrs Salmon-Jamieson and Mrs Martin regarding the Maternity Review – there is a cohesive team but there are resource issues.
Themes across directorates
Good to focus on a couple of main items
Right agenda topics being considered by the committee but papers to be more focused
Need to identify the difference between assurance and reassurance
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Title of Report Quality & Performance Committee Minute – 28 April 2015
Executive Summary
The minutes of the Quality & Performance Committee held on 28 April 2015 are attached. Items for escalation to the Trust Board were:-
Clarity of escalation and assurance on the maternity review via the Incident Management Group
Clinical Audit & Effectiveness Committee – not assured around its operation
Resource and capability issues, particularly in relation to governance and divisional changes – 2 month time lag
Diagnostic 6 week standard missed – could take 6 months to resolve
Maternity Review to be included on Strategic Risk Register
Handover of Care (Inpatient) – March 2015 95% target achieved
Interim GI bleed rota solution identified
Monitoring progress against the SUI policy of which Duty of Candour would be an element
Actions Requested:
The Board is asked to note the content of the minutes
Corporate objectives supported by this paper: All Corporate Objectives are supported by the work of the Quality & Performance Committee
Risks: Any risks identified at the meeting are referred to the relevant manager for possible inclusion on the relevant part of the risk register.
Public and/or Patient Involvement: Not relevant for this paper
Resource Implications: Not relevant for this paper
Communication: The Quality & Performance Committee communicates its work through the Trust Board and the Divisional Quality & Performance Committees.
Have all implications been considered? YES NO N/A
Assurance √
Contract √
Equality and Diversity √
Financial / Efficiency √
HR √
Information Governance Assurance √
IM&T √
Local Delivery Plan / Trust Objectives √
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National policy / legislation √
Sustainability √
Name Shauna Dixon
Job Title Non-Executive Director
Month and Year May 2015
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Minute
Quality and Performance Committee Room 237, Second Floor, Trust HQ
28 April 2015 9am – 12 noon
Owner
Timescale
Present Mrs S Dixon, Non-Executive Director (Chair) Mrs D Ashton, Divisional Director, Surgery Mr G Barclay, Assistant Chief Executive/Board Secretary Dr I Conyon, Performance Manager Mrs C Guereca, Non-Executive Director Ms P Jones, Chief Pharmacist Mrs S Jones, Head of Clinical Professions Mrs C Mayer, Non-Executive Director Mrs J Moore, Divisional Director, Medicine Mr H Mullen, Director of Operations Mrs K Salmon-Jamieson, Acting Chief Nurse Dr A Sinniah, Acting Medical Director Mr B Steven, Deputy Chief Executive/Director of Finance Mr S Taylor, Divisional Director, Integrated & Community Care Mrs C Trinick, Director of Midwifery Dr S Woby, Director of Research and Development
In Attendance Mrs K Hingley, Head of Patient Safety Mrs C Parker, Lead Nurse, Patient Experience Mrs D Pullen, Head of Corporate Governance
Apologies Mrs G Harris, Chief Nurse Mrs U Martin, Director of Clinical Governance Dr R Prudham, Deputy Medical Director (Quality) Mr J Wilkes, Director of Estates & Facilities
Procedural Business
122/15 Welcome and Apologies Mrs Dixon welcomed everybody to the meeting.
123/15 Declarations of Interest There were no declarations of interest relevant to items on the agenda.
124/15 Chairman’s Remarks Mrs Dixon said that it was important that the meeting started on time due to the long agenda and asked that when reports and items were presented that attendees concentrated on assurance, impact and outcomes for patients as the role of the committee was to provide assurance to the Trust Board.
125/15 Minutes of the Previous Meeting The minute of the meeting held on 24 March 2015 was accepted as a true record.
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126/15 Review of Action Checklist/Matters Arising From the Previous Meeting Mrs Dixon took the committee through the action checklist and spoke to the updates provided therein. It was noted that many of the items were included as a separate agenda item or updates were included in the highlight reports submitted to the committee. 89/15 – National Bowel Cancer Audit Dr Sinniah advised that Dr Prudham had an agreement that the review would be completed before September and that the action plan would be completed and shared with the reviewer. 84/15 – HpB Pathology Services Miss Jones said that this item related to fine needle aspiration activity and Pathology had an SLA in place, although due to pricing, alternatives were being considered. It was agreed that Mr Mullen would take forward this action with his fellow Executive colleagues at Central Manchester.
HM
May 15
127/15 Governance Arrangements Mr Barclay said that a detailed review of the governance arrangements had taken place with the Chief Nurse, Chief Executive and Director of Governance: to be discussed at the Board’s Confirm and Challenge on Thursday.
Safety
128/15 External Review – Maternity Service Mrs Trinick provided assurance to the Committee that the Division was making progress on the improvement plan, which was being monitored via the Internal Management Group. The plan followed the CQC domains and clinicians and midwives were committed to delivery of the improvement plan. The Trust had agreed to work with another NHS tertiary maternity provider and reciprocal learning could be achieved. The TDA/CCGs were noted to be supportive and impressed with the improvements undertaken to date. A look back exercise had been completed with no new themes emerging. The importance of liaising with families and the offer of meetings which had been extended to the families was discussed. Mrs Mayer said that the improvement plan was now very comprehensive and she felt more assured. Cultural and team working improvements were discussed. Mr Mullen felt that this was an area that needed further consideration; this was included in the improvement plan. Mrs Dixon felt that the culture of the organisation should enable staff to set internal standards with the staff having the pride and passion to be the best. Mrs Salmon-Jamieson said that the ward accreditation scheme created the internal want and buy-in from staff to improve and then maintain standards. Maintaining standards in the future was also discussed: the Kirkup review required the Trust to undertake a self assessment which had already been completed. Mr Barclay asked what assurance the Committee required in relation to this important agenda item. It was discussed and agreed that:-
Exception reporting of any slippages against the improvement plan
Maternity would be a feature of a future clinical audit
Div UM
May and ongoing
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129/15 National Bowel Cancer Audit – progress on actions Mrs Ashton provided the Committee with an update on actions. It was noted that a single MDT needed to be in place before assurance could be provided to the Committee: this was expected by August 2015. It was agreed that the updated action plan would come back to the Committee in May 2015 and it had already been noted in previous meetings that this agenda item would stay as a regular item until the matter was concluded.
DA
May 15
130/15 NHS England – Peer Review of Colorectal & Upper GI MDTs Mr Mullen said that the Trust had been notified that the colorectal MDT had been stood down by the Peer Review team, however, he stated that it would be sensible to leave the single colorectal MDT open on the agenda and ask the Surgical Division for a monthly update until the single MDT commenced. It was agreed that the Upper GI and colorectal updates would come to the Committee in June 2015.
HM
June 15
131/15 SUI Report Mrs Hingley spoke to the report. Focus would be on investigating incidents appropriately, delivering of recommendations and actions and ensuring investigations were closely linked to any inquests, so that RCAs were supplied to HM Coroner in a timely manner. GM Police were investigating a death in 2012 on behalf of the Coroner: discussion followed in relation to the need for full support to staff, which the Division was providing. The assurance in relation to the Duty of Candour was discussed and it was noted that oversight of this would be via the Serious Incident Management Review rollout. Mr Steven raised the role of the Audit Committee if incidents were not being closed down: discussion followed in relation to personal accountability and the final escalation processes which existed, including the Chief Nurse and the role of the Audit Committee.
132/15 Safety Committee Highlight Report & Minutes Dr Sinniah spoke to the report drawing the Committee’s attention to C Diff being over trajectory and resuscitation documentation and ceilings of treatment. The minutes of the March meeting were noted.
Clinical Effectiveness
133/15 Clinical Effectiveness Committee Highlight Report The report submitted on behalf of Dr Prudham was noted. The Committee was not assured about the role of the Clinical Audit & Effectiveness Committee as the April meeting had been cancelled. It was noted that the next meeting was planned for 18 June 2015. It was agreed that Dr Sinniah would feedback to Dr Prudham; in addition to one division not being aware that Mrs Hingley was reviewing mortality.
AS
May 15
Patient Experience
134/15 Patient Experience Committee Highlight Report & Minutes Mrs Parker spoke to the highlight report and minutes from the March
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meeting. There were no items for exception or escalation reporting. The CQUIN had been achieved and text messaging as a way of obtaining feedback was discussed. Work continued on nursing metrics which had escalation built into the process. Friends and Family Test was discussed, including the improvement works undertaken. It was agreed that more information on the Friends and Family Test would be specifically reported to the Committee in May.
CP
May 15
Quality Accounts
135/15 Quality Accounts Highlight Report The report was noted.
136/15 Quality Account Minutes There had been no meeting since the last Q&P.
Research & Development
137/15 Research & Development Highlight Report
Dr Woby spoke to the highlight report and took the Committee through the various items of assurance in relation to the performance, initiation and delivery of clinical trials. He said it was very pleasing to see how favourably the Trust compared with teaching hospitals. In relation to initiation, the trust had met 71.4% of its studies within the 70 day target, compared with the mean percentage of 44.8%.
Caldicott & Health Informatics
138/15 Caldicott & Health Informatics Committee Highlight Report Not due.
139/15 Caldicott & Health Informatics Committee – 23 Jan 2015 Not due.
Medicines Management
140/15 Medicines Management Quarterly Report Not due.
141/15 Medicines Management – Omitted Medication Audit Report Not due.
External Performance Monitoring and Reports
142/15 External Reviews – External Log & Horizon Scanning Mr Barclay said that whilst there was an outstanding action to fully review the external log, members had been asked to identify any other external reviews of which they were aware. Mr Barclay said that the value of the log was identifying commonalities within different reviews. Mrs Dixon said that the divisions should be using the external log within their own Q&P meetings and it was agreed that they would do so.
Trium. Rep
May 15
Policies
143/15 Document Management Highlight Report The document management highlight report was received and noted.
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Mrs Salmon-Jamieson drew attention to the worsening position in relation to out of date documents, including priority1 documents. Mrs Dixon stated that this was disappointing as the Committee had been reviewing this report and performance for some time. A risk based approach had already been taken on the Trust’s priority documents: 137 of 730 trust-wide documents had passed their expiry dates. Mrs Guereca stated that she was aware that previously the approach had been considered to be appropriate in the way in which documents were reviewed and updated but the process was being simplified. Resources were noted to be an issue and this was discussed at length. Mrs Salmon-Jamieson was confident that the nursing policies would be completed. It was agreed that if Divisions were unable to meet the target reduction included in the report, they needed to advise Mrs Martin directly. It was also agreed that the Committee supported the recommendations in the report, with the exception of not agreeing the recommendation about withdrawing some documents from the Document Management System.
Trium. Rep
Performance
144/15 Monthly Integrated Performance Report Mr Steven spoke to the report: a new indicator for readmissions was now included. An expanded suite of mortality KPIs was being developed and the report was being refreshed to meet the 2015-16 national and local requirements. The summary integrated scorecard trends were up to 31 March 2015. In respect of business capability, work was underway to make better use of SLR, elective length of stay reduction was ahead of target and non-elective length of stay was behind target. Activity versus plan deteriorated in month and was behind plan for elective and day case. In relation to quality, the handover of care inpatient communication had improved and the 95% target was achieved for the first time in March 2015. C. Diff had exceeded the annual plan in 2014/15 at a rate of 72 cases against a plan of 62. There were a total of 6 MRSA cases in year. Mrs Salmon-Jamieson said that the key items to note were the “don’t wait, isolate”, the difficult strain of O27 and the new assessment form for positive C.Diff patients. There was an EU and Non-EU campaign to recruit an additional 110 nurses. One never event was reported in March and a full investigation was underway. In relation to operational performance, all 3 national RTT standards were achieved for the sixth consecutive month. Future reporting by individual CCG level would be needed from 1 April 2015. The diagnostic 6 week standard was narrowly missed by 0.01%: short and long term solutions were discussed and the 6-month lead in time to resolve was noted. Mr Mullen said that the TDA needed to be notified that the target would be missed and the improvement
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plan discussed with the 4 CCGs to provide them with assurance of the actions to achieve this target. The 4 hour standard was achieved in Q1 and Q2: March had seen an improvement but was still below target. Mrs Moore said the situation was exacerbated by 162 patients being medically fit for discharge, which equated to 20% of the bed stock. The availability of social workers on site was discussed and the impact on surgery at Fairfield. Inter-site transfers were discussed as was substantive versus agency staff ratios in A&E, which equated to approximately 50% of the staffing. It was agreed that the ratio of substantive versus agency staff would be included in future reports. The month 12 financial position would be discussed at the Finance, Infrastructure & Business Development Committee. In relation to workforce, sickness absence was 5.55% against a trajectory of 4.2%. Bank and agency spend had increased and was above target for the year. Staff Friends and Family Test scores for Q4 had improved for both indicators. Regulatory assessments levels were noted: the TDA escalation score was unchanged and the draft CQC Intelligent Monitoring Report showed the Trust to be Band 6 (lowest risk). In relation to contract KPIs, Mr Steven said that there was no guarantee that penalties would be reinvested in 2015-16. There was the opportunity for bespoke items to be included in the Integrated Performance report for time-limited periods and any suggestions would be considered.
IC
June 15
145/15 Handover of Care Performance – Year End Position Mr Mullen reported on the contractual KPI compliance for inpatient handover of care communications. In March, 95% had been achieved which was tremendous and would be shared with CCG colleagues. Mr Mullen paid tribute to Libby Woodcock from IT who trains all the junior doctors. Members agreed that another year of sustained focus was needed on achievement of this important target which spoke to quality and performance/financial agendas. Junior doctors were key to this process and it was confirmed that training would continue for the new intake of juniors in August.
146/15 Performance Management Group Highlight Report The report was for noting as the items had already been discussed.
147/15 Performance Management Group Minutes – March 15 The minutes were noted.
Reports from Divisional Quality and Performance Committee
148/15 Surgery Q&P Highlight Report Mrs Ashton provided an updated on matters of exception and assurance. In relation to escalation, there was willingness by clinicians to start the GI Bleed rota and an update was provided on the point prevalence survey. Gap analysis work was being undertaken for the next 10-12 weeks of the rota. Mrs Ashton spoke
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of the impact of the reduction from 12 to 8 clinicians on the rota. Assurance was given around the amount of work undertaken in both permanent and interim solutions prior to the July implementation date. Lists would commence in the new hybrid theatre at Oldham on 15 April. The new stroke rota was in place.
149/15 Diagnostics & Clinical Support Miss Jones spoke to the highlight reports from January, February and March and said she would establish the whereabouts of the divisional Q&P minutes as Mrs Pullen had been advised that these were no longer produced. After discussion, it was agreed that Miss Jones would arrange for the wording of the February highlight report around the patient story to be amended, although it was noted that the system for patient stories was under review.
PJ PJ
May 15 May 15
150/15 Medicine Mrs Moore spoke to the highlight report and provided an update on matters of exception and assurance. In relation to escalation, the division was clearing the backlog of red incidents and the division planned to review all RCAs on 1 May. Nursing vacancies were high at 70 qualified and 17 unqualified as was staff sickness at just below 7%. Clearly the backlog of complaint responses was being addressed. Mrs Moore said that the divisional risk register had been discussed.
151/15 Integrated & Community Services Ms Jones spoke to the highlight report including matters of assurance. There were no exception items. In relation to escalation, the division was working towards their health and social care integrated governance framework. In relation to the major trauma review, action plans were being developed for rehabilitation. Mrs Mayer raised the absence of mortality and morbidity reference in Divisional Q&P minutes. Members of the committee agreed that structures needed to be reviewed to ensure input and inclusion of M&M at Divisional Q&P meetings. Mr Barclay commented that standardisation would come following the Confirm and Challenge event, although he expected the timeframe for the output to be 2 months. Mrs Dixon asked where community worker risks were being assessed: Ms Jones said that staff undertake an informal risk assessment upon entering community premises and there was a Lone Worker Policy and Procedure followed by staff.
152/15 Women & Children’s Division Mrs Trinick spoke to the highlight report including matters of exception and assurance. In relation to escalation, Mrs Trinick said that all staff had been advised regarding the escalation policy for staff shortages. Outstanding NICE guidelines had been redistributed to all the applicable reviewers for urgent review and feedback. Mrs
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Trinick reported that no formal audit of the Trust guideline on Foetal Monitoring in Labour appeared to have been undertaken. Work on the divisional risk register had been undertaken.
153/15 Divisional Quality & Performance Minutes The divisional Q&P committee minutes from the following were received and noted:- Surgery – January, February March 2015 Medicine - March 2015 Integrated & Community Services – January, February, March 2015 Women & Children – March 2015 It was acknowledged that the highlight report each month was for the divisional Q&P committee held that month with a month's time lag for provision of the minutes.
Risk
154/15 Strategic Risk Register The Committee was asked to review and if appropriate, make proposals to the Trust Board in relation to any changes to the Strategic Risk Register. In particular, the Committee was asked to consider whether, in addition to the potential service failure and reputational damage risks described more widely in the register, whether there was a specific issue in relation to maternity and whether this merited inclusion on the strategic risk register as a specific risk. This would impact on the Board Assurance Framework and the Trust’s strategic risks which were included in the Annual Governance Statement.
Members felt maternity should be a specific risk.
Mrs Trinick was also asked to reflect on the content of Women & Children’s divisional risk register.
GB CT
May 15 May 15
155/15 Issues for Escalation to the Trust Board The immediate items noted for escalation to the Trust Board were:
Clarity of escalation and assurance on the maternity review via the IMG
Clinical Audit & Effectiveness Committee – not assured around its operation
Resource and capability issues, particularly in relation to governance and divisional changes – 2 month time lag
Diagnostic 6 week standard missed – could take 6 months to resolve
Maternity Review to be included on Strategic Risk Register
Handover of Care (Inpatient) – March 2015 95% target achieved
Interim GI bleed rota solution identified
Monitoring progress against the SUI policy of which Duty of Candour would be an element
156/15 Date of Next Meeting The next meeting would be held on the Tuesday 26 May 2015 at 9:00-12:00 in room 237.
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