There will be a meeting of the Board of Directors on Wednesday 14 November 2018 at 11.00 in The Deakin Learning Centre, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0QQ
(*) = paper enclosed (+) = to follow
AGENDA
General business Purpose 11.00 1 Welcome and apologies for absence For note
2 Declarations of interest For note To receive any declarations of interest from Board members in relation to items on the agenda and to note any changes to their register of interest entries
A full list of interests is available from the Director of Corporate Affairs on request
3* Minutes of the previous Board meeting For approval To approve the Minutes of the Part 1 Board meeting held on 12 September 2018
4* Board action tracker and matters arising not covered For review by other items on the agenda
11.05 5 Patient story For receipt To hear a patient story
11.20 6* Chair’s report For receipt To receive the report of the Chair
11.25 7* Report from the Council of Governors For receipt To receive the report of the Lead Governor
11.30 8* Chief Executive’s report For receipt To receive the report of the Chief Executive
Quality, access standards, workforce and finance Purpose 11.45 9* The items in this section will be discussed with reference to the Integrated Report and other specific reports
9a* Quality (including nurse safe staffing) For receipt To receive the report of the Chief Nurse and Medical Director
9b Access standards For receipt To receive the report of the Chief Operating Officer
9c Workforce For receipt To receive the report of the Director of Workforce
9d Improvement For receipt To receive the report of the Director of Improvement and Transformation
9e* Financial performance For receipt To receive the report of the Chief Finance Officer
12.20 10* 2018/19 Workforce Influenza Vaccination Programme For receipt To receive the reports of the Director of Workforce
12.30 11* Cambridge Transition Programme For receipt To receive the report of the Director of Strategy and Major Projects
Governance and assurance Purpose 12.35 12* Education, learning, training and development For receipt To receive the report of the Director of Workforce
12.50 13* Learning from deaths report For receipt To receive the report of the Medical Director
12.55 14* Board Assurance Framework For approval To receive the report of the Director of Corporate Affairs
13.00 15* Board assurance committees – Chairs’ reports For receipt 15.1 Quality Committee: 7 November 2018 • Infection Control Annual Report 15.2 Performance Committee: 7 November 2018 15.3 Remuneration and Nomination Committee: 7 November 2018
Other items Purpose 13.05 16 Any other business
17 Questions from members of the public
18 Date of next meeting For note The next meeting of the Board of Directors will be held on Wednesday 16 January 2019 at 11.00 in The Deakin Learning Centre, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0QQ.
19 Resolution That representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest (NHS Act 2006 as amended by the Health and Social Care Act 2012).
13.20 20 Close
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Minutes of the meeting of the Board of Directors held in public on Wednesday 12 September 2018 at 11.00 in The Deakin Learning Centre, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0QQ
Member Position Present Apologies Dr M More Trust Chair X Mr D Abrams Non-Executive Director X Ms N Ayton Director of Strategy and Major Projects X Dr E Cameron Director of Improvement and Transformation X Mr A Chamberlain Non-Executive Director X Dr A Doherty Non-Executive Director X Mr S Higginson Chief Operating Officer X Ms L Szeremeta Chief Nurse X Dr M Knapton Non-Executive Director X Prof P Maxwell Non-Executive Director X Prof S Peacock Non-Executive Director X Ms S Pointer Non-Executive Director X Mr P Scott Chief Finance Officer X Dr A Shaw Medical Director X Mr R Sinker Chief Executive X Mr I Walker Director of Corporate Affairs * X Mr D Wherrett Director of Workforce X
* Non-voting member
In attendance Position M G Burgess Assistant Trust Secretary (minutes)
For particular items Ms J Loudon Lead Governor (for item 84/18) Dr J MacDougall Guardian of Safe Working (for item 91/18)
79/18 Welcome and apologies for absence
Apologies were received from Shirley Pointer.
Lorraine Szeremeta was welcomed to her first meeting as Chief Nurse.
80/18 Declarations of interest
Standing declarations of interest of Board members were noted.
81/18 Minutes of the previous meeting
The minutes of the Board of Directors’ meeting held in public on 11 July 2018 were approved as a true and accurate record.
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82/18 Board action tracker and matters arising not covered under other agenda items
Received and noted: the action tracker.
83/18 Chair’s report
Mike More, Trust Chair, presented the report which had been circulated.
Noted: 1. The Reverend Dr Derek Fraser (Lead Chaplain), Damian Hebron (Head of Arts), Sharon McNally (Deputy Chief Nurse) and Anna Shasha (Head of Midwifery) would all be leaving their roles at the Trust in the near future. The Board of Directors expressed its thanks for their hard work and dedication and wished them well for the future.
Agreed: 1. To note the contents of this report.
84/18 Report from the Council of Governors
Julia Loudon, Lead Governor, presented the report which had been circulated.
Noted: 1. The Scrutiny and Performance Governor/Director Working Group had met on 5 September 2018 and received an update on the work of the Cambridgeshire and Peterborough Sustainability and Transformation Partnership (STP). Further discussions were planned with the STP Interim Chair and Interim Accountable Officer. 2. The Communications and Engagement Governor/Director Working Group had met on 5 September 2018. Work was ongoing to increase the diversity of governors and the Trust membership.
Following the introduction, the following points were made in discussion:
1. The importance of the Carers’ Strategy was highlighted and it was proposed that it be presented to a future meeting of the Board of Directors.
Agreed: 1. To note the activities of the Council of Governors. 2. That the Carer’s Strategy would be presented to a future meeting of the Board of Directors.
Minute Action Executive Target date Ref lead/s 84/18 Carer’s Strategy to be presented to a Chief Nurse To be future meeting of the Board of Directors. scheduled
85/18 Chief Executive’s report
Roland Sinker, Chief Executive, presented the report which had been circulated.
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Noted: 1. Staff were thanked for their input into the Trust’s Provider Information Return (PIR) to the Care Quality Commission (CQC). While the exact timescale for the CQC inspection was still to be confirmed, it was likely to be within the next six months. 2. While the position on capital, Delayed Transfers of Care (DTOC) and capacity was broadly on track, the underlying position remained fragile. 3. Led by the Director of Workforce, work continued on diversity, organisational culture and meeting behaviours. 4. Led by the Director of Improvement and Transformation, work continued on patient pathway transformation and the Cost Improvement Programme (CIP). 5. The Trust continued to work with Royal Papworth ahead of its move to the Cambridge Biomedical Campus. The move was now planned for April 2019. 6. The main focus of the STP was Emergency Department performance, DTOCs and system finances. The importance of building strong GP and social care engagement and the development of a locality model was highlighted. 7. The Trust continued to work alongside Cambridgeshire Fire and Rescue Service on fire safety and compartmentation. 8. Work was ongoing on Epic optimisation and transition to the new IT contract. 9. The Trust had been asked to co-write the research and innovation workstream of the NHS 10 Year Plan. 10. The Trust continued to play a leading role in the implementation of the UK Life Sciences Industrial Strategy particularly with respect to cancer, data and medical technology. Relationships continued to be strengthened with all industry and campus partners.
Following the introduction, the following points were made in discussion:
1. Bed occupancy remained high with a shortfall of between 100 and 200 beds as set out in the Trust’s Capacity Plan. 2. Phase 2 of the Trust’s Capacity Plan would aim to address capacity challenges alongside a system-wide commitment to address DTOCs. 3. Achieving the DTOC target of 3.5% would free up approximately 50 beds. This was therefore only part of the solution and reducing length of stay and improving demand management would also be required. 4. Options for additional capacity on site included a modular build on the 2020 land and additional inpatient space on the top floor of the Addenbrooke’s Treatment Centre. Discussions regarding capital continued through the STP. 5. Approximately 100 beds would need to be freed up in order to undertake the required fire safety works. 6. If agreement on capital had not been reached by December 2018, discussions would need to take place on future service provision. 7. The importance of a system-side approach to the capacity challenges through the STP was highlighted. 8. There were currently four drivers to the financial challenges facing the STP: structural deficits, market forces and funding, acute capacity and utilisation of the wider health and care estate.
Agreed: 1. To note the contents of this report.
86/18 Integrated report
Agreed: 1. To note the Integrated Report for July 2018 (2018/19 Month 4).
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Workforce
David Wherrett, Director of Workforce, gave a verbal update.
Noted: 1. Mandatory training compliance was above 95% for the first time. 2. The appraisal compliance rate was at 93% for non-medical staff and 98.7% for medical staff. 3. During July and August 2018 a number of health and safety incidents related to the extreme heat had been reported. Advice had been given to staff and the Estates and Facilities team were investigating possible mitigations.
Following the introduction, the following points were made in discussion:
1. While the appraisal compliance rate was positive, feedback from the staff survey indicated that the quality of the appraisal process needed to be improved. Work was underway to simplify the process, revise the appraisal forms and provide additional training. It was noted that he Trust was not an outlier in this area and was following best practice in the sector. 2. While the vacancy rate for Health Care Assistants (HCAs) had seen a slight increase of 0.2%, it had reduced when taking into consideration nurses who were currently working as HCAs pending receipt of their Nursing and Midwifery Council (NMC) registration. 3. The majority of HCAs left the role as a result of career development or increased training opportunities. A higher banding of the role in other trusts could also be a contributing factor. 4. All staff leaving the Trust were given the opportunity of an exit interview. 5. The Trust’s vacancy rate was discussed in detail by the Workforce and Education Committee. 6. Work was ongoing to improve vacancy rates for Estates and Ancillary staff and further information was requested in future reports. 7. Staffing would grow by 4.7% in 2018/19, with a similar figure expected for 2019/20. Approximately 50% of this would be establishment growth, with the remainder accounted for by filling gaps in existing staff establishment. 8. Nationally, the expected NHS staff increases were not sustainable. Work was underway to look at new ways of working and the increased use of technology. 9. Currently the Trust was transferring £5-£6m of work to the private sector. Increased staffing levels would help some of this work to be undertaken in- house. The Performance Committee would be discussing this going forward.
Quality (including nurse safe staffing)
Lorraine Szeremeta, Chief Nurse, presented the report which had been circulated.
Noted: 1. While all wards had achieved an overall fill rate of 90% in June 2018, there were currently 13 wards not achieving the Registered Nurse (RN) fill rate. A full review and deep dive of the affected wards was underway. 2. The frequency of using contingency beds had reduced in June and July 2018. 3. Lewin Ward had closed eight beds in August 2018 due to staff vacancies and long-term sickness. A deep dive was currently being undertaken and it was expected that all beds would re-open by the end of September 2018. 4. 97 EU nurses were awaiting Objective Structured Clinical Examinations (OSCE) and 81 EU nurses were awaiting International English Language Tests (IELTs). The Trust was supporting these staff through the processes.
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Agreed: 1. To note the report for June and July 2018. 2. To note that it was necessary to close 8 beds in August on Lewin ward due to staffing shortages and skill mix. 3. To note the improving trajectory of nurse vacancies with current nursing vacancy rate of 11.7% with a trajectory to be below 10% for winter 2018, although the actual vacancy rate excluding those staff without NMC registration would remain challenging at 18%. This was an improving position, and was reliant on the timely start date and successful completion of OSCE and IELTS of those nurses commencing in employment from overseas.
Ashley Shaw, Medical Director, gave a verbal update.
Noted: 1. Flora Jessop had been appointed as Medical Examiner and would be reviewing all deaths at the Trust. Work was also underway to build links with the multi- faith bereavement team and the coroner. 2. To encourage learning, all Structured Judgement Reviews (SJRs) and post- mortem reports were shared between the Trust and the coroner. 3. The Hospital Standardised Mortality Ratio (HSMR) for May 2018 was 69.20 and was continuing to fall. 4. There had been no never events reported in July 2018. 5. Ward C10 had been closed temporarily due to a C. difficile outbreak. Patients had been transferred to allow for a deep clean of the ward to be undertaken. 6. There had been no cases of MRSA bacteraemia in July 2018. 7. Updates on Gram-negative infections, vaginal mesh surgery and the Serious Incident (SI) related to the storage of anti-D medication had been provided to the Quality Committee on 5 September 2018.
Following the introduction, the following points were made in discussion:
1. The Board of Directors welcomed HSMR performance and thanked staff for their hard work and dedication. 2. While compliance with in-scope SJRs in May, June and July 2018 appeared to have fallen significantly this was due to a lag time in the data. A further update would be included in the next Integrated Performance Report. 3. Reviewing the deaths of patients with complex pathways and disorderly lives had proved challenging. 4. The importance of reviewing the deaths of patients receiving cross- organisational care was highlighted. 5. An SI had been declared in relation to a failure in the Trust’s fridge monitoring process with respect to use of anti-D. The fridge had been replaced and the affected medication destroyed. All affected patients had been contacted and a review of escalation processes and human factors was being undertaken. The Board of Directors and the Quality Committee would continue to monitor this going forward.
Access standards
Sam Higginson, Chief Operating Officer, gave a verbal update.
Noted: 1. Despite significant capacity pressures, the Trust had continued to slightly over perform against its elective plan in July 2018. 2. Bed occupancy had remained high at 93.9% in July 2018 compared to the 92% that was set in the plan. This trend had continued into August 2018. 3. Performance against the four hour standard had improved to 88.5% in July 2018 from 87.4% in June 2018.
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4. The overall waiting list size had increased by 140 compared to the March 2018 baseline. This represented an in-month reduction of 411 compared to June 2018. The variance compared to the baseline had therefore reduced to 0.4%. 5. The Trust had achieved the 62 day cancer standard and the 1% diagnostic 6 week wait standard for July 2018. 6. The stroke target of 80% had been achieved for July 2018.
Following the introduction, the following points were made in discussion:
1. Reablement and domiciliary care remained a challenge for the Trust and had affected DTOC numbers. Work was ongoing with system partners to address this in the run up to winter. Work was also ongoing through the STP to identify process improvements. 2. An increase in demand, capacity challenges and late referrals from other Trust could put additional pressure on the 62 day cancer standard. Endoscopy was already running a 7 day service and there was a national push to look at the first 24 days of the cancer pathway.
Improvement
Ewen Cameron, Director of Improvement and Transformation, gave a verbal update.
Noted: 1. £11.6m had been delivered through the Cost Improvement Programme (CIP), which was currently £650,000 behind plan. Work was ongoing across the Trust to look at DTOC and length of stay reductions. 2. Accelerated design events had been held and improvement work was ongoing with the Advancing Quality Alliance. 3. Empowering staff through improvement work could have a positive effect on the staff survey results. 4. 200 staff were currently involved in the Leadership Programme.
Following the introduction, the following points were made in discussion:
1. The importance of both internal and external transformation and an improvement-focused approach to transformation were highlighted. 2. The time taken to build internal improvement capability should not be underestimated. 3. The importance of presenting the Board of Directors with examples of good practice, not just methodology, was noted.
Financial performance
Paul Scott, Chief Finance Officer, presented the report.
Noted: 1. The Trust’s financial position was broadly on track at Month 4. 2. Risks remained around capacity pressures. 3. The long term financial model was currently being updated and work was ongoing with system partners.
Following the introduction, the following points were made in discussion:
1. While the Trust’s financial plan would not be reforecast, the challenges around DTOC and capacity would be fully reflected. 2. The draft 2019/20 financial plan, including underlying pressures and drivers, would be presented to the Performance Committee in November 2018.
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Agreed: 1. To note the report of the Chief Finance Officer.
87/18 Review of nursing and midwifery staffing
Lorraine Szeremeta, Chief Nurse, presented the report.
Noted: 1. The Trust’s Registered Nurse vacancy rate was 14% in July 2018. 2. Following the establishment review in June 2018 an increase of 2.56 WTE Band 2 Healthcare Support Workers (HCSW’s) had been proposed for D6 (Neuro) to allow for one extra HCSW on night shift. A review of Birth Rate Plus was also planned in the next three months.
Agreed: 1. The establishment changes set out in Figure 4 of the report. 2. To note that the mid-year establishment review demonstrated that staffing levels in nursing and midwifery remained compliant with national safe staffing guidance. 3. The recommendation of the Chief Nurse to review current processes for establishment review.
88/18 Staff story
David Wherrett, Director of Workforce, presented a patient story.
Noted: 1. The Board of Directors received a story about the challenges faced by a member of staff who had come to work at the Trust from overseas.
89/18 Workforce Race Equality Standard (WRES) action plan
David Wherrett, Director of Workforce, presented the report which had been circulated.
Noted: 1. The Trust’s WRES metrics for 2018 had been submitted to NHS England. 2. A 2018/19 WRES action plan had been produced. 3. Successful race equality strategies required activity over a sustained period of time. 4. The WRES action plan had been presented to Management Executive for discussion. Support for further work at a senior level was proposed and supported.
Following the introduction, the following points were made in discussion:
1. BME staff groups had been fully engaged in development of the action plan. 2. 19% of Trust staff were from BME communities. 3. Evidence suggested that diverse teams made better decisions. The importance of BME representation at more senior levels of the Trust was therefore highlighted. 4. Nationally the NHS was dealing with similar challenges. 5. Recruitment processes such as more diverse panels could be looked at. 6. The proposed use RCN Cultural Ambassadors was supported. 7. The importance of triangulating data from staff appraisals, exit interviews and the Freedom to Speak Up Guardian was highlighted.
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8. The importance of building on the current mentoring arrangements to build a stronger two–way dialogue for Board members was highlighted. 9. The value of looking at best practice from others was highlighted. 10. The Trust Chair and Chief Executive had hosted a tea party for members of Trust staff who had been nominated for an NHS Windrush 70 Award. 11. While the direction of travel was fully supported it was felt that the work should be progressed at an increased pace.
Agreed: 1. To approve the WRES reporting template and revised WRES action plan for publication. 2. The direction of travel and supported the work being progressed at an accelerated pace.
90/18 Research and Development
Ashley Shaw, Medical Director, presented the report.
Noted: 1. Lynsey Spillman undertook a one year pump priming research fellowship supported by Addenbrooke’s Charitable Trust, and had now been awarded a NIHR Doctoral Research Fellowship. 2. Dr Menna Clatworthy had been awarded a NIHR Research Professorship to identify ways of improving outcomes of kidney transplantation.
Agreed: 1. To note the report
91/18 Guardian of Safe Working quarterly report
Dr Jane MacDougall, Guardian of Safe Working, presented the report.
Noted: 1. The process of exception reporting provided data on working hours and training opportunities. The process continued to work well at the Trust. 2. Triangulation with the GMC trainee survey suggested that trainees were under-reporting, in particular for missed training opportunities. 3. Gaps in rotas continued to be a major concern for the Trust and nationally. 4. The Trust’s Guardian of Safe Working would be attending a national Guardian’s Conference on 17 September 2018. 5. A survey of trainees had been organised by the Junior Doctors’ Forum (JDF) to assess their access to, understanding and use of the exception reporting process. Reasons for not reporting included: IT challenges, dislike of more paperwork and active discouragement from colleagues or consultants. 6. The Guardian of Safe Working would be attending staff inductions to highlight the importance or exception reporting.
Following the introduction, the following points were made in discussion:
1. While attendance at the JDF meetings had increased, concern remained about its sustainability. Meeting venues had been revised and refreshments provided in order to encourage attendance. Regular newsletters were also being produced and the open ‘drop-in sessions’ continued. 2. The Chief Resident’s Forum continued to engage with JDF. 3. Staff groups were collated differently in the GMC trainee survey and the exception reporting processes, which may be problematic.
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4. A percentage figure for the population of each sector would be included for future reports.
Agreed: 1. To note the 2018/19 Q1 report from the Guardian of Safe Working.
92/18 Learning from deaths report
Ashley Shaw, Medical Director, presented the report.
Received and noted: the report.
93/18 Medical and Nursing Revalidation
Agreed: 1. To note the 2017/18 Medical Revalidation report. 2. The designated body statement of compliance for submission by 28 September 2018 to the higher level responsible officer at NHS England (Midlands and East) Region. 3. To note that the Annual Organisational Audit Report had been submitted following review by the Medical Director. 4. To note the report on nurse revalidation and to note that there were no issues requiring escalation.
94/18 Risk Management Strategy and Policy
Agreed: 1. To approve the Risk Management Strategy and Policy including the Trust’s Risk Appetite Statement.
95/18 Conflicts of interest policy
Agreed: 1. To approve the revised Conflicts of Interest policy.
96/18 Board Assurance Framework
Ian Walker, Director of Corporate Affairs, presented the report.
Noted: 1. The risk score for 005/18 (quality governance) had been reduced from 15 (I5xL3) to 10 (I5xL2), achieving the target level. 2. The risk score for 009/18 (financial plan) had been reduced from 16 (I4xL4) to 12 (I4xL3) reflecting NHS Improvement’s acknowledgement of the Trust’s financial plan and cash cover for 2018/19. 3. The 011/18 risk relating to IT had been divided into two separate BAF risks covering IT infrastructure failure and cyber security given the differing, albeit inter-related, nature of the two components of the previous single risk.
Following the introduction, the following points were made in discussion:
1. An Internal Audit report had been produced on cyber security. As a result of this, and the increased national focus, there was a case for reviewing the risk
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score for 011a/18. It was agreed that this would be presented to the Risk Oversight Committee for consideration. 2. It was proposed that the Risk Oversight Committee should review the existing risk relating to resilience and emergency planning. 3. The importance of a deep dive of the risk assurance process was highlighted. It was proposed that this could be undertaken by the Audit Committee.
Agreed: 1. To approve the latest version of the Board Assurance Framework. 2. That the Risk Oversight Committee would specifically review the risks relating to cyber security and emergency planning.
Minute Action Executive Target date Ref lead/s 96/18 Risk Oversight Committee to specifically Director of 24 October review the risks relating to cyber Corporate 2018 security and emergency planning. Affairs
97/18 Trust Constitution
Ian Walker, Director of Corporate Affairs, presented the report.
Noted: 1. The Board of Directors and the Council of Governors were required to periodically review the Trust’s Constitution. 2. The revised Constitution had adopted the Model Constitution for NHS Foundation Trusts, as recommended by the governance reviews undertaken in 2015 and 2016.
Agreed: 1. To approve the updated Constitution for presentation to the Council of Governors on 26 September 2018.
98/18 Board Committee Annual Reports and membership
Ian Walker, Director of Corporate Affairs, presented the report.
Noted: 1. Thanks were expressed to the Chairs of the Committees, lead Executive Directors and the Trust Secretariat team. 2. The requirement for executive attendance at the Audit Committee would be discussed outside the meeting.
Agreed: 1. The annual reports from Board assurance committees. 2. The membership of Board committees, as set out in the table appended to the report.
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99/18 Board Assurance Committees – Chair’s Reports
Audit Committee- 25 July 2018
Received and noted: the report.
Performance Committee - 5 September 2018
Received and noted: the report.
Quality Committee - 5 September 2018
Received and noted: the report.
100/18 Any other business
None raised.
101/18 Questions from members of the public
The following written questions were submitted:
1. At section 3.1.3 of his report the Chief Executive writes “On phase two capital, there are two options to progress with respect to a rapid build on site with a deadline for decision of Christmas”. This has no meaning to an outsider. What is the anonymous ‘rapid build’ which needs so quick a decision and what are the options and the basis for choice?
Roland Sinker, Chief Executive, provided the following response:
In order to ease capacity pressures and maintain patient safety two options were under consideration; a new modular build on the 2020 land and an additional inpatient facility on the top floor of the Addenbrookes Treatment Centre. Whilst the ATC option could be done in partnership with the private sector, neither option would be progressed through a private finance initiative (PFI).
2. At section 3.4.2 of his report the Chief Executive writes of ‘good relationships’ with a number of international private businesses. Can he explain the nature of these relationships now, and into what sort of ‘relationships’ he intends that they should grow?
Roland Sinker, Chief Executive, provided the following response:
The Trust wold continued to strengthen its already good relationships with the University sector, health and social care partners, industry and research.
3. When will My Chart be released to all patients allowing access to test results, and maybe discharge letters, as rapid discharges mean patients are being sent home without test results which is worrying for them?
Ewen Cameron, Director of Improvement and Transformation, provided the following response:
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The Trust was continuing to roll out MyChart progressively with approximately 2000 patients currently active. The roll out would be accelerated over the coming year pending agreement of additional resource. In order to roll out MyChart safely and smoothly there would need to be discussions with each clinical team to ensure that any specific local issues had been addressed.
A Trust wide approach to the automatic release of results was being formulated and would be taken to Management Executive for final agreement. The version of MyChart being implemented was an outpatient version so would not impact on inpatient results.
4. What preparations are being made for DTOCs in the winter months, as the care in the community is at breaking point already due to Black alerts at the hospital and staff shortages/provision in the community?
Sam Higginson, Chief Operating Officer, provided the following response:
Working alongside system partners the Trust was currently focusing on internal DTOC processes and full implementation of discharge to assess. Ensuring the right level of domiciliary and re-enablement care would also be key moving into winter.
102/18 Date of next meeting
The next meeting of the Board of Directors will be held on Wednesday 14 November 2018 at 11.00 in The Deakin Learning Centre, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0QQ.
103/18 Resolution
That representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest (NHS Act 2006 as amended by the Health and Social Care Act 2012).
Meeting closed: 13.22
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Board of Directors (Part 1): Action Tracker/Decision Log
Minute Ref Action Executive lead Target Action Status RAG date / rating date on which Board will be informed 12 September 2018
84/18 Carer’s Strategy to be presented to a future Chief Nurse tbc AMBER meeting of the Board of Directors.
96/18 Risk Oversight Committee to specifically review Director of 27 Sep Action complete GREEN the risks relating to cyber security and Corporate 2018 emergency planning. Affairs
Key to RAG rating: 1. Red rating: for actions where the date for completion has passed and no action has been taken. 2. Amber rating: for actions started but not complete, actions where the date for completion is in the future, or recurrent actions. 3. Green rating: for actions which have been completed. Green rated actions will be removed from the action tracker following the next meeting, and transferred to the register of completed actions, available from the Assistant Trust Secretary.
Cambridge University Hospitals NHS Foundation Trust
Report to the Board of Directors: 14 November 2018
Agenda item 6 Title Chair’s Report Sponsoring executive director Mike More, Chair Author(s) As above. To receive and note the contents of the Purpose report. Previously considered by n/a
Executive Summary This paper contains an update on a number of issues pertinent to the work of the Chair: • Diary Events • You Made a Difference Awards
Related Trust objectives All Trust objectives Risk and Assurance n/a Related Assurance Framework Entries n/a Legal / Regulatory / Equality, Diversity & n/a Dignity implications? How does this report affect Sustainability? n/a Does this report reference the Trust's values of “Together: safe, kind and n/a excellent”?
Action required by the Board of Directors The Board is asked to note the contents of this report.
Cambridge University Hospitals NHS Foundation Trust
14 November 2018 Board of Directors Chair’s Report Dr Mike More
1. Introduction
1.1 As is placed on public record by himself, Clive James is a patient of this hospital and I thought I would begin this month’s report with an extract from his most recently published long poem, entitled The River in the Sky. It gives a sense of the scale of the hospital, if not ambition – I don’t believe we have plans to stretch to Edinburgh! It also is a fitting tribute to the work of promoting art in the life of the hospital:
As now I scan the chapels leading Off the longest corridor Of Addenbrooke’s Between the Outpatients vestibule And the portico Of the main hospital Which, putting out more annexes, Will one day stretch all the way To Scotland. Once I could walk it, Now I must be pushed And just to turn and look Is an exhausting effort But gradually, as the wings and walks advance They call the decorators in And almost any previous dull stretch Becomes a rich collection Of pictures that redeem The illusion of randomness One piece at a time.
1.2 I am grateful to Clive James, and also to Pan Macmillan, for their kind permission to reproduce this extract from The River in the Sky in my report.
1.3 I am delighted to celebrate the award of HIMMS Level 6 to the Trust for the use of technology to deliver high quality patient care. We are one of only three hospitals in the UK to be so accredited, and the only one to be accredited under the new, more exacting regime.
1.4 The Mayor has announced his response to the report on the economic prospects for the county, published by the committee chaired by Dame Kate Barker. I was on the panel alongside the Mayor and I will continue to press the economic importance of the hospital and the need for this to be reflected in the economic and infrastructure approach of the Mayor.
Board of Directors: 14 November 2018 Chair’s Report Page 2 of 6
2. Diary events
2.1 I was pleased to host, along with the Chief Executive, a visit to the Trust of the Secretary of State for Health and Social Care, the Rt Hon Matt Hancock MP. Earlier in the day, the Secretary of State had visited Granta Medical Practice in Sawston to meet with Lead Partner James Morrow, along with his team, Heidi Allen MP, and the elected mayor for Cambridgeshire and Peterborough. CUH also attended this meeting in the form of the Chief Executive and Director of Strategy and Major Projects to talk about how the Trust and Granta are working together and with the wider system to the benefit of patients.
2.2 The Secretary of State then visited the Genome Campus in Hinxton before coming to CUH where he met with myself, the Chief Executive, the Medical Director and Chief Nurse, ahead of a visit to the Neuro Critical Care Unit to see the Epic system in use, along with the Trust’s Chief Clinical Information Officer Dr Afzal Chaudhry and NCCU consultant Dr Ari Ercole.
2.3 Since the last meeting of the Board of Directors the Trust held its Annual Public Meeting. This was a great opportunity to discuss developments and challenges over the past year with patients, the public and staff. I am grateful to those who came along to support the hospital.
2.4 I attended the Cambridgeshire and Peterborough Healthwatch Board in my capacity as Interim Chair of the Cambridgeshire and Peterborough Sustainability and Transformation Partnership (STP) to discuss the plan for the STP. I am grateful to Healthwatch for their ongoing support as the STP moves forward.
2.5 In addition, I also attended the Health and Social Care Proposal Programme Board, which was also attended by the elected mayor of Cambridgeshire and Peterborough to take part in discussions regarding the provision of Health and Social Care. It is important that the many efforts underway in this respect are complementary rather than cross-cutting and the role of the STP and its partners remains key here.
2.6 The Cambridgeshire and Peterborough STP regional review has taken place since the last meeting of the Board of Directors and I took part in this process as Interim Chair of the STP. The review reflected the huge amount of energy and joint working which is underway in a number of areas across the system to ensure sustainable health and social care provision, and it also reflected the challenge of meeting the needs of all a finite resource and competing priorities. This is why a determined focus on some key issues is important to delivering sustainable change which will benefit patients and service users.
2.7 I attended the Chairs and Chief Executive’s Network which is convened by NHS Providers. As ever this was a stimulating and useful meeting where those running provider organisations are able to discuss issues and share information and ideas.
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2.8 It was a pleasure to attend and present awards at a recent ceremony and celebration for colleagues who have recently qualified. Awards presented included Level 2 Diplomas in Clinical Health Care Support; BSc in Adult Nursing with registration with the NMC; Inter-professional Preceptorships; EU nurses achieving NHM UK registered nurse status; and NMC test of competence leading to UK registered nurse status. Congratulations to all of our newly qualified colleagues.
2.9 It was also a pleasure to attend, along with the Director of Corporate Affairs, a music and dance event. During September and October the Trust has had some musicians in residence. This event was to celebrate this, and also to fundraise for future provision of these kinds of initiatives which improve the environment for our patients and their visitors, as well as staff. Addenbrooke’s Charitable Trust and Dunhill Medical Trust who currently fund the programme were also present.
2.10 I attended the new consultant induction programme to welcome a number of new colleagues and talk to them about the Trust’s strategy and culture and wish them well in their career here.
2.11 It was very heartening to attend an event to celebrate the work undertake in Women’s and Children’s Services as part of the ongoing events to mark the 70th anniversary of the NHS.
2.12 A Workforce Race Equality Standard (WRES) breakfast seminar took place in Cambridge and I was pleased to attend and represent CUH, along with a number of colleagues from the organisation. The Trust is committed to responding to issues raised in the last staff survey around equality and the Board will continue to maintain its focus on this very important area.
2.13 I was delighted to attend on behalf of the Trust, the graduation ceremony at the Faculty of Health, Social Care and Education at Anglia Ruskin University for nursing and midwifery graduates.
2.14 I also attended and spoke at the NIHR Cambridge Biomedical Research open evening. This was a very good event which brought the importance of research to both patient care and the local and national economy to the fore.
2.15 I was pleased to attend, along with a large number of staff, an Outpatient Accelerated Design Event (ADE). Accelerated design is an evidence-based approach to change built on a simple idea: people believe in what they design and own what they co-create. At the heart of the approach are accelerated design events. These events bring together large numbers of colleagues, between 50 and 100, from different areas, to work through challenges and issues important to us and develop action at pace. ADEs use a variety of techniques and methods, which have been proven to create the conditions for large-scale change. The event was led by our improvement and transformation team, with support from Professor Helen Bevan (chief transformation officer - NHS Horizons) and the Horizons team.
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3. You Made a Difference Awards
3.1 The September individual winners of You Made a Difference were Jennie Roy, Specialist Speech and Language Therapist, and Diana Addison, Nurse on Ward K3. Jennie has been working as a specialist speech and language therapist with the East of England regional Cleft Lip and Palate Service based at Addenbrooke’s Hospital since April 2012. This involves educating and empowering families in the first few months of a child’s life to support their child’s speech, language and communication development. Jennie undertakes assessment, differential diagnosis and intervention with children and adults presenting with what can be highly complex speech and communication impairments. Jennie is a thoughtful, thorough and conscientious clinician who puts a huge amount of effort into her work on a daily basis.
3.2 Diana was a student nurse on Ward K3 in her second year and made a great impression on the team. They were delighted to when she successfully applied as a newly qualified nurse and she has been with the ward since October 2016. Diana has a gregarious character and is welcoming to staff, visitors and patients alike. She is fun but professional and this nomination is a perfect reflection of her considerate and caring nature.
3.3 The September team award winner was Ward C7. Sarah Stevens, Ward Manager, Ward C7 has said she is immensely proud of what the team has achieved and she is stunned by the knowledge and skills shown by the team. They manage diabetics, nutritional challenges, post-operative patients, palliative patients, acute pain issues, emotional problems, and patients with complex discharge and social needs. All of this is done with a commitment to delivering excellent patient care whilst also maintaining their own sanity through humour and the ability to talk through their problems and concerns. Sarah is keen to ensure that Medirest colleagues are included in the C7 team – some of whom have been with the ward for over 20 years. The ward has developed a culture of openness and honesty, reflected in the kindness and compassion demonstrated by all members of the team. Sarah values the open culture on the ward. Despite significant previous staffing issues the team continues to support new colleagues and deliver excellent teaching and support. All of this is done with the support of the Division C Practice Development team, who contributed a great deal to developing new staff, ensuring they have the skills and confidence to practice independently.
3.4 The October individual winners were Emma Pearce Slade, Physiotherapist, and Sharon Wilson, Consultant, Cardiology. Emma graduated from King’s College, London in 2013 and after an initial period of travel, was so keen to work at Addenbrooke’s that she accepted a physiotherapy assistant post in March 2014. She was keen to come here from her student and personal experiences of the hospital, and within six months had more than proved herself and moved into a physiotherapy post. Emma continues to work here in a rotational post, although she has managed to squeeze in two long periods of travel abroad. Emma has gone the extra mile prioritising frail older people for proactive physiotherapy intervention, which her colleagues believe in many instances has shortened patient stays. She has been a great advocate for patients’ best interests in the geriatric
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multidisciplinary team meetings and has paid great attention to psychosocial complexity and provided extremely valuable professional opinions to assist with the discharge planning of frail elderly patients.
3.5 Sharon joined the cardiology department in January 2015 as a senior clinical fellow from Australia and went on to be appointed first to a locum consultant post and then a substantive consultant post. She was initially appointed to help with standard and complex echocardiography but is now the driving force behind delivery of that service. Sharon has a busy weekly schedule but will always roll up her sleeves to help out at short notice in the event of sickness and unexpected events. She has also been the first proper Educational Supervisor for the department, overhauling and defining training for Cardiology SpRs at CUH. Sharon has trained in cardiac imaging, a growing specialty; much needed at CUH and elsewhere, with a focus on complex echocardiography and is generally fairly forthright in her views. It is the norm for Sharon to go above and beyond.
4. Recommendation
4.1 The Board is asked to note the contents of this report.
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Cambridge University Hospitals NHS Foundation Trust
Report to the Board of Directors: 14 November 2018
Agenda item 7
Title Report from the Council of Governors
Sponsoring executive director n/a
Julia Loudon, Lead Governor of the Council of Author(s) Governors
To summarise the activities of the Council of Purpose Governors, highlight matters of concern and note successes.
Previously considered by n/a
Executive Summary The report summarises the activities of the Council of Governors.
Related Trust objectives All
Risk and Assurance n/a
Related Assurance Framework Entries n/a
Legal / Regulatory / Equality, Diversity & Dignity n/a implications?
How does this report affect Sustainability? n/a
Does this report reference the Trust's values of n/a “Together: safe, kind and excellent”?
Action required by the Board of Directors
The Board is asked to note the activities of the Council of Governors.
Cambridge University Hospitals NHS Foundation Trust
14 November 2018 Board of Directors Report from the Council of Governors Julia Loudon
1. Recent Governor meetings (since the last Lead Governor report)
1.1 The Annual Public Meeting was held on 17 September 2018. As Lead Governor I provided members with a brief perspective from the Council of Governors on i) the Trust’s performance, ii) on other governor responsibilities, and iii) on Council priorities for the coming year. Key points made were:
• To assure members of the keen attention paid by governors to performance indicators such as: o Emergency Department performance o Delayed Transfers of Care o Staffing levels and staff morale o Quality o Financial performance
• Governor interest and involvement in the development of Trust strategy, and the work of the broader Cambridgeshire and Peterborough Sustainability and Transformation Partnership (STP).
• Governor participation across a range of hospital committees and in Trust-led initiatives such as 15 Steps, PLACE events and patient focus groups.
• Forward looking priorities for the Council of Governors, including: o Reviewing our effectiveness as a Council. o Through our membership and engagement strategies, attracting new members and governors increasing diversity and thus ensuring good representation from all groups across our community. o Continue to both support and challenge the NEDs on all areas of Trust business.
1.2 The Council of Governors met on 26 September 2018. The Chief Executive provided updates on all key areas of Trust operations including quality, finance, access targets, workforce and leadership, highlighting both areas of strong performances and areas of concern. Questions were raised by governors, including:
• Income generation opportunities for the Trust. • Capacity issues, including ongoing challenge with Delayed Transfers of Care, capacity planning for winter and capital funding to address capacity challenges, including the longer-term strategic projects for the cancer and paediatric hospitals. • Given the high volume of new housebuilding in Cambridgeshire, how the provision of primary care will be approached via the STP. • Action being taken in relation to staff morale.
1.3 The Council also received a presentation from the Director of Improvement and Transformation, which provided an update on the progress being made with improvement and transformation initiatives across the Trust.
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1.4 The quarterly NED/governors meeting was held on 3 October 2018, where topics raised by governors were discussed. These included:
• The Trust’s winter plan. • The Cambridgeshire and Peterborough STP. • How NEDs make themselves visible across the Trust.
2. Upcoming meetings
2.1 A Medicine for Members lecture is scheduled for 7 November 2018.
2.2 As part of the CQC’s inspection of the ‘Well Led’ domain, a group of governors will meet with the CQC on 27 November 2018.
2.3 The Director/Governor Working Groups on Scrutiny & Performance and Communications & Engagement are scheduled for 5 December 2018.
2.4 The next Council of Governors meeting is scheduled for 19 December 2018.
3. Other Governor activities
3.1 I regret to report the resignation of Laura Minter as a Patient Governor. Laura was elected as a governor in 2017 and brought both her strong business experience and a deep understanding of the workings of Addenbrooke’s Hospital to bear in her role. During her time as governor, she made a very strong contribution to the Council, participating across a broad range of Trust initiatives and discussions. She represented governors on a number of hospital committees, was a governor observer at the Board Assurance sub- committee for Performance, and was a member of the CCG Clinical Policies Group.
3.2 We are also very sorry to say goodbye to John Wells, the Partnership Governor for the Biomedical Campus, who has retired from the Council. During his tenure John has been an extremely dedicated governor, always providing a well thought-through and pragmatic perspective on the issues and challenges being experienced by the Trust. He was a member of both the Governors’ Nomination and Remuneration Committee and the Governor Strategy Group.
3.3 We will miss the insightful contributions from both Laura and John and wish them all the best for the future.
3.4 Along with other Trust directors and external stakeholders, governors are preparing to provide input to the NED 360 appraisals.
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Cambridge University Hospitals NHS Foundation Trust
Report to the Board of Directors: 14 November 2018
Agenda item 8 Title Chief Executive’s report Sponsoring executive director Roland Sinker, Chief Executive Author(s) As above Purpose To receive and note the report. Previously considered by n/a
Executive Summary
This paper provides the Board with an update on the Trust’s performance, under the five main operational areas, as well as the four areas of strategy. Detail regarding the main operational areas can be found within the Integrated Performance Report. The Trust has continued to experience high levels of bed occupancy since the last meeting of the Board of Directors and has spent a number of days at Critical Internal Incident status. The Trust is part-way through a comprehensive inspection by its regulators, both CQC and NHS Improvement. Financial performance remains broadly on track and there is additional focus on CIP identification and delivery, length of stay and stranded patients. On strategy, the focus continues on DTOC under improving patient journeys; working with our communities and the STP; capital and IT under strengthening the organisation; and the life sciences strategy, and 10 Year Plan for the NHS, alongside cancer under contributing nationally and internationally.
Related Trust objectives All objectives A number of items within the report relate Risk and Assurance to risk and assurance, particularly within the Quality section. A number of items covered within the Related Assurance Framework Entries report relate to Board Assurance Framework entries. Legal / Regulatory / Equality, Diversity & n/a Dignity implications? How does this report affect Sustainability? n/a
Does this report reference the Trust's values of n/a “Together: safe, kind and excellent”?
Action required by the Board of Directors The Board is asked to note the report.
Cambridge University Hospitals NHS Foundation Trust
14 November 2018 Board of Directors Chief Executive’s report Roland Sinker
1. Introduction
1.1 Since the last meeting of the Board of Directors, members of the Board have undertaken a wide range of visits to meet with and listen to staff and patients in a number of areas, both internally and externally, including visits to the Emergency Department, a number of wards and departments, attending the Allied Health Professionals Day, attending 15-steps challenges in a number of areas, and attending the Staff Awards Celebration Event.
2. Five Operational Areas in Summary
2.1 Quality
There are some areas of strong quality performance, however there are also concerns that high levels of bed occupancy and large numbers of patients are leading to pressure on some core indicators. As detailed below, the Trust welcomed the CQC for a three-day unannounced inspection at the end of October.
2.1.1 Areas of strong performance include:
2.1.1.1 Mortality. HSMR for July 2018 (the latest available data) is 72.84, (June was 61.88) and is 81.6 for the rolling 12 month period ending July 2018. Latest peer data shows CUH is the best performing when compared to similar teaching trusts outside of London and fourth best performing inclusive of London Teaching Hospitals.
2.1.1.2 Infection Control, particularly MRSA. There were no cases of MRSA bacteraemia in September.
2.1.1.3 Stroke Care. In September the Trust met its target that 80% of stroke patients should spend 90% of their time on the stroke unit, with performance of 83.3%.
2.1.1.4 Quality Governance. The Trust continues to make good progress on quality governance standardisation.
2.1.1.5 Staffing. Recruitment continues to progress well.
2.1.1.6 Flu Vaccination. The Trust’s annual campaign to ensure as many staff as possible receive the flu vaccination continues. Staff continued to be encouraged to undertake the vaccine in order to protect their patients, themselves, and their families.
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2.1.1.7 A recent Topspot is a new campaign to highlight that fractured neck of femur patients are now given a femoral nerve block to manage pain earlier in their stay. As this results in patients being unable to feel and move their affected leg or foot, it could result in a hospital acquired pressure ulcer on the heel. Chris Gray, Matron for the Musculo-Skeletal service, has been instrumental in highlighting to staff that it is important to use an appropriate repose device to off-load the pressure on patients’ heels.
2.1.2 Areas of concern include:
2.1.2.1 Pressure on the Emergency Department, exacerbated by capacity pressure and DTOCs.
2.1.2.2 Infection control, particularly C.difficile. 10 inpatients were confirmed with C.difficile infection in September (eight Trust acquired and two community acquired). Seven patients were isolated within the CUH standard of two hours (70% compliance), and compliance with the C.difficile care bundle was 97.4% in September and 95.8% in August.
2.1.2.3 Serious Incidents. A Serious Incident previously reported related to a failure to identify that a refrigerator containing anti-D was out of temperature range. Over 300 women have been contacted by the Trust and advised that the anti-D they received may not have been as effective as possible. Risk to these patients is low, and clinics have been established for those affected to be seen. All women affected have been contacted, and the Trust is following up with those from whom no response has yet been received. Improvements are being overseen by the Medical Director.
2.1.2.4 Patient falls. There is some concern relating to a slight rise in inpatient falls, and this is being monitored and action taken as necessary.
2.1.2.5 Hospital acquired pressure ulcers. There is also some concern that numbers of hospital acquired pressure ulcers have increased. A deep dive has taken place within Division C and an action plan is in place.
2.1.2.6 Recent Hotspots relate to intravenous antibiotic labels and medication fridge temperatures. There have been reported patient safety incidents relating to similar medication labels on intravenous medication. Communications have been cascaded to clinical areas asking areas whether storing such medical separately could prevent errors in their areas. A recent serious incident has highlighted the risk of out-of-range fridge temperatures resulting in medication potentially becoming ineffective. Staff have been reminded to check medication fridge temperate regularly and provided with 24 hour contacts details should there be an issue. The serious incident investigation continues.
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2.1.3 CQC unannounced inspection. From 30 October to 1 November the Trust welcomed colleagues from the CQC who were undertaking an unannounced inspection of four core services: Emergency Department, Surgery, Medicine, and End of Life Care. The Board is grateful to staff who welcomed the inspectors to a number of areas. Initial feedback from the inspectors was positive, with some individual concerns were highlighted to the Trust each day. The intelligence gathered by the CQC will form one part of its rating of the organisation, together with planned inspections during November of the ‘Use of Resources’ and ‘Well-Led’ domains. Further information will be provided once the Trust has received formal feedback from the CQC.
2.2 Finance
2.2.1 The Trust is broadly on track financially at the end of September. At Month 6, the Trust had a deficit of £51.6m, in line with the plan. Total income was 5.6m greater than plan, and total expenditure was adverse by 5.1m. Focus remains on DTOCs, and CIPs. The Trust’s financial forecast for 2018/19 remains a £94m deficit, which remains consistent with the plan, however it is likely that increased non-recurrent support of £9.0m will be required in order to achieve this result. There is a renewed focus on CIP identification and delivery.
2.2.2 A recent article in the Health Service Journal reported that CUH is seeking support for an approximate £90m deficit. This is factually accurate, however over the last three years the Trust’s financial performance has improved in a planned manner with deficits of £84.3m, £53.0m and £32.2m in 2015/16, 2016/17, and 2017/18 respectively with Government support. This year, significant one-off IT transition costs and physical capacity relating to essential maintenance and demand have meant the Trust is forecasting a larger deficit in a planned manner. It would be unrealistic for the Trust to sign up to achieving its control total and it therefore will not benefit financially as trusts who have signed up to this will do. This support could have been expected to be approximately £20m. This is no reflection on continued financial grip, CIP delivery and productivity which continues to be strong. Capital for additional physical capacity and continued progress with our partners in the STP to manage demand and DTOCs is essential in moving the Trust towards financial balance.
2.2.3 On cost savings (CIPs), the Trust made a good start to the year, however it is important that the momentum is maintained. The target for savings throughout 2018/19 is to deliver £40.0m recurrent savings. At Month 6, the Trust had delivered £19.18m of savings against a plan of £19.15m, with a year to date variance of £0.03m over performance. Staff throughout the organisation continue to work hard to achieve these savings and to identify opportunities for recurrent savings.
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2.2.4 Backlog Maintenance. The Trust’s minimum capital budget requirement for 2018/19 is £41.0m. Available funding totals £20.7m and therefore additional cash funding of £20.3m has been requested as a loan from NHS Improvement. The Trust has not yet spent more than its currently available capital funds, but has approved spending of over £34m and contracted £23.4m. The Capital Advisory Board continues to act as guardian of the process to ensure that schemes which demonstrably address significant risks are appropriately expedited.
2.2.5 Structural Deficit and Capital. There remains a gap of £20.3m between the Trust’s 2018/19 capital programme and the funding available. The Trust has not as yet contractually committed to capital expenditure greater than the current funding available, however it is likely that this will happen in the next two months. The Board will be involved in decisions regarding expenditure over this threshold. The five areas of capital request for the STP relate to Hinchingbrooke, community services, modular build at CUH, and paediatric and cancer for the region. The structural deficit of the Trust remains a key area of work for the Board, with a range of options under consideration both within the Trust and the STP, cognisant of developments in the Long Term Plan for the NHS.
2.3 Access Targets
2.3.1 On access, the Trust remains slightly ahead of the elective surgery plan despite significant pressure on beds, whilst under- performing against its non-elective plan.
2.3.2 Planned surgery. During September the Trust continued to slightly over perform against its elective plan despite significant capacity pressures, whilst underperforming against its non-elective plan. The capacity plan for the year focusses on six areas: Demand management, length of stay, stranded patients, pathway redesign, identifying short term opportunities to increase capacity, and identifying longer term opportunities to increase capacity.
2.3.3 Occupancy. Bed occupancy has seen an increase in September to 92.8%, not achieving the under 92% target that was set in the plan. The level is cumulatively – 0.7% below the activity plan Year to Date.
2.3.4 Emergency Department (ED) Performance decreased slightly in September compared with August, exacerbated by capacity pressures and DTOCs throughout the organisation. Performance against the four hour standard decreased slightly to 85.8% in September from 88.2% in August. The type 1 performance for September was 80.9% compared to 84.0% in August. Type 1 attendances grew by 2.7% compared to September 2017. In September 2018 there were 2,561 conveyances to CUH which was a decrease of 144 (5.3%) from 2,705 in September 2017. 1,506 (59%) were completed within 15 minutes compared to 1,596 (59.6%) in August. In comparison to the rest of the region (28 hospitals), CUH was the second highest performing hospital for ambulance turnaround times within 15 minutes. Admissions from the Emergency Department Year to Date are 697 (3.4%) down on 2017. Board of Directors: 14 November 2018 Chief Executive’s report Page 5 of 11
Of these, 196 (28%) relate to admissions with zero length of stay 501 (72%) with less or one day length of stay.
September however did show an increase in admissions of 1.9% compared to the previous year, only the second month in 2018/19 to show a rise. Internal critical incidents due to bed capacity have been called during October, and some patients have been bedded overnight in the Emergency Department during this time. The ED action plan has been updated to provide more detail around recovery actions, and the new plan is reviewed on a weekly basis by the members of the daily ED Performance Group. Five areas of focus are admissions avoidance, GP streaming, ED processing, patient flow, and complex discharges. A great deal of direct engagement work is ongoing with ward and service teams regarding the Trust’s own internal discharge processes and stranded patients. ED together with acute medicine are preparing for the launch of the acute hub model which will see medicine patients receiving senior reviews outside of ED and all patients flowing through three acute wards, with the exception of those needing a specialist inpatient bed. This model will launch on 15th November and should lead to reduced patient times in ED, patients moving onward to appropriate areas within the hospital and therefore reduced length of stay. The Trust has invited in external reviewers from NHS England and NHS Improvement to review progress.
2.3.5 Referral to Treatment (RTT) Performance in September was 88.9%. The number of patients waiting over 18 weeks increased by 83. The overall waiting list size did however decrease by 767 from August and is therefore now below the March 2018 baseline which the Trust needs to sustain. This is ahead of trajectory for the total waiting list size and shows a -1.1% variance. September showed a lower demand, however on a per working day basis, referrals did increase back above the volumes seen in August. The total treatments for RTT are running 12% higher year to date when compared to 2017. New risks are emerging for some high volume outpatient services (ophthalmology, allergy and dermatology) as a consequence of some gaps in medical staffing. The services are exploring actions to mitigate these in order to minimise impact. It is anticipated that the Trust will remain ahead of trajectory for total waiting list size on October.
2.3.6 Delayed Transfers Of Care (DTOC) The DTOC position slightly improved in September. September saw an improvement in position from 8.1% to 7.5% occupied days and reduction in bed days from 2,198 to 1,998. The system plan for DTOC is being implemented, however this performance may reflect normal variation, and is similar to the position in September 2017. Each individual provider is to hold its part of the action plan, and escalate issues as necessary. The Local Authority has completed an exercise modelling the demand and capacity for both home care and beds. The picture for Cambridge shows a deficit in both, however the greatest short term risk is with home care. Pressure in the private domiciliary care market is impacting the ability of reablement to provide short term intervention and discharge. Internally, the Super Stranded Peer Review Panel has commenced,
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overseeing, challenging and supporting the ward, division and corporate processes to ensure appropriate and timely patient discharge. Individuals cases are scrutinised, and pathways and processes identified where improvement can be made.
2.3.7 Cancer In August the Trust achieved all cancer standards with the exception of the 62 day urgent and screening standards. The Trust had submitted a plan for 2018/19 expecting to sustain performance against the 62 day urgent standard above the required 85%. Performance in September is forecasting to fail to meet the 62 day urgent and two week wait standard. Patient choice has had a high impact on two week wait performance in September. The Diagnostic 6ww performance in September was achieved at 0.64% with a total of 49 breaches.
2.3.8 Diagnostics The diagnostic six week wait performance in September was sustained below the required 1% standard at 0.64%.
2.4 Staff and Transformation Programme
2.4.1 The Senior Leaders’ Programme continues to progress well. In October team eight commenced their modules with the Kings Fund. Three cohorts are currently on the programme with cohort 1 ending their Cambridge Judge Business School Masterclasses in February. The Trust looks forward to complementing the Senior Leaders’ Programme in November, when Professor Michael West will speak at the Wider Leadership Team Workshop. Professor West is highly influential in the approach to leadership and leadership development within the NHS and was one of the architects of the national strategic framework for leadership, ‘Developing People – Improving Care‘. At the heart of the framework is compassionate leadership. Michael will also discuss interventions that create cultures in which high quality care can flourish.
2.4.2 During October CUH has been pleased to promote and support staff networks in a number of events including a Black History month film night showing Black Nurses, The Women Who Saved the NHS Full BBC Documentary; World Mental Health Day – Open Mind Night; Time to Change Stall in the concourse; and a lunch time speaker discussing addiction and mental health. A member of CUH staff attended Management Executive to share their experience of living and working with a mental illness, and their story and experience was supported by a Health and Wellbeing paper identifying support available to the workforce. An expert panel consisting of CUH consultants and a GP also met regarding the menopause, and this was followed by a menopause café for staff to meet and discuss menopausal issues affecting them.
2.4.3 The current national staff survey is under way and it is important that as many of our staff as possible complete this in order to provide a reliable source of information regarding areas of focus for the Trust.
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2.4.4 Focus continues on the staff survey, with ongoing work addressing five key areas; i. Meaningful staff appraisals ii. Staff feel listened to, valued, appreciated, confident to speak up and report concerns iii. Staff feel supported to have a healthy and safe work experience iv. Equality of opportunity and inclusion (incorporating the Workforce Race Equality Standard) v. Tackling bullying, harassment and abuse
2.5 Improvement and Transformation
2.5.1 A large amount of work continues within the Trust in relation to improvement and transformation. An outpatient accelerated design event (ADE) was undertaken on 12 October, with patients, staff and colleagues from across the system attending. This was run by the improvement and transformation team, with coaching support from Professor Helen Bevan (Chief Transformation Officer, NHS Horizons) and the NHS Horizons team. Feedback from colleagues has been very positive and supporting actions will be monitored and progressed through the Outpatient Steering Group. The team is currently planning an ADE to support corporate areas.
2.5.2 In September the Improvement Steering Group received a presentation from Dr Jo Leithead, Consultant Hepatologist, regarding improvements for patients undergoing liver transplant assessments. The team has moved from inpatient assessments to undertaking them within outpatients; this has improved the quality of the service for patients, as well as the referring centres, has reduced length of stay, as well as supported achievement of associated performance targets.
2.5.3 In November the Improvement Steering Group received a presentation from Mr Manj Gohel, Consultant Vascular Surgeon, regarding improvements for patients with leg and foot ulcers. With the use of photographs to assess the patient’s wound, patients can be treated in the most appropriate way; this will include for some patients being seen in an inpatient clinic. As a consequence, there will be improved patient outcomes, reduced use of inappropriate antibiotics and length of stay reductions. Once the clinic has been evaluated the service could be extended to managing patients within the Emergency Department to help prevent unnecessary admissions.
2.5.4 At month 6 the Trust delivered £19.18m of savings against a plan of £19.15m, with a year-to-date variance of £0.03m over-performance.
2.5.5 Under the leadership of the Director of Improvement and Transformation, the Trust has worked with Advancing Quality Alliance (AQuA) to progress an organisation-wide improvement stocktake in order to understand the maturity of the Trust both in respect to the existence of a culture for improvement, and the extent to which approaches or systems for continuous improvement are deployed. AQuA is currently finalising its report and this will be presented to the Board in due course. Board of Directors: 14 November 2018 Chief Executive’s report Page 8 of 11
2.5.6 The improvement and transformation team is supporting nine wards (C8, D8, D9, F6, G3, N3, A4, D7 and Lady Mary) to help them improve patient discharges, along with reducing, where clinically appropriate, the time patients spend on these wards. The team is utilising a structured improvement approach and this is enabling the ward teams to identify areas of opportunity to improve, in order that they can start to test out possible solutions. This links strongly to Trust work on length of stay, stranded patients and capacity.
3. Four Areas of Strategy in Summary
3.1 Improving patient journeys
3.1.1 This area of the strategy covers continuous improvement, led by the Director of Improvement and Transformation, and a detailed update can be found under section 2.5 above.
3.1.2 Other strategic priorities within this part of the strategy are Length of Stay and Delayed Transfers of Care, led by the Chief Operating Officer, and Medium Term Capacity, led by the Chief Operating Officer and the Director of Strategy and Major Projects.
3.1.3 On phase two capital, as reported in the last report, there are two options to progress with respect to a rapid build on site with a deadline for decision of Christmas.
3.2 Working with our communities, e.g. through the System Transformation Programme
3.2.1 This area of the strategy includes the STP, where the structured and planned focus is Emergency Department performance, and DTOC, as well as the locality model, devolution and digital as well as the longer term leadership model. The CUH contribution on STP Acute Services, is led by the Chief Operating Officer, and the Locality Model for which the Trust lead is the Director of Strategy and Major Projects. CUH continues to play a leading role in the southern alliance. It remains key to build on strong GP and social care engagement and the development of a locality model. The STP Board will meet in public in November.
3.2.2 Working with Royal Papworth Hospital falls under working with our communities, and the lead for the Trust’s part in the transition of Royal Papworth Hospital to the Cambridge Biomedical Campus is the Director of Strategy and Major Projects. The Trust continues working with Royal Papworth ahead of its move to the Cambridge Biomedical Campus in spring 2019.
3.2.3 The other strategic priority area under this part of the strategy is System Finances which is led on the Trust’s behalf by the Chief Finance Officer. The Trust continues to work with STP partners on system finance.
3.3 Strengthening the organisation
3.3.1 This area of the strategy includes workforce and culture, led by the Director of Workforce, Digital Strategy led by the Director of Improvement Board of Directors: 14 November 2018 Chief Executive’s report Page 9 of 11
and Transformation, Governance and Accountability led by the Director of Corporate Affairs and Chief Operating Officer, Hospital Campus and Estates Plan led by the Chief Finance Officer, and Education and Training led by the Director of Workforce.
3.3.2 This month CUH learned that it was, for the second time, the first Trust in the UK to achieve a quality standard that recognises the use of technology to deliver high quality patient care. The Trust has validated against the new Stage 6 criteria of the Healthcare Information and Management Systems Society’s (HIMMS) international Electronic Medical Records Adoption Model (EMRAM). Stage 6 is more difficult to achieve than previously, as it now includes the use of ‘technology enabled medication, blood products and human milk administration, risk reporting and full clinical decision support.’ Stage 6 means that the Trust has established clear goals for improving safety, minimising errors, and recognising the importance of healthcare IT and puts it on course to achieve Stage 7, the highest EMRAM status, an accolade only held by a handful of overseas medical organisations. The achievement of Stage 6 is testament to the hard work of staff throughout the organisation, for the benefit of the patients we serve.
3.3.3 In September, the Trust learned that it had been recognised as a 2018 Most Wired organisation. As part of this, CUH is also recognized as a top scoring International organization.
3.3.4 After a competitive re-tendering exercise, the Trust has selected the company Novosco to provide IT infrastructure and support services for the next seven years. This change is important for further improving patient care and working more effectively with partners in research and industry. It recognises how the Trust’s technology needs have changed over the five years since the eHospital programme was launched, and means that the use of Epic can be maximised. Working with Novosco will enable CUH to update its computers and devices and further develop IT assistance and support. It will also bring new data centres to keep information secure and enable flexible sharing of information. The new contract also delivers excellent value for money, supporting he Trust’s strategic goal of strengthening the organisation. CUH is looking forward to working with Novosco at an exciting time for the Trust when it is taking forward its status as a Global Digital Exemplar, delivered through its eHospital digital transformation programme. The Trust continues to work with the current and new providers to transition carefully and safely during 2019. I am grateful to the clinical, digital and finance teams for their hard work in getting the Trust to this important point.
3.3.5 On capital for Estates works, particularly with reference to fire safety, good progress continues to be made, with progress on fire alarm upgrade, including progress on the range of workstreams to improve compartmentation, with a solution including full ward works. The Trust continues to work alongside Cambridgeshire Fire and Rescue Service. A total of £13.8m has been allocated this financial year to address infrastructure related issues. The key issue is capital and capacity in order to enable a sustainable decant plan.
Board of Directors: 14 November 2018 Chief Executive’s report Page 10 of 11
3.4 Contributing nationally and internationally, e.g. through membership of Cambridge University Health Partners (CUHP)
3.4.1 Through this area of the strategy, the Trusts’ strategic priorities are contributing to the national Life Sciences agenda and Cambridge being open for business (in conjunction with CUHP), led by the Chief Finance Officer, and Director of Strategy and Major Projects, a Cancer Research Hospital, and Children’s Hospital, both led by the Director of Strategy and Major Projects, and Research, led by the Medical Director.
3.4.2 Through CUHP, the Trust was disappointed not to have been successful in its bid for digital pathology and radiology exemplar status. Work continues with the University and industry partners in order to explore continuing to implement the plan. Work also continues with NHS Digital with respect to Local Health and Care Record Exemplar (LHCRE) status and the Trust is preparing to be a digital innovation hub.
3.4.3 The Trust continues to play a leading role in the implementation of the UK Life Sciences Industrial Strategy particularly with respect to Cancer, data and medical technology. Also via CUHP the Trust continues to work on innovation and highlighting that the local Cambridge economy is open for business. Relationships continue to be strengthened with partners including Roche, Baxter, Johnson & Johnson, Philips, and ARM, as well as AstraZeneca and Abcam, and a number of events are taking place with CUHP and ACT over the autumn and winter.
3.4.4 As reported previously, the Board has considered a Cancer Research Hospital for the eastern region Outline Business Case, and Paediatric Hospital for the eastern region Strategic Outline Case. There is a concerted effort with partners to progress the cancer case at present and the Chief Executive, along with University and research partners continues to meet with key stakeholders at the most senior level in Government and elsewhere.
3.4.5 Along with campus partners, and through CUHP, the Trust also continues to engage in campus planning.
4. Engagement
4.1 Work continues in terms of both internal engagement, including the CEO brief, 8.27 briefings, Executive visits and meetings with consultants, and external engagement, including liaison with regulators, such as NHS Improvement, NHS England, the Care Quality Commission, as well as local authorities and partners, particularly via the STP.
5. Recommendation
5.1 The Board of Directors is asked to note the report.
Board of Directors: 14 November 2018 Chief Executive’s report Page 11 of 11
Cambridge University Hospitals NHS Foundation Trust
Report to the Board of Directors: 14 November 2018
Agenda item 9 Title Integrated Report Chief Operating Officer, Chief Nurse, Sponsoring executive director Medical Director, Director of Workforce, Chief Finance Officer Author(s) As above To update the Trust Board on performance Purpose during September 2018. Previously considered by Performance Committee, 7 November 2018
Executive Summary The Integrated Report provides details of performance to the end of September 2018 across quality, access standards, workforce and finance. It provides a breakdown where applicable of performance by clinical division and corporate directorate and summarises key actions being taken to recover or improve performance in these areas.
Related Trust objectives All objectives The report provides assurance on Risk and Assurance performance during Month 6. BAF Ref: 002/18, 004/18, 007/18 and Related Assurance Framework Entries 009/18 Legal implications/Regulatory requirements n/a How does this report affect Sustainability? n/a Does this report reference the Trust's values of “Together: safe, kind and n/a excellent”?
Action required by the Board of Directors The Board is asked to note the Integrated Report for September 2018 (2018/19 Month 6).
Integrated Report – Quality, Performance, Finance & Workforce to end September 2018
Chief Financial Officer Chief Nurse Chief Operating Officer Director of Workforce Medical Director Contents
Context for the Integrated Report * Aug Sep 1. Executive Summary 2 Emergency department attendances 9,662 9,638 Outpatient attendances 65,692 64,445 2. Quality Account scorecard 4 Inpatient admissions 5,850 5,774 3. Harm Free Care 8
4. Delay Free Care 15 Other (regular day patients, day 10,938 10,357 5. Person Centred Care 27 cases etc) Total 92,142 90,214 6. Clinically Effective Care 30 Operations undertaken 2,921 3,064 7. Financial performance 38 Trend (on prior period) 8. Workforce: Staff as Partners 42 Improvement on previous month/period Decline on previous month/period Appendix: Divisional structure 51 No real change on previous month/period No significant change Targets are shown for the full year. Last rolling twelve months are labelled "LTM". Financ ial year to date is "FYtD".
1 Integrated Report Executive Summary The Trust strategy for 2018/19 is based upon delivering the highest quality service we can for patients whilst improving patient flow through the hospital in order that we can deliver our activity plan and our Cost Improvement Programme for the year. During September the Trust has continued to slightly over perform against its elective plan despite significant capacity pressures, whilst underperforming against its non-elective plan. Bed occupancy has seen an increase in September to 92.8% not achieving the < 92% that was set in the plan. We are cumulatively - 0.7% below the activity plan Year To Date. In patient activity YTD w/e 27th October Elective + 1.8% Non-Elective - 4.2% Outpatients + 4.1% Our capacity plan for the year is now focussing on six areas: Demand management, we are working with the CCG and GPs to more effectively manage demand, for example this year we are implementing more extensive advice and guidance. Demand remains ahead of projections set at the beginning of the year Length of Stay, where we are converting inpatient surgery into day case or 23hr stay. We have also worked to cohort our medical and surgical beds to reduce length of stay. We remain behind plan on Length of Stay principally driven by performance for medicine patients in Division C and D Stranded patients, we have launched our transformation projects on 8 wards to improve board rounds and red to green and safer processes. We have a review process in place for all stranded patients. As a system we are continuing to work on a shared plan to reduce delayed transfers of care but remain significantly behind our 3.5% target Pathway redesign, we are continuing to work with our partners in the STP to redesign pathways. The implementation of early supported discharge pathway for stroke patients is going well. The redesign of the Stroke and Neuro rehabilitation patient pathway requires further discussion with partners Identifying short term opportunities to increase capacity. We have developed plans to move the discharge lounge to the J3 seminar room freeing up capacity and C4. We are also planning to increase capacity on N2 by 1 room. These schemes will go live In November Identifying longer term opportunities to increase capacity. We are continuing to engage with NHS England following the submission of capital bids through the STP (our bids included funding for a Cancer research hospital, phase 1 of a Childrens hospital and temporary capacity) Quality summary CUH is ranked 7th in the Shelford Group for the Trust Safety Thermometer in September with a score of 97.30% (in relation to new harm only) which is below the national average of 97.88%. More detail can be found on page 13. The reported Hospital Standardised Mortality Ratio (HSMR) for the latest available data, July 2018 is 72.84 (June was 61.88) and is 81.6 for the rolling 12 month period ending July 2018. CUH is the best performing Trust in our Outside London Teaching peer group,(ATHOL) 4th best performing inclusive of London Teaching hospitals. Details can be found on page 32. There were no cases of hospital acquired MRSA bacteraemia in September. The latest MRSA bacteraemia rate comparative data (12 months to August 2018) put the Trust 7th out of 10 in the Shelford Group of teaching hospitals. There were 10 inpatients confirmed with C. difficile infection (8 hospital acquired and 2 community acquired cases) in September. 7 patients were isolated within the CUH standard of 2 hours (70% compliance). Compliance with the C. difficile care bundle was 97.4% in September (95.8% in August). The latest C. difficile rate comparative data (12 months to August 2018) put the Trust 8th out of 10 in the Shelford Group of teaching hospitals. Performance summary Our plan, from a performance perspective is aiming to: Achieve 90% performance or above on the 4 hour Emergency Target with a particular focus on the first 9 months of the year. Performance against the four hour standard decreased slightly to 85.8% in September from 88.2% in August. The type 1 performance for September was 80.9% compared to 84.0% in August. Type 1 attendances grew by 2.7% compared to September 2017. In September 2018 there were 2,561 conveyances to CUH which was a decrease of 144 (5.3%) from 2,705 in September 2017. 1,506 (59%) were completed within 15 minutes compared to 1,596 (59.6%) in August. In comparison to the rest of the region (28 hospitals), we were the 2nd highest performing hospital for ambulance turnaround times within 15 minutes. Maintain our waiting list for elective surgery at the level we saw in March 2018.The overall waiting list size did decrease markedly by 767 from August, and is therefore now 349 below the March 2018 baseline that we need to sustain. This represents a -1.1% variance. The Trusts RTT 18 week performance deteriorated in September to 88.9%, with the number of patients over 18 weeks increasing by 83 (39 admitted and 44 non-admitted). Reduce to 3.5% occupied bed days for Delayed Transfers of Care (DTOC). September saw a small improvement in position from 8.1% to 7.5% occupied bed days and reduction in bed days from 2198 to 1998. We are now implementing our system plan for DTOC but this improvement could reflect normal variation, and is a similar position to September 2017.
2 Integrated Report Page author: Sam Higginson, Paul Scott, Ashley Shaw, Lorraine Szeremeta, David Wherrett Executive Summary – cont. Achieve the Cancer standards with a particular focus on the 62 day from urgent referral standard. In August the Trust achieved all cancer standards bar the 62 day urgent and screening standards. 2ww performance did recover this month although the volume of 2ww patients seen remained at over 1600 for the fourth consecutive month. Achieve the 1% diagnostic 6 week wait standard. The Diagnostic 6ww performance in September was achieved at 0.64% with a total of 49 breaches Meet our stroke objective that 80% of stroke patients spend greater than 90% of time on the stroke unit. Target compliance was achieved for September at 83.3%. Lack of beds (6) was the main contributory factor to the breach position of 8 patients. Workforce summary The Trusts full time equivalent staff (FTE) saw an increase of 74 in September 2018. This was primarily due to an increase in the Nursing & Midwifery, Medical, and Health care scientist staff groups which increased by 14 FTE, 35 FTE and 12 FTE respectively. Overall the Trust saw a 5.7% growth in its substantive workforce over the past 12 month. Turnover rate saw a further drop of 0.2 % from the previous month to 13.8%. The vacancy rate for Registered Nurses saw a further drop of 0.9% from the previous month to 10.2%, making it the sixth consecutive month of a decrease. The Trust continues to work with partners to recruit from overseas and liaise closely with Universities locally and nationally to attract newly qualified nurses. The Vacancy rate for HCAs remains static from the previous month at 28%. However, when taking into consideration nurses who are currently working as HCAs pending the receipt of their NMC registration the HCA vacancy rate is reduced to 14% (with the corresponding Registered Nursing vacancy rate at 16%). This is due to the investment in a large intake of overseas nurses over the past few months. Total sickness absence rate is static from the previous month at 3.2% and remains below the 3.9% NHS National average. September reflects a 2% increase in the total temporary shifts requested and have therefore returned to a similar level seen in July 2018. Overall the Trust saw a 1% decrease from the previous month in total filled shifts at 81% but maintained the 73% Bank filled shifts from the previous month. The overall Trust position on mandatory training compliance remains above 95% and above the Trust’s KPI of 90% at 95.7%. The compliance rate for both Prevent WRAP 3 and Safeguarding Children level 3 remains above 90% at 91% and 90% respectively. Divisions and teams are continuing their efforts to ensure we achieve the compliance target for all training that falls below the KPI. Appraisal compliance is at 98% for non-medical staff and 99% for medical staff. Divisions and teams are continuing their efforts to ensure we improve on the 98% overall rate achieved in the previous financial year. This month we report the results of the quarter two Staff Friends and Family Test (FFT) and Staff Engagement Survey. The Trust’s recommender score for staff extremely likely/likely to recommend CUH for care and treatment has remained the same as quarter one at 93%; the score for staff rated as extremely likely/likely to recommend CUH as a place to work has fallen by one per cent from 73% to 72%. The Workforce Experience committee continues to oversee the development and implementation of the Trust's Staff engagement and experience plan for the year. This month the Trusts planned vs. actual staff in post (SIP) figures shows that the actual SIP is above the planned figures by 81 FTE, resulting in a 3.2% growth from March 2018. This is higher by 0.9 % than the planned growth of 2.4%. This is mainly due to unplanned increase in Admin staff working within the R&D directorate and a higher growth than planned for Medical & Dental and Nursing staff groups. Finance summary The Trust’s financial position at the end of month 6 was in line with plan (£51.6m deficit). The Trust’s most likely financial forecast for FY1819 remains a £94m deficit (in line with plan), however, it looks likely that increased non recurrent support (£9.0m) will be required in order to achieve this result. There remains a gap of £20.3m between the Trust’s FY1819 capital programme and the funding available. The Trust has not (as yet) contractually committed to capital expenditure greater than the current funding available. It is likely that this will happen in the next two months, and the CFO will ensure any decisions on commitments above this funding threshold go to Board. Reduce to 3.5% occupied bed days for Delayed Transfers of Care (DTOC). September saw a small improvement in position from 8.1% to 7.5% occupied bed days and reduction in bed days from 2198 to 1998. We are now implementing our system plan for DTOC but this improvement could reflect normal variation, and is a similar position to September 2017.
3 Integrated Report Page author: Sam Higginson, Paul Scott, Ashley Shaw, Lorraine Szeremeta, David Wherrett 2018/19 Quality Account Scorecard Priority Indicators Data to: Trend Target Jul-18 Aug-18 Sep-18 FYtD LTM Patient safety thermometer (new harm only) Sep > 98% 97.1% 97.4% 97.3% 97.53% 97.8% Number of avoidable hospital associated grade 4 pressure ulcers Sep 0 0 0 0 0 0 Vacancy rate for registered nurses / registered midwives Sep ≤ 11% 11.4% 11.1% 10.2% 11.5% 12.6%
Vacancy rate for healthcare assistants Sep ≤ 15% 29.0% 28.0% 28.0% 28.7% 27.0% Reduce by 2% Sep Number of cardiac arrests per 1000 admissions per month (excluding peri-arrests) (to 1.55 or below) 0.94 1.61 1.46 1.34 1.30 Safe % of deaths reviewed (using new national methodology) Aug . >50% 75.0% - - 90.4% 95.1% Lead investigators for serious incidents to have attended NPSA accredited (or Jul 100% by Q4 100.0% #N/A #N/A 100.0% - equivalent) training in root cause analysis within the previous two years > 2% of 16/17 Sep Average reported patient safety incident rate per 1000 bed days (to 29.3 or above) 43.86 36.85 34.98 37.04 36.40
Priority Indicators Data to: Trend Target Jul-18 Aug-18 Sep-18 FYtD LTM
Frailty - CFS screen <72 hrs from admit Sep ≥ 90% 87.2% 89.4% 92.3% 88.9% 87.4%
Number of avoidable deaths from sepsis established through mortality review - . 0 - - - 0 0
Cancelled operations Sep ≤ 1% 0.63% 0.86% 0.99% 0.85% 1.11% Bed days lost to delayed Complex Care cases (including DToC) as a percentage of total
Effective/ Sep < 2.5%
Responsive 11.7% 10.2% 10.4% 10.0% 10.4% occupied beds
Priority Indicators Data to: Trend Target Jul-18 Aug-18 Sep-18 FYtD LTM ≥ 62.2% (10% Pain assessment recorded with every set of observations Sep increase on 16/17) 80.0% 80.9% 82.5% 79.4% 76.1% % of patients aged 16 and over admitted as inpatients for more than 24 hours who ≥ 73.3% (10% Sep 71.6% 73.7% 74.9% 74.9% 74.6% have had a nutrition screening documented within 24 hours of admission. increase on 16/ 17) Positive responses to catering service satisfaction survey Sep ≥ 95% 98.7% 97.8% 99.1% 98.6% 98.8% Indicators Data to: Trend Target Apr-18 May-18 Jun-18 FYtD LTM Patient / Caring Percentage of complaints responded to within 30 working days or within extension
Experience Jun ≥ 85% 83.8% 76.6% 65.2% 75.7% - agreed with complainant (provisional)
Q2 - Q3 - Q4 - Priority Indicators Data to: Trend Target 2017/18 2017/18 2017/18 FYtD LTM
Q4 - ≥2% (increase on I would recommend my organisation as a place to work (FFT) 71.0% 0.0% 69.0% 2017/18 16/17)
Indicators Data to: Trend Target 15/16 16/17 17/18
When errors, near misses or incidents are reported, my organisation takes action to ensure that ≥2% (increase on 16/17 . - 65.0% - they do not happen again 16/17) /Well-Led
≥2% (increase on I would feel confident that the organisation would address concerns about unsafe clinical practice 16/17 . - 61.0% - Staff Experience Experience Staff 16/17)
4 Integrated Report Page author: VARIOUS, Owner – Giles Thorpe Performance Framework - Quality Indicators Jul 18 Aug 18 Sep 18 Previous Previous Current Previous Target Trend FYtD LTM Score Weighting Domain Indicator Data to Month-1 Month status FYR MRSA Bacteraemia Sep-18 0 0 1 0 2 0 2 33.3% 50% over 3 E.Coli Bacteraemias (Total Cases) Sep-18 31 43 31 197 350 363 16.6% Infection Control years C. difficile Infection Sep-18 TBC 9 9 8 43 66 73 25.0% Hand Hygiene Compliance Sep-18 TBC 99.57% 99.61% 99.16% 99.5% 99.5% 99.5% 25.0% Rounded score Moderate/Severe/Death harm incidents Sep-18 10% 0 0 - . 1.1% - 1.1% 13.3%
Serious incidents Sep-18 n/a 10 4 5 24 81 61 0.0%
Monthly % compliance SI Final Report Submission Aug-18 100% 33.3% 66.7% - . 53.3% - 53.3% 20.0% Number of overdue SI actions/recommendations Sep-18 0 9 3 3 15 - 15 20.0% Monthly % compliance duty of candour (Stage 1) Jul-18 100% 100.0% - - . 100.0% - 100.0% 13% Patient Safety (month in arrears) Monthly % compliance duty of candour (Stage 2) Jul-18 100% 100.0% - - . 100.0% - 100.0% 13% (month in arrears) Monthly % compliance duty of candour (Stage 1) within Jul-18 100% 60.0% - - . 72.7% - 72.7% 33% 10 days (month in arrears) Monthly % compliance duty of candour (Stage 2) within Jul-18 100% 100.0% - - . 80.0% - 80.0% 33% 10 days (month in arrears) Rounded score NatSSIPs protocols completed Jan-00 95% - - - . - - - 50.0% Surgical Safety WHO surgical checklist compliance (exc.implant pause) Oct-18 95% - - - . - 88.8% 91.2% 50.0% Rounded score Patient falls (moderate harm or greater) per 1000 Mar-20 0 ####### ####### ####### ####### ####### ####### 16.6% beddays Patient falls (moderate harm or greater) Sep-18 0 2 1 2 5 - 5 16.6%
Hospital acquired PU (grade 2, 3 & 4) per 1000 beddays Sep-18 0 0.33 0.34 0.50 0.39 - 0.39
Harm Free Care AVOIDABLE Grade 2-4 CUH acquired Pus Sep-18 TBC 11 41 58 110 - 110 16.6% Avoidable Pressure Ulcers (Grade 3 & 4) Sep-18 TBC 0 0 0 0 - 0 22.2% ALL CUH-acquired pressure ulcers category Sep-18 TBC 3 3 2 8 - 8 22.2% unstageable (necrotic) or suspected deep tissue injury Sepsis 6 compliance (within 1 hour) (ED only) Jun-18 95% - - - . 196% 57.7% 588% 16.6% Safety Thermometer (new harms only) Sep-18 2% 2.9% 2.6% 2.7% 2.5% 2.0% 2.2% 16.6% Rounded score Number of medium/high level complaints Jul-18 N/A 0 - - . 0 - 0 11.8% Patient Number of overdue complaints Jul-18 0 7 - - . 7 - 7 23.5% Experience Re-opened complaints Jul-18 N/A 6 - - . 6 - 6 23.5% Mixed sex accommodation breaches Sep-18 0 4 0 1 10 16 18 23.5% Rounded score Monthly % compliance of SJRs completed (deaths in Mortality Aug-18 100% 70.0% 76.9% 76.9% 83.3% 100.0% 91.1% 100.0% scope) (month in arrears) Rounded score
5 Integrated Report Page author: VARIOUS, Owner - Giles Thorpe Performance Framework - Quality Indicators Cont. Jul 18 Aug 18 Sep 18 Previous Previous Current Previous Target Trend FYtD LTM Score Weighting Domain Indicator Data to Month-1 Month status FYR % of NICE Technology Appraisals on Trust formulary Sep-18 100% 66.7% 66.7% 57.1% 63.6% - 63.6% 24% within three months. (‘last month’) % of relevant NICE recommendations recorded as met Sep-18 85% 2.8% 91.1% 89.0% 57.0% - 57.0% 7% in the returned baseline assessment. (‘last month’) % of NICE quality standards where the gap analysis Sep-18 100% 0.0% 0.0% - . 0.0% - 0.0% 24% Clinical was returned in line with the NICE policy. (‘last month’) % of data submitted to national clinical audits (rolling Sep-18 100% 96.6% 96.6% 100.0% 97.7% - 97.7% 24% Effectiveness YTD) Target is 100% at FYR end % of national clinical audits with an action plan in place Sep-18 100% 100.0% 100.0% 50.0% 78.6% - 78.6% 7% at 12 weeks post publication (last month) % of national clinical audits with completed Sep-18 100% - - 0.0% . 0.0% - 0.0% 7% recommendations (last month) % of external reviews where action plan was either Sep-18 10% - 66.6% - . 56.5% - 56.5% 7% overdue or no date for completion was provided Rounded score Performance Framework - Quality Indicators Cont. Jul 18 Aug 18 Sep 18 Previous Previous Current Previous Target Trend FYtD LTM Score Weighting Domain Indicator Data to Month-1 Month status FYR Blood Administration Patient Scanning Sep-18 90% 98.6% 99.4% 99.2% 98.6% 98.7% 98.8% 3 Care Plan Notes Sep-18 90% 79.6% 82.1% 83.8% 79.0% 62.4% 75.3% 1 Care Plan Presence Sep-18 90% 84.9% 84.9% 90.2% 84.1% 77.4% 82.6% 1 Falls Risk Assessment Sep-18 90% 79.0% 81.9% 80.9% 79.8% 77.4% 78.1% 2 Moving & Handling Sep-18 90% 67.0% 70.4% 69.6% 66.4% 60.7% 63.2% 2 Nurse Rounding Sep-18 90% 99.7% 99.7% 99.7% 99.7% 99.5% 99.6% 1 Nutrition Screening Sep-18 90% 71.6% 73.7% 74.9% 74.6% 74.1% 74.3% 2 Nursing Quality Pain Score Sep-18 90% 80.0% 80.9% 82.5% 79.4% 69.3% 76.1% 2 Metrics Pressure Ulcer Screening Sep-18 90% 71.1% 74.1% 74.1% 73.2% 71.3% 72.1% 3 EWS MEOWS Score Recording Sep-18 90% 95.6% 96.3% 96.3% 96.1% 96.6% 96.3% 3 PEWS Score Recording Sep-18 90% 98.9% 98.3% 96.4% 98.4% 98.3% 98.5% 3 NEWS Score Recording Sep-18 90% 95.6% 95.7% 95.3% 95.5% 94.4% 95.4% 3 VIP VIP Score Recording (1 per day) Sep-18 90% 87.8% 89.5% 89.7% 88.5% 86.6% 87.7% 3 PIP Score Recording (1 per day) Sep-18 90% 87.6% 86.2% 89.6% 87.7% 90.1% 98.5% 3 Rounded6 Integrated score Report Page author: VARIOUS, Owner - Deirdre Miller Performance Framework – Operational Performance Jul 18 Aug 18 Sep 18 Previous Previous Current Previous Target Trend FYtD LTM Score Weighting Domain Indicator Data to Month-1 Month status FYR RTT total waiting <18 weeks >92% Sep-18 92% 90.3% 89.4% 88.9% 89.7% 90.1% 89.5% 100.0% RTT >52 weeks Sep-18 0 1 1 4 16 28 34 Rounded score Diagnostics Waiting over 6 weeks Sep-18 1% 0.3% 1.2% 0.6% 1.4% 2.9% 2.5% 100.0% Rounded score 62 days from urgent referral Aug-18 85% 83.4% 80.1% - 80.3% 82.0% 81.1% 100.0% Cancer >104 day waits Aug-18 0 9 10 - 48 106 97 Rounded score Stranded patients >7 days Sep-18 TBC 507 488 505 2998 3429 5946 50% Timely discharge Pre 12 discharge Sep-18 20% 15.6% 15.6% 15.2% 15.4% 17.8% 16.1% 50% Rounded score Surgical Session usage (exc Rosie) Sep-18 TBC 92.3% 81.3% - . 90.7% 85.1% 89.5% 100.0% Rounded score Outpatient Overdue follow ups Sep-18 TBC 17524 17571 18452 106827 167259 196391 100.0% Rounded score Stroke >90% of time on stroke unit Sep-18 80% 80.0% 59.0% 83.3% 73.0% 75.3% 72.6% 100.0% Rounded score Eme rge ncy 4hr ED target (Inc MIU) Sep-18 95% 88.4% 88.1% 85.7% 88.0% 89.2% 86.0% 100.0% department 12 hour trolley wait Sep-18 0 0 0 0 1 28 27 0 Rounded score DNA Rate Sep-18 TBC 4.5% 4.4% 4.7% 4.3% 4.9% 4.4% Utilisation of 30 day readmissions Sep-18 TBC 12.4% 12.0% 3.6% 10.8% 12.8% 11.4% Resources Pre-op LOS Elective Sep-18 TBC 0.17 0.17 0.16 0.18 0.17 0.18 Pre-op LOS Non-Elective Sep-18 TBC 0.90 0.86 0.71 0.90 0.99 0.97 Rounded score
7 Integrated Report Page author: VARIOUS, Owner – Linda Clarke Patient Reporting Incident Safety 8 Patient Safety Incident Reporting
• Report Integrated • impact was graded as: September 2018. The actual in submitted August and LearningReports were (SLR) A points above the above the points are fifteen consecutive data there reports; learning safety of patient reporting in shift upward significant a is There total of of total • • • • • • 10%). is (threshold 1.54% total above of Patient as 0.04% 0.3% moderate 1.2% low/minor 11.9% graded as 86.7% moderate harmmoderate and death 2,597
(30) as as (30) (7) (7)
Safety incidents incidents Safety (1) were graded(1) (308) as (2,251) were
severe no
Patient Safety Patient Safety harm mean.
harm.
harm, harm,
harm
1000 1100 1200 1300 1400 1500 1600 1700 1800 800 900 10 15 20 25 30 35 0 5 PatientSafety SLRs moderate and above by date of occurrence
Data Data Patient Safety SLRs by date of occurrence of date by SLRs Safety Patient UCL UCL LCL LCL Mean Mean Nicholson Jane author: Page Patient Reporting Incident Safety 9 Patient safety and serious incidents SIs reported in to the CCG September 2018 Report Integrated SLR55387 SLR54521 SLR53146 SLR55103 SLR55137 Ref 10 12 14 2 4 6 8 0 1 9217 09/201 01/ Date of occurrence of Date 1 4 15/09/2018 29/08/2018 03/08/2018 07/08/2017 11/09/2018 1 0217 10/201 01/ Serious Incidents in Incidents Serious the last 13 months 1 2 6 STEIS number 2018/22719 2018/22279 2018/23278 2018/22749 2018/22743 1 1217 11/201 01/ IG 5 7 1 2217 12/201 01/ Unexpected/potentially avoidable death Unexpected/potentially avoidable death continue to deliver an acceptable quality of of quality healthcare acceptable services an to deliver ability to continue organisations threatening Incident of quality healthcare acceptable services an to deliver ability to continue organisations threatening Incident causing injury harm serious avoidable Unexpected/potentially 4 4 1 1218 01/201 01/ 1 7 STEIS SI Category SI STEIS
Serious Incidents 1 2218 02/201 01/ 3 3 1 3218 03/201 01/ 2 6 1 4218 04/201 01/ Treatment delay leak/information governance breach information Confidential leak/information governance breach information Confidential Fall only Maternity/Obstetric incident: Baby (by date reported to CCG) to reported date (by 2 3 STEIS SI Sub categories Sub SI STEIS 1 5218 05/201 01/ 3 5 1 6218 06/201 01/ Never Events Never 1 4 5 1 7218 07/201 01/ Actual Impact Actual 2 8 Moderate No Harm No Harm No Death Death Nicholson Jane author: Page 1 8218 08/201 01/ 2 2 1 9218 09/201 01/ Div. D D D C E 2 2 Falls All patient falls by date of occurrence Inpatient falls per 1000 bed days
200 6.00
180 5.00 160
140 4.00 120
100 3.00
80 2.00 60
40 1.00 20
0 0.00
Data UCL LCL Mean Per 1000 bed days UCL LCL Mean
Falls Moderate and above inpatient falls Witnessed and Executive Summary 9 unwitnessed patient falls (last • There is normal distribution in all three 12 months) graphs shown. 7 Unwitnessed Witnessed • The ratio of witnessed to unwitnessed
5 in the last 12 months is shown in the pie chart; further analysis of these two
3 subcategories of falls shows there is no 31% significant change during this period. 1
-1 69%
-3
All falls UCL LCL Mean
10 Integrated Report Page author: Louise Maris, Debra Quartermaine Hospital-acquired Pressure Ulcers (HAPUs)
All HAPU per 1000 bed days Category 2-4 HAPU by date of occurrence
1.00 25
20 0.80
15 0.60
10
0.40 5
0.20 0
0.00 -5
Per 1000 bed days UCL LCL Mean Data UCL LCL Mean
Unstageable and suspected deep tissue injury HAPU Executive Summary by date of occurrence 4 • Incidents have remained x9 consecutive data points above the mean since January 2018. The majority of these have been category 1 / 2. Division C 3 PressureUlcers has reported incidents x7 consecutive data points above the mean in this period. 2 • A deep dive of Division C category 2 HAPUs shows 59% had good 1 documentation of preventative care. Themes where care was not well documented centre around risk assessment, skin inspection and 0 repositioning. Action plans are in place on D7 and C7 following two category 3/unstageable HAPUs. -1 • New NHSI guidance has stated that Trusts must have oversight of the two categories of HAPUs - unstageable and suspected deep tissue injury. -2 There is normal distribution shown in this graph. These HAPUs are monitored weekly by TVNs until the true depth is visible and then they are -3 re-categorised appropriately. • Device related HAPUs are included within this data. Further in-depth data Data UCL LCL Mean including body location and moisture lesions is available within the bi- monthly PU and Falls steering group reports.
11 Integrated Report Page author: Louise Maris, Carole Young Safety thermometer
Harm Free Care (new harm only) Shelford Group 100% 8% 7%
99% 6%
5% 98% 4% Ol d Harm s 97% 3% New VTE s 2% Catheters & New UTIs
96% Falls with Harm CUH National Shelford average (excl CUH) 1% Pressure Ulcers – New
0% Target 95%
The safety thermometer undertaken in September 2018 audited 964 patients. Of these, 95.95% (925/964) were reported as receiving harm free care and this is inclusive of “old harm” (i.e. patients who acquire harm in the community before coming into hospital) which is favourable to the national average of 94.28%. The Trust ranked 5th in the Shelford Group of teaching hospitals for September for all harms [NB King’s College and Guy’s & St Thomas’ no longer submit data]. For new harms, 97.30% patients were reported to have harm-free care in CUH (only 26 patients were reported to have “new harm”) which is below the 97.88% national average. The Trust ranked 7th in the Shelford Group of teaching hospitals for September for new harms. Patient safety thermometer safety Patient
12 Integrated Report Page author: Josefina Gil-Moya Infection control Infection 13 Infection control - context • • • • analysis trend CUH Report Integrated C. difficile date and 25 cases are unavoidable. areunavoidable. 25 casesand date 10 20 30 40 50 60 70 80 There are 41 cases of hospital acquired acquired hospital of cases 41 are There cases. acquired C. difficile case). acquired community date(1 avoidable andonset, hospital 1 unavoidableto case year bacteraemia MRSA onset hospital of cases 2 are There cases. acquired hospital MRSA bacteraemiaceiling for 2018/19 is zeroavoidable - 0 1/12 201 ceiling ceiling for 2017/18 is no 48 morethan hospital 0 2/13 201 C. difficilecases 0 3/14 201
Infection Control Control Infection
0 4/15 201
0 5/16 201 MRSA Bacteraemias
0 6/17 201 - C. difficile context 0 7/18 201 0 8/19 201 year to to year
- 1 2 3 4 5 6 7 MRSA bacteraemias MRSA
MRSA Bacteraemias • • MRSA • 3 0 1 2 to August 2018) put the Trust 7 September. September. acquired hospital of cases no were There The latest latest The Compliance with thewith Compliance ofhospitals. teaching 98.2% (98.8% September in in August).
bacteraemia MRSA bacteraemias MRSA
bacteraemiarate comparative data (12 months
MRSA
year performance year
care bundle (decolonisation) was (decolonisation)bundle care th
outof 10 in the - Page author: Infection Control Team Control Infection author: Page cumulative financial financial cumulative
MRSA
bacteraemia in in bacteraemia Shelford
Group Group
Infection control Funnel chart showing Cambridge University Hospital's (in red) position C. difficile - Avoidable & Unavoidable Cases amongst Shelford group in England for C. difficile rates (C difficile 14 infections per 1000 occupied bed days)
12 0.29 10
8 0.24
6 0.19 4
0.14 2
0 0.09 Rate Mean
3sd 2sd 0.04 Total C. diff icile cases +2 Std Devs 250000 300000 350000 400000 450000 500000 550000 600000 650000 700000 -2 Std Devs Control Line (12m ave)
C. difficile infection
• The latest C. difficile rate comparative data (12 months to August 2018) put the Trust 8th out of 10 in the Shelford Group of teaching
and otherand key infections hospitals.
• There were 8 cases of hospital acquired C. difficile infection in August. All cases were reviewed with the CCG, 6 cases were confirmed as unavoidable and 2 cases were avoidable.
• Isolation compliance for a selected group of inpatients tested for C. difficile was 88.0% in September (85.2% in August). C.difficile
• There were 10 inpatients confirmed with C. difficile infection (8 hospital acquired and 2 community acquired cases) in September. 7 patients were isolated within the CUH standard of 2 hours (70% compliance).
• Compliance with the C. difficile care bundle was 97.4% in September (95.8% in August).
14 Integrated Report Page author: Ashley Shaw National targets
15000 100 Emergency Department Four Hour Standard - Type 1 and Type 3 Performance 14000 95
13000 90
12000 85 O ct to 30th 85.5% 11000 80
10000 75
9000 70 Patients who have waited more than 4 hours Patients who have waited less than 4 hours 8000 Trajectory 65 % in 4 hours (all types) 7000 60 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 2018 2018 2018 2018 2018 2018 2018 2018 2018 2019 2019 2019
Emergency Department (ED) performance September Performance against the four hour standard decreased slightly to 85.8% in September from 88.2% in August. The type 1 performance for September was 80.9% compared to 84.0% in August. Type 1 attendances were 24 lower across the month in September, but due to the fewer numbers of days in September this represents an increase of 2.8% on the daily average which increased to 321. The growth in Type 1 attendances YTD which is 1.8%. Across both type 1 and 3 attendances the Trust is 1.2% above 2017/18 YTD, but 1.7% below the plan. There were no 12 hour trolley waits in September.
Admissions from the Emergency Department YTD are 697 (3.4%) down on 2017. Of these, 196 (28%) relate to admissions with 0 LoS and 501 (72%) with ≥1 day LoS. September however did show an increase in admissions of 1.9% compared to the previous year, only the second month in 2018/19 to show a rise.
A&E performance forecast and recovery Performance for October month to date is 85.5% against our expected trajectory for the month of 90%. Daily average attendances have increased to 328 in October from 321 in September; it is level with the same point in the month in October 2017. Internal critical incidents due to bed capacity have been called during October, and some patients have been bedded overnight in the Emergency Department during this time.
Emergency A&EDepartmentwait (ED)4hr Areas of focus to improve performance continue The ED action plan has been updated to provide more detail around recovery actions, and the new plan is reviewed on a weekly basis by the members of the daily ED Performance Group.
•Admissions avoidance: Effective use of the JET service, management of GP referrals, increased ambulatory care offering, reduction in ambulance conveyances; •GP streaming: Maximise use of the GP streaming service by extending opening hours, closing shift gaps, reviewing clinical criteria and verifying whether GP referrals can be streamed; •ED processing: Recruit additional ACPs and ED consultants, boosting phlebotomy resources and re-launching Trust Internal Professional Standards; •Patient flow: Reduce ‘super stranded’ (21+ LoS) patients by 25%, re-launch the acute hub, agree updated repatriation policy for the region; •Complex discharges: Implement patient choice letters in the Trust, utilise new discharge notification process in Epic, review support agreed for self-funders.
15 Integrated Report Page author: Linda Clarke, David Monk National targets Internal Professional Standards - September '18 ED Performance - September '18 Breach No. with No. % Measure Analyses data achieved achieved Emergency medicine Delayed senior review Ambulance handover will occur within 15 minutes of Delayed initial medical assessment 2561 1503 59% Ward bed not ready ambulance arrival at the emergency department Delayed referral to specialty All patients will have a nurse assessment within 15 Change in clinical state minutes of arrival that will include a plan for the Delayed imaging 9622 9407 98% P sy chia tric pa ti e nt appropriate placement of the patient within the Other department. C hange in admitting specialty Initial medical assessment by a decision making clinician No CDU Capacity Delayed blood results will occur within 60 minutes of arrival and will include the 8248 3138 38% C ritical care bed required initiation of appropriate investigations. Delayed transfer All emergency medicine referrals to another specialty to Delayed senior 557 230 41% Delayed venesection be completed within 120 minutes of arrival. review Emergency Department Full Ward bed not 40% Delayed initial nursing assessment Surgery (all specialties), medicine (all specialties), ready Monitored bed required Infection control required paediatrics, obstetrics and gynaecology, neurology, 12% neurosurgery, oncology Initial assessment of patients referred by their GP to be 1136 379 33% Delayed initial undertaken within 60 minutes of arrival Senior review for patients referred by their GP will be medic al 448 54 12% undertaken within 120 minutes of arrival. assessment 29% Mental Health Review of referred patients will be undertaken within 60 145 53 37% minutes of referral
Bed Allocation Patients to be transferred to the ward or unit within 15 1461 541 37% minutes of the “ready” time
Emergency Department (ED)Performance IPS Commentary
ED together with acute medicine are preparing for the launch of the acute hub model which will see medicine patients receiving senior reviews outside of ED and all patients flowing through three acute wards, with the exception of those needing a specialist inpatient bed, this model will launch on 15th November and should lead to reduced patient times in ED, patients moving onward to appropriate areas within the hospital and therefore reduced length of stay.
16 Integrated Report Page author: David Monk National targets
% Incomplete < 18 weeks and Backlog T otal RT T Waiting List RTT Waits over 40 Weeks 93% 2500 34000 160 33500 92% 2000 140 33000
91% 120 32500 90.3% 1500 90.0% 100 89.9% 90% 32000 80 89.3% 89.4% 1000 31500 88.9% 89% 60 Incomplete pwathways % Incomplete < 18 weeks 18 < Incomplete % 31000 500 40 88% 30500 20
87% 0 30000 0
% within 18 wks >18 weeks withDTA >18 wks NoDTA Total Complete Waiting List March 18 Baseline 52+ Still Waiting 40-52 weeks waits
The Trusts RTT 18 week performance deteriorated in September to 88.9%, with the number of patients over 18 weeks increasing by 83 (39 admitted and 44 non-admitted). The overall waiting list size however did decrease markedly by 767 from August, and is therefore now 349 below the March 2018 baseline that we need to sustain . This represents a -1.1% variance. This is ahead of our trajectory for the total waiting list size, and is in part due to a higher focus on the validation of lower waiting pathways which contributed a ~150 increase in the average monthly removals through validation.
Year to date RTT clock starts are 7% higher than in 2017. Referrals overall are 10% higher, within which GP referrals are seeing a growth of 6%. September appears to be a lower month for demand but on a per working day basis, referrals did increase back above the volumes seen in August. The total treatments for RTT are running 12% higher YTD compared to 2017 in response to this demand.
Over 52-week waiters We reported 4 over 52 week breach still waiting at the end of September:- • The Orthopaedic patient who was reported first in August and chose to wait until October. They have now been treated. • 1 ENT patient referred via the ENT community service earlier in 2017. There is no record of the original referral being received, and then on re-referral no Minimum data set was provided so it took time to identify the correct start date. The Patient then delayed their OPA until October and then did not attend. A clinical decision has been made to discharge. • 1 complex Interventional neuroradiology case who was delayed due to multiple cancellations because of to the restricted IR capacity whilst one suite was being upgraded. This led to strict prioritisation of the most clinically urgent cases. The patient has now been treated. • 1 Paediatric Neurosurgery patient referred at 27 weeks from N&N. They waited 3 months for their first appointment here, and had had a plan for surgery before 52 weeks but it 18 week referral referral treatment(RTT) 18weekto transpired the consultant was not available on that date and so it was never confirmed. Now treated.
The number of patients waiting over 40 weeks reduced to 77 in September. ENT has 21% of the longest waiters with 16. Orthopaedics, Plastic Surgery and Paediatric ENT all have 7. There are no patients forecast to be over 52 weeks for the end of October.
RTT Forecast and Recovery The Trust is now ahead of the annual trajectory submitted to NHSI for 2018/19 in relation to the total waiting list size, and has a negative variance -1.1%. The volume over 18 weeks has increased by 13% in the last 2 months, and over 60% of this growth is driven by 3 specialities: Ophthalmology, ENT and Gynaecology.
March 2018 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 New risks are emerging for some high volume outpatient services baseline (Ophthalmology, Allergy and Dermatology) as a consequence of Planned Total Waiting List Size 32991 33416 33026 32670 33621 33828 33527 33019 32647 32262 32137 31956 32370 medical staffing gaps. The services are exploring actions to mitigate Planned > 18 weeks 3674 3687 3647 3607 3567 3580 3540 3500 3460 3473 3473 3473 3473 88.9% 89.0% 89.0% 89.0% 89.4% 89.4% 89.4% 89.4% 89.4% 89.2% 89.2% 89.1% 89.3% these to minimise the impact. We anticipate remaining ahead of Planned % within 18 weeks Actual Total waiting list size 32820 33459 33542 33131 33409 32642 trajectory for total waiting list size in October. Actual > 18 weeks 3498 3331 3376 3204 3550 3633 Actual % within 18 weeks 89.3% 90.0% 89.9% 90.3% 89.4% 88.9
17 Integrated Report Page author: Linda Clarke National targets Specialty Level Performance
Baseline - March 2018 Variance to March 18 Incomplete > 18 DOH Group Total Clock Starts Total Treatments Total Incomplete % Incomplete Total Incomplete Baseline Weeks
Trust 32991 12959 11752 32642 -349 3633 88.9% 100 - General Surgery 926 377 223 860 -66 67 92.2% 101 - Urology 1533 633 529 1489 -44 182 87.8% 110 - T&O inc Spinal 2380 605 599 2181 -199 478 78.1% 120 - ENT 1912 696 627 2230 318 458 79.5% 130 - Ophthalmology 2773 990 843 3318 545 424 87.2% 140 - Oral Surgery 869 245 223 686 -183 86 87.5% 150 - Neurosurgery 1003 368 378 1027 24 136 86.8% 160 - Plastic Surgery 943 427 416 886 -57 99 88.8% 300 - General Medicine 153 109 92 109 -44 2 98.2% 301 - Gastroenterology 1643 575 410 1348 -295 60 95.5% 320 - Cardiology 1023 258 230 819 -204 62 92.4% 330 - Dermatology 1919 833 710 2072 153 104 95.0% 340 - Thoracic Medicine 464 185 135 492 28 14 97.2% 400 - Neurology 1112 450 426 1172 60 47 96.0% 410 - Rheumatology 853 442 375 1070 217 41 96.2% 430 - Geriatric Medicine 88 50 36 102 14 6 94.1% 502 - Gynaecology 1413 539 463 1523 110 182 88.0% X01 - X-Other 11982 5177 5037 11258 -724 1185 89.5%
Ophthalmology – saw a further increase in waiting list size by 26 in September, which represents a slowing of the deterioration. Their variance to March baseline is now 545, and remains the greatest risk to the Trust position. The volume of patients over 18 weeks is also the greatest increase this year by 269. The growth in the total admitted waiting list now represents 70% of the growth since March, and in September the service did the lowest volume of admitted treatments this year with the exception of August. With the commencement of the new substantive MR Consultant the service expects to be able to improve backfill of sessions relinquished for leave, but are also continuing to explore outsourcing options.
ENT waiting list stabilised in September at exactly the same volume as August which remains a variance of 318 above March baseline. The total treatments for ENT were the highest they have been since November 2017 for both admitted and non-admitted care this month; however, clock starts (demand) were higher still by 69 and only validations enabled the stable waiting list position. The Trust has confirmed it’s commitment to funding to shortfall in the STP business case for a GPSI community service, but the CCG are still delaying confirmation this will proceed from January due to a wider strategic aim to pass community contracts to acute providers to manage.
Rheumatology saw a growth of in waiting list size of 14 patients in September, and ended the month 217 above baseline. The admitted waiting list drove the growth by 43 due to insufficient access the infusion capacity on G2 which led to a reduction in admitted treatments. Division A are working with Division C to see how G2 activity can be facilitated. Outpatient activity remained high with the locum consultant and clinic 9 activity in place, and demand was stable.
Dermatology total waiting list size saw a slight decrease of 41 taking the service to 8% (153) above the baseline. Demand reduced for the second consecutive month which supported this position. Treatments remain
18 week referral referral treatment(RTT) 18weekto slightly lower than average due to junior registrars working at 70% capacity following rotation. This is due to increase from November. The waiting list reduction was achieved through validation in September. The monthly locum clinics have been reinstated this month and a case for a consultant with paediatric interest will be submitted to the next MDWC panel. Unexpected consultant absence is a new threat to the service in quarter 3.
Gynaecology has a growth of 110 compared to March baseline, but achieved an in-month reduction of 31. Outpatient activity increased with the commencement of the Urogynaecology locum, and will contribute more to the rate of recovery with another locum in reproductive medicine starting in Mid-October. This will help to reduce the backlog over 18 weeks which has increased by 74 in the last 2 months. 2 Substantive consultants were appointed at interview on 25th September.
Neurology has a variance of 60 compared to March baseline and this was a static position compared to last month. At 1172 their waiting list size remains on their recovery trajectory.
Allergy saw a decrease in total waiting list by 4 patients, leaving a variance of 97 to baseline. Treatments were lower in September, with an experienced consultant now on maternity leave and no success from a locum advert which will be resubmitted. The consultant team agreed amendments to the existing referral criteria, and are in the process of setting up a GP training day at Granta Park on 30th November. Two information videos have been made to give helpful advice on the primary care management of more common allergy complaints. The unexpected absence of a second consultant is a significant threat to the service and will lead to a rapid deterioration.
Neurosurgery achieved a reduction of 144 in September leaving a variance of just 24 from baseline. Treatments exceeded demand and additional validation was beneficial. The backlog over 18 weeks also reduced by 4, but at 136 remains above the trajectory presented to NHSE who commission this service to recover to 92%. Referrals are running 11.4% higher than 2017 YTD, 8% for GP referrals. The service is continuing to consider options to meet the shortfall in capacity needed in outpatients per week to meet demand.
18 Integrated Report Page author: Linda Clarke 19 National targets National Cancer Standard waits Cancer Board discussed the on Cancerdiscussed Board the pathway shared a in provider 31 of Analysis factor. particular a being capacity robotic prostate with days, 24 within treatment achieve r days 24 the capacity withinoffer now can review whetherthey toasked beenteams September some cancer sites, havefor and Se in performance 2ww on impact high a had has choice Patient standard. 2ww and urgent day 62 the meet to fail to forecasting ire requ the above standard day urgent 62 the against performance sustain to expecting 2018/19 for plan a submitted had Trust The trajectory performance Cancer undertake for Northern Ireland will be repatriated by the of end Quarter3. approved.been yetnot robotic Some activity hasbut September wein Committee Investment the to presented was robot second a for case business A capacity. prostate robotic tomonth. capacitybreachesrelated 2 the againstandards in dayBoth 31 achievedwere able to treat within 24. Urology and day but not we werebefore 38 referred were patients the where breaches of 5 reallocation of being themreferred post day 62. Under the new guidance havewe also had to accept 4 despite guidance, reallocation Times waiting Cancer National the of requirements stringent more the 24 days given within not treatedthose to reallocate unable been have We referred. the26shared of breaches, 13 of whichwewere ableto treat within 24 daysof thembeing breaches,and Bedford werethe next highest with 8. Late referralspost day 38 accounted for 11 shared the of referred Anglia North West Trusts. with other pathways shared were CUH only pathways32 and were 10 which urgent standardof day62 the patients breached42 date.yearto lowest the is which month the down toin 130.5 standard day August.62 urgentTotaldroppedtreatments in the back achieve not did We November.rolled in out be excluded.should This 2wwwith theofaim emphasising theimportance of attending urgently to havecancer aon for patientsreferred leaflet Boardapproval patientgained representativenew our for a Cancer October At the choice. patient to due were 78% occur did that breaches Of the 2ww. February. since time first the consecutivemonth in August,higher 9% than August 2017. 93%The standard wasmetfor fourth the for standard cancer suspected 2ww the against seen were patients 1600 Over standards. screening and day urgent 62 the bar standards cancer all achieved Trust the August In Analysis of 62 of Analysis 2 of Analysis 2018. October for reported data cancer to nationally applied be will guidance new reallocation the though even Alliance the by off sign received not still has This made. be should referral how and what at point and locally, performed be tests should which regarding centres cancer the and units referring the of expectations wid EoE revised a finalise to Alliance Cancer the with met we Norwich, and Norfolk from Manager Cancer Lead the with Together 18% from teams range Currently November. start the at of taskforce Operational to the 7 within appointment first achieving rise to asked been have sites Cancer referral. after days 7 first the into pathway the expediting review to asked also were
Report Integrated
- week wait (2ww) performance performance (2ww) wait week - - day performance day performance(seedetail next on page ) Gynaeoncology
-
going challenges with recovering the 62 day performance. Imaging reporting was raised as an area area an as raised was reporting Imaging performance. day 62 the recovering with challenges going
Gynaeoncology
had a record month, seeing 169 patients a on
are the 2 services most challenged to to challenged most 2 services the are
Cancer 62Day (PostCancer reallocation) Trajectory breaches Trajectory Trajectory % <= % 62days Trajectory Actual / forecast breaches forecast / Actual Actual / forecast % <= % 62days forecast / Actual Other cancers suspected ies Malignanc Haem Other Sarcomas Head & Neck al Urologic al ologic Gynaec Skin GI Lower Upper GI Lung Children's Breast August 2018 performance by site by performance 2018 August 2wk Wait SBR (93%) Wait 2wk (93%) 2Wk Wait with realloc ations (50% - CCG) - (50% ations realloc with Upgrade from62 Day Consultant (90%) ations realloc with Referral reening Sc from Day 62 (85%) ations realloc with Referral Urgent from Day 62 (85%) Referral Urgent from Day 62 (90%) Referral reening Sc from Day 62 (94%) (Surgery) Subs 31 Day (94%) (Radiotherapy) Subs 31 Day (93%) (Other) Subs 31 Day (98%) Cancer) (Anti Subs 31 Day (96%) FDT 31 Day To August 2018 August To Cancer Standards 18/19 Standards Cancer Apr-18 86.6% 80.8% 16 25 Breaches 62 Day from Urgent Urgent from Day 62 0.5 0.5 0.5 9.5 4.5 0.5 May-18 87.4% 83.3% 4 1 3 1 1 23.5 15 Referral Actual Jun-18 85.6% 82.2% 24.5 75% 93% 83% 73% 53% 90% 58% 94% 79% 82% 95% 18 Target % 50% 90% 85% 90% 93% 93% 85% 94% 94% 93% 98% 96% to to 87.2% 84.6% Jul-18 62 Day from Sc reening reening Sc from Day 62 27.5 - 16 Breaches 17-18 Q1 17-18 81% o 92.7% 84.7% 100.0% the 7 day challenge and provide a trajectory for trajectory a provide and challenge day 7 the 81.8% 92.7% 97.3% 95.9% 79.1% 96.0% 97.0% 99.1% 96.9% 1 3 Referral e I Aug-18 pte 87.2% 83.2% equ 16 22 nter provider transfer policy; clarifying clarifying policy; transfer provider nter f first appointments within 7 days. days. 7 within appointments first f 17-18 Q2 17-18 mber. Capacity delays are more evident in in evident more are delays Capacity mber. for further attention; and the MDT Chairs Chairs MDT the and attention; further for 100% 100% d 85%. Performance in September is is September in Performance 85%. d 94.3% 89.8% 100.0% 45% 92.9% 93.3% 96.7% 94.6% 84.7% 92.1% 96.9% 99.5% 98.1% % ired to meet the obligations of the treating treating the of obligations the meet ired to Sep-18 85.6% 79.6% 26.5 18
Breaches 17-18 Q3 17-18 78.9% 86.0% 100.0% Oct-18 85.6% 74.6% 76.5% 77.2% 98.0% 94.5% 81.4% 96.8% 98.0% 99.2% 98.0% 2 1 31 Day FDT Day 31 18 33 Nov-18 87.2% 83.1% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 97% 97% 16 22 17-18 Q4 17-18 77.1% 86.9% % 80.0% 76.1% 95.4% 92.4% 82.5% 92.3% 98.1% 99.3% 96.9% 91.7% Forecast Page author: Linda Clarke Linda author: Page Dec-18 86.1% 31 Day Subs (Surgery) Subs Day 31 16 Breaches 18-19 Q1 18-19 1 1 1 83.1% 82.3% 100.0% 91.7% 83.1% 95.1% 88.0% 79.1% 95.9% 97.8% 99.3% 97.7% Jan-19 85.6% 18 100% 100% 100% 100% 100% 100% 100% 95% 92% 88% % 100.0% 91.4% 84.6% 100.0% Feb-19 85.7% 50.0% 86.5% 95.7% 89.7% 83.4% 95.8% 97.2% 99.1% Jul-18 15 Breaches Mar-19 87.2% 21 41
1 4 2 2 2 1 4 8 9 16 100.0% 77.8% 83.2% 100.0% Aug-18 2Wk Wait 90.0% 77.8% 96.6% 94.1% 80.1% 96.1% 95.8% 98.9% 83% 88% 83% 99% 95% 85% 98% 83% 97% 98% 97% %
National targets National 20 Cancer 62-day and 104-day breach analysis 62 Day from Urgent Referral from Total Urgent 62 Day Target Type 62 Day from Screening Referral Total from Screening 62 Day 62 Day from Urgent from Urgent 62 Day days. 8 only currently are waits colonoscopy screening Bowel reasons. health other to due were 2 patient choice delays, were 2 due to colonoscopy capacity and was 1 delayed screening breaches All were theBowel screeningfrom services. breaches total, 5 Of in endoscopy, and CT reporting. reporting. CT and endoscopy, to related GI Lower in delays capacity diagnostic and outpatients, plastics for delays to due were incurred delays Provider The month. this breaches of 11% for accounted both delays care provider Health and choice patient referrals, late to Secondary Gynaeoncology. in 17% by followed breaches, accountable the of 38% with Urology Breaches were incurred across 11 cancer sites August.in The highest volumes were in outcome and themes key 62-day Screening Referral Screening
62 Day from 62 Day Report Integrated Referral 100 120 100 120 20 40 60 80 20 40 60 80
0 0 Late referral treated within 24days within referral treated Late Late referral not treated within 24days within treated referral not Late Treatment delayed for medical reasons for medical delayed Treatment /treatment diagnostic to delay PATIENT initiated Health Care Provider delay to diagnostic/treatment to Care Provider delay Health inadequate capacity Elective inadequate capacity Out-patient Complex diagnostic pathway diagnostic Complex Delay Reason Delay PATIENT initiated delay to diagnostic /treatment /treatment diagnostic to delay PATIENT initiated diagnostic/treatment to Care Provider delay Health Treatment delayed for medical reasons for medical delayed Treatment Weekly Trend Weekly Trend
- - Patients over 62 days days 62 over Patients Patients over 62 days days 62 over Patients
3.5 4.5 9.5 1.5 Urological 0.5 0.5 3 2 3 1 1 1 Lower GI 0.5 2.5 0.5 4.5
1 Gynaecological 0.5 2.5 1 4 Head & Neck 1 1 1 1 Skin 1 1 Breast 0.5 0.5
1 Lung 0.5 0.5 Total > 62 with DTT with 62 > Total DTT no 62 > Total Total > 62 with DTT with 62 > Total DTT no 62 > Total Sarcomas 0.5 0.5 Upper GI 0.5 0.5 Haem Malignancies 0.5 0.5 Other 2.5 6.5 6.5 1.5 26 3 2 1 3 1 1 4 2 Grand Total Trust. the for Clinician Lead Cancer the and Clinicians Lead MDT the by reviewed been have RCAs The priority. taking condition to was pathway due CUH only 1 The treatment. radiotherapy of complexity the to 1 due and to treatment; prior tests CUH at diagnostic additional required 1 capacity, brachytherapy to due 1 capacity, robot to due delayed were 3 patients between 66 days 10. was August during treatment for days 104 over waited who patients of number The review and harm RCAs 104-day 62 Day from Screening Referral Total from Screening 62 Day Grand TotalGrand Referral from Total Urgent 62 Day 10 15 20 25 62 Day from Urgent from Urgent 62 Day Screening Referral Screening 104 day Breaches 104 day 0 5
9 of these were shared pathways with other organisations and were received received were and organisations other with were pathways shared these of 9 62 Day from 62 Day Referral - 145. Delay Reason Delay Treatment delayed for medical reasons for medical delayed Treatment 24days within referral treated Late Late referral not treated within 24days within treated referral not Late Weekly Trend
pathways. all on Harm unlikely is
3 patients were treated within 24 days. Of the remaining 6 6 remaining the days. Of 24 treated were within patients 3
treatment being delayed for another medical medical another for delayed being treatment - Patients over104 days Page author: Linda Clarke Linda author: Page 3 4 7 7 Urological Total > 104 with DTT with 104 > Total DTT no 104 > Total 1 1 1 2 1 Lower GI 1 1 1 Lung 10 3 1 6 1 9 Grand Total
Cancelled operations
Key performance issues Cancelled Operations on or after day of admission Cancelled operations on or after the day were 0.99% of all elective 200 20 admissions in September with 69 cancellations.
180 18 Of the 69 operations cancelled on the day of admission:-
160 16 32 were due to lack of operating time (46%). 7 of these occurred in Ophthalmology. Orthopaedics had 5 and HPB surgery had 5. 140 14 Emergency/trauma/transplant cases taking priority, and previous cases
28 day breaches day 28 overrunning were the causes. 120 12 There were 29 cancellations due to bed availability in the month which is 100 10 the highest since March. These were spread across 15 different specialties and 50% of the occurred during the week of 17th September. 80 8
Cancelledoperations
60 6 4 cancellations were due to equipment availability, with 2 further due to unexpected surgeon unavailability and 2 due to anaesthetist availability.
40 4 There were 6 patients who could not be rebooked within 28 days. All 20 2 patients have now been treated.:
0 0 • 3 Ophthalmology cases were cancelled due to higher priority emergency cases and required a specific consultant to be rebooked. 2 were rescheduled in time but cancelled for a second occasion for the Ot her Medical Shortage (Staff/Equip) Bed short age No Op Time Breaches same reason. The third was offered a date within 28 days which they declined, but reasonable notice (3 weeks ) was not given. Cancelled Operations on or after day of admission - % • A Paediatric ENT case was rebooked in accordance with the parents 3.0% wishes due to school commitments but no record of a reasonable 2.5% offer within 28 days was recorded. 2.0%
1.5% • An Endoscopy case could not be rescheduled within 28 days due to
1.0% requirement for a specialist protocol requiring a particular endoscopist.
Operations cancelled on or after the day of admission admission of day the after or on Operations cancelled 0.5% % 0.0% • An Interventional Radiology patient who was not able to be rebooked within 28 days due to the restricted IR capacity and the requirement to prioritise according to urgency.
21 Integrated Report Page author: Linda Clarke Diagnostic waits
Diagnostic 6ww Standard Flexi sigmoidoscopy 500 5% Colonoscopy Barium Enema 450 Gastroscopy 400 4% Respiratory physiology - sleep studies 350 DEXA Scan
300 3% Computed Tomography Urodynamics - pressures & flows 250 Cystoscopy 200 2% Audiology - Audiology Assessments
150 Neurophysiology - peripheral neurophysiology Cardiology - echocardiography 100 1% Non-obstetric ultrasound 50 Magnetic Resonance Imaging
0 0% &>6Wks Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Apr 18 May 18 Jun 18 Jul 18 Aug 18 Sep 18
The Diagnostic 6ww performance in September was achieved at 0.64% with a total of 49 breaches.
The 2 notable services for this month that experienced pressures were Neurophysiology (11 breaches) and Urodynamics ( 13 breaches):-
Neurophysiology were impacted by sickness of key clinical staff in the month that will be on-going. As a small specialist team this has had a significant impact on capacity and this is going to be felt to a greater extent in October where we are forecasting ~70 breaches for
Diagnosticwaits the service. Capacity will improve for November but given the backlog created, the service are working through whether some referring Trusts could in the short term direct requests to other providers.
Urodynamics have had some capacity challenges due to equipment breakdown. The unit has been repaired in October but does require replacement. The residual impact for October is 3 breaches.
All services with the exception of Neurophysiology have had a very strong month in October, and the Trust is forecasting to be at 1.2%.
Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Fe b-19 Mar-19 Trajectory > 6wks 255 175 79 79 79 79 79 79 79 79 79 80 Trajectory % > 6wks 3.2% 2.2% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% Actual / Forecast > 6wks 259 229 36 26 95 49 Actual / Forecast % 3.1% 2.6% 0.4% 0.3% 1.3% 0.6% ------
22 Integrated Report Page author: Linda Clarke Outpatients Overdue Follow Ups Trust DNA rate 20000 18452 7.0% 17823 17835 17622 17524 17571 18000 16453 15974 15929 6.0% 16000 14083 13443 13682 13122 5.0% 5.6% 14000 5.3% 12000 4.8% 4.0% 4.5% 4.5% 4.5% 4.3% 4.3% 4.4% 10000 4.1% 4.0% 4.0% 4.2% 8000 3.0% 6000 2.0% 4000 1.0% 2000 0 0.0%
Division E Division D Division C Division B Division A Follow up New Overall
Appointment Slot Issues (C&B) 1200 Number of Appointments Cancelled WOM 120000 40000 31201 33344 31253 31031 SURG 29227 30065 29460 33390 29547 30791 35000 1000 100000 28897 Respiratory Medicine 28840 30000 779 803 774 26186 800 80000 673 PATH 25000 584 NEURO 600 60000 20000 473 MED 411 424 15000 383 40000
356 Cancellations 349 IMG 400 10000 250 197 GI and Liver (Med and 20000 Surg) 5000 200 AppointmentsAttended Child & Adolescent Servs 0 0 0 AHPS 2WW
Patient Initiated Cancellation Trust Cancellation Appointments Attended Outpatients
Key performance issues Overdue follow-ups Overdue follow-ups increased this month. All areas with significant backlog numbers have recovery trajectories which are continuing to be monitored through the monthly Performance Meetings within Divisions.
Did Not Attend (DNA) rates DNA rates continue at healthy levels although there was a small increase this month due to a technical issue which stopped reminders being sent out for a week in September.
Appointment Slot issues (ASIs) received Appointment slot issue (ASI) performance in September 2018 has decreased from 4.7% to 3.2%. Based on September 2018 data, the Trust performance is 3.2% in comparison to the previous months’ data (August 2018), the National Average was 18.6% and the East of England average for that month was 17.3%.
This month (September 2018), we have received 11856 eReferral bookings; 383 of those were ASI’s.
Appointment cancellations Highest cancellation rates were in Ophthalmology, Rheumatology and Trauma and Orthopaedics and Urology at 8%, 4.8% and 4.7% respectively. For Ophthalmology the main reasons were due to annual leave and the new junior doctor intake and having to use more clinical fellows to cover the Emergency I service, although the number did reduce significantly from 9.4% last month. For Rheumatology and Trauma and Orthopaedics it was a combination of PTL management, junior doctor intake and prioritisation of consultant time to theatre.
23 Integrated Report Page author: Andi Thornton Delayed transfers of care
Validated Lost Bed Days to Delayed Transfers of Care (DTOC)
3000 12%
2500 10%
2000 8%
1500 6%
1000 4% Validatedlost bed days per month
500 2% Rateof delayed dischargesas % occupied beds
0 0%
Health Assessment Delays Health Delays (excluding assessment) Social Care Delays Joint Health and Social Delays Rate of Delayed Discharges as % of occupied beds (grey marker is estimated) Target 3.5% of Occupied Bed Days Comparison to Previous Year September saw a very slight improvement in position from 8.1 to 7.5% occupied bed days and reduction in bed days from 2198 to 1998 ,this would
Delayed transfers transfers (DTOC) ofcare Delayed reflect normal variation, and is a similar position to September 2017. The Local Authority has completed an exercise modelling the demand and capacity for both home care and beds. The picture for Cambridge shows a deficit in both, however the greatest short term risk is with home care. Whilst the reablement service has continued to grow and the Local Authority have had successful recruitment campaign’s the pressure in the private domiciliary care (DOM) market is impacting the ability of reablement to provide short term intervention and discharge (pathway 1) it is often holding patients or providing long term care to fill the gap. Likewise the lack of DOM care is creating waits at the back end of community beds and so causing delay for our patients waiting rehabilitation beds (pathway 2.) We continue to wait for the CHC pathway staff consultation and redesign to be completed this has had significant impact on our most complex cases, including fast-track. Internally the Super Stranded Peer Review Panel has commenced, overseeing, challenging and supporting the ward, division and corporate processes to ensure appropriate and timely patient discharge. Individuals cases are scrutinised, and pathways and processes identified where improvement can be made. The key message from the system Peer Review was that they saw some excellent work/services across the system, but there was a lack of consistency, and no clear articulated vision that staff understood or patients co owned.
24 Integrated Report Page author: Sandra Myers Bed Occupancy and Length of Stay
Non-Elective LOS Elective LOS - Excluding Day Cases 4.00 6.50
6.25 3.75 6.00 3.50 5.75
5.50 3.25
5.25 3.00 5.00 2.75 4.75
4.50 2.50
4.25 2.25 4.00 2.00
Month - Excluding DTOC Month Rolling 12 months - excluding DTOC Rolling 12 months Month Rolling 12 months
Trust Midnight Occupancy Rate by Month Adult Midnight Occupancy Rate by Month Paediatric Midnight Occupancy Rate by Month (1st @00:00) (includes Maternity) (1st @00:00) (1st @00:00) 1200 110% 1000 100% 80 100%
95% 70 1000 100% 800 90% 90% 60 85% 800 90% 50 600 80% 80% Stay Occupancy and Bed Lengthof
600 80% 40 75%
400 70% 70% 30 400 70% 65% 20 200 60% 60% 200 60% 10 55%
0 50% 0 50% 0 50%
EL Occupied Non-EL Occupied Occupancy Rate EL Occupied Non-EL Occupied Occupancy Rate EL Occupied Non-EL Occupied Occupancy Rate
25 Integrated Report Page author: Linda Clarke Discharge summaries
% summaries sent in 7 day rolling period 95
90
85
80 No. of discharges in 7 day rolling period 2500 03/04/2017 10/04/2017 17/04/2017 24/04/2017 01/05/2017 08/05/2017 15/05/2017 22/05/2017 29/05/2017 05/06/2017 12/06/2017 19/06/2017 26/06/2017 03/07/2017 10/07/2017 17/07/2017 24/07/2017 31/07/2017 07/08/2017 14/08/2017 21/08/2017 28/08/2017 04/09/2017 11/09/2017 18/09/2017 25/09/2017 02/10/2017 09/10/2017 16/10/2017 23/10/2017 30/10/2017 06/11/2017 13/11/2017 20/11/2017 27/11/2017 04/12/2017 11/12/2017 18/12/2017 25/12/2017 01/01/2018 08/01/2018 15/01/2018 22/01/2018 29/01/2018 05/02/2018 12/02/2018 19/02/2018 26/02/2018 05/03/2018 12/03/2018 19/03/2018 26/03/2018 02/04/2018 09/04/2018 16/04/2018 23/04/2018 30/04/2018 07/05/2018 14/05/2018 21/05/2018 28/05/2018 04/06/2018 11/06/2018 18/06/2018 25/06/2018 02/07/2018 09/07/2018 16/07/2018 23/07/2018 30/07/2018 06/08/2018 13/08/2018 20/08/2018 27/08/2018 03/09/2018 10/09/2018 17/09/2018
2000
1500
1000 Dischargesummaries
Date % summaries sent incomplete Discharge summaries • Weekly feedback to all Clinical Directors with charts highlighting areas of 23-Apr 0 poor performance. 21-May 0 • Alerting mechanism within Epic now implemented to notify consultants of 18-Jun 0 patient discharged without a summary. 23-Jul 0 • New development underway to make it more obvious to clinicians when summaries are incomplete was deployed on 18 January 2017. 20-Aug 0 • Additional indicators to highlight if a summary has been sent were 17-Sep 0 deployed on 6 April 2017.
26 Integrated Report Page author: Afzal Chaudhry Patient experience • The Inpatient (adult & paediatrics) rolling year response rate is 22.4%, recommend score is 94.5% & not recommend score is 2.5%. Monthly breakdown is given below:
Recommend Not Recommend Response Rate JUL 96.0% 2.1% 22.6%
AUG 94.6% 1.7% 21.6% SEP 94.0% 3.0% 21.7%
• The Day Case (adult and paediatrics) rolling year response rate is 4.6%, recommend score is 97.8% and not recommend score is 0.8%. Monthly breakdown is given below: Recommend Not Recommend Response Rate
JUL 97.9% 0.6% 4.6% AUG 98.7% 0.7% 3.7%
SEP 96.6% 1.8% 4.0%
• The Emergency Department (adult & paediatrics) rolling year response rate is 21%, recommend score is 93.4% and not recommend score is 2.8%. Monthly breakdown is given below :
Recommend Not Recommend Response Rate
JUL 94.4% 2.4% 20.6% AUG 93.1% 2.4% 21.7%
SEP 93.2% 3.2% 21.6%
• The Maternity rolling year recommend score is 92.6% and not recommend score is 2.1%. Monthly breakdown of the combined 4 touch points is given below :
Recommend Not Recommend
JUL 92.0% 2.1%
AUG 93.3% 2.4% SEP 90.2% 3.2%
• The Outpatient rolling year response rate is 3%, recommend score is 93.3% and not recommend score is 2.2%. Monthly breakdown is given below : Friends & Family Test Recommend Family &Friends scores
Recommend Not Recommend Response Rate JUL 92.7% 2.9% 3.1%
AUG 94.3% 1.6% 2.8%
SEP 92.5% 2.4% 3.0%
Bi-monthly Patient Experience Group report • The most recent bi-monthly meeting of the Patient Experience Group took place on 17 October 2018. The next meeting will be on 19 December 2018.
Page author: Kate Homan 27 Integrated Report
Complaints and Patient Advice and Liaison Service (PALS) cases Complaints [source – QSiS]
PALS
Upheld complaints graded medium or above: summary and actions taken:
July 2018: 1.Relative of patient who died following ED attendance has raised a complaint regarding the care he received - whether aortic dissection was considered, why a scan was not requested and why a senior review not undertaken. The case has transferred to the Patient Safety team to be investigated as a Serious Incident. 2. Patient’s family raised concerns about the standard of care provided on a ward and the effectiveness of communication from staff. Patient’s family provided with an explanation and apology for a failure to provide thickened fluids to patient; education undertaken by staff.
28 Integrated Report Page author: Amy Smith PALS & Complaints PHSO Activity
June 2018 July 2018 Aug 2018
Number of CUH cases 0 1. Patient has raised a number of 1. Concerns raised about treatment of a patient’s skin accepted for concerns relating to referral for condition in 2013. Relative of deceased diabetic patient investigation by the treatment at the Pain Clinic, and considers that treatment was inappropriate and progression through the treatment PHSO investigations were not carried out to discover the cause of pathway. skin condition. Case also involves Hinchingbrooke Hospital and CPFT.
Number of cases 0 0 1. Partially upheld: Apologies to be offered to relatives of investigated by the deceased patient for lack of support provided at discharge. PHSO and Action for CUH – to ensure that carers’ needs are given upheld/partially upheld, appropriate consideration prior to the discharge of patients. recommendations made and action plan (two other cases were concluded and not upheld) formulated
PALS Cases Total number of PHSO cases accepted for investigation in 2018/19 to date = 3 Total number of PHSO cases accepted for investigation in 2017/18 = 16 PALS
Cases investigated by PHSO and upheld/partially upheld in 2016/17 to date = 1 Cases investigated by PHSO and upheld/partially upheld in 2017/18 = 7
Top 5 Patient Experience Categories (PALS Concerns)
29 Integrated Report Page author: Amy Smith Mortality Mortality 30 HSMR, SHMI and crude mortality • • • Integrated Region. Eastern the in lowest the is and deaths of number expected than lower trusts with the of one is CUH committee. Surveillance Mortality at shared data reviewed, and investigated fully been have and HSMR through identified those with line in are alerts other The undertaken. being is review case A note devices. adjustment and prostheses of care, fitting rehabilitation availableApril 2017 to March 2018 is Hospital Summary The or medications and a 2 a and medications or drugs other agents, pyschotropic by poisoning for one alerts new two is There
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alert for a broad category including allergic reactions, reactions, allergic including category broad a for alert HSMR HSMR by Financial Year Expected % National Benchmark SHMI by Quarter by SHMI 86.8.
HSMR ue otlt ate R Mortality rude C Nat Benchmark 120 0 20 40 60 80 100
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Mortality - learning from deaths Structured Judgement Review (SJR) of Deaths
SJRs No. of No. of Compliance Potentially Potentially % avoidability of deaths triggered KPI deaths in deaths in- with in-scope avoidable deaths avoidable death reviewed by family / month scope SJRs identified from SJR SIs reported (by total deaths in carers month) 100% 0.8% April 18 130 21 1 1 1 (21/21) (1/130)
94% 1% 0.6% May 18 118 18 1 2 3 (17/18) (1/118) (2/355) 93% 1% June 18 107 14 0 1 2 (13/14) (0/107) 85% 0% July 18 126 20 0 0 1 (17/20) (0/126) 0.40% 77% 0.7% (1/271) August 18 145 26 1 0 0 (20/26) (1/145) SJR - Structured Judgement Review PFD - Prevention of Future Deaths Distribution of Avoidability Scores Executive Summary
Slight Definitely • In August 2018 there was 1 new probably avoidable death recorded Definitely Evidence of Probably Possibly evidence of not KPI avoidable avoidability avoidable avoidable, not relating to access to other specialist services this has been raised as an avoidablility avoidable (1) (2) (3) very likely (4) SI. (5) (6) • The Cambridgeshire and Peterborough Coroner has indicated that he April 18 1 0 0 1 5 14 would like to receive all SJR’s that score 4 or below. May 18 0 0 1 1 4 11 • A Medical Examiner has been appointed to review all deaths in CUH st th
Subjective Judgement Review (SJR) SubjectiveJudgement Review from 1 April 2019, a pilot phase will begin locally from 5 November in June 18 0 0 0 0 2 11 JVF ICU, NCCU and the Rosie (obstetrics). During this phase, all deaths July 18 0 0 0 4 2 11 (excluding stillbirths) in these clinical areas will be reviewed by the Medical Examiner. August 18 0 0 1 4 4 12 • Pathways being developed across STP to discuss cases involving different providers and share learning, new developments include a monthly case Judgement Score for Avoidability of Death review meeting with CPFT– reporting into Mortality Surveillance Score 1 Definitely avoidable committee. Score 2 Strong evidence of avoidability • The Patient Safety Team along with the Medical Directors office plan to Score 3 Probably avoidable (more than 50:50 chance) undertake a comprehensive review of the SJR process in October after Score 4 Possibly avoidable but not very likely (less than 50:50 12 months of operation to report to the Mortality Surveillance Committee Score 5 Slight evidence of avoidability in December and the Quality Committee in January. Score 6 Definitely not avoidable
32 Integrated Report Page author: Sue Broster This data set provides Care of Patients with Dementia information to Board Known Dementia Admissions by month Emergency Readmission Rate In Patients with for oversight and Dementia (within 30 days) governance in line with the National 0.25 Audit of Dementia Framework. 0.2 Dementia 114 123 The data set is 0.15 rate evolving, and further data relating to 0.1 13% DTOC, complaints by age and incident Trust rate 0.05 reporting for those patients with dementia are being 0 Jun 17 Sep 17 Dec 17 Mar 18 Jun 18 Sep 18 Sep17 Dec17 Mar18 Jun18 Sep18 worked through.
The trend remains Formal Complaints/PALS concerns related to Falls in patients with dementia stable across Dementia admissions and complaints, with a 3 slight reduction in emergency readmissions rate & inpatient falls in 2 dementia patients in 15 9 the last three months.
1 The number of complaints are small with no current 0 themes identified Jan18 Apr18 Jul18 Sep17 Dec17 Mar18 Jun18 Sep18 Care Care ofpatients Dementia with The Dementia Strategy Group provides the oversight of the work plan for the CUH Dementia Strategy (reporting into the Patient Experience Group)
On-going work Common reasons for readmission have been identified & the Dementia team are working with other specialities within CUH & the Dementia Champions to reduce where possible the risk of readmission, through education & support to carers & patients, along with collaboration with CPFT to establish if earlier intervention would reduce admission, and to signpost appropriately. Currently working with Falls Specialist Nurse to look at data captured around falls and dementia for inpatients and further education to staff on falls and agitation in this client group. “What is important to me” poster has been rolled out across the adult wards to use with patients with cognitive impairment, to enhance patient centred care. The Dementia Champions will audit this tool. Individual wards where complaints have been identified have undergone additional dementia awareness training Continue to act on PLACE findings re environmental changes, moving towards being dementia friendly areas. Participated in the National Dementia Audit in 2018.
33 Integrated Report Page author: Jacqueline Young Stroke care 34 Stroke care Integrated Summary May-16 May-17 May-18 Aug-16 o-16 Nov- Aug-17 o-17 Nov- Aug-18 Sep-16 Dec-16 Feb-17 Mar-17 Sep-17 Dec-17 Feb-18 Mar-18 Sep-18 Apr-16 Jun-16 Oct-16 Jan-17 Apr-17 Oct-17 Jun-17 Jan-18 Apr-18 Jun-18 Month Jul-16 Jul-17 Jul-18 40% 50% 60% 70% 80% 90%
184 Report 11 10 20 19 10 23 13 10 6 9 8 3 8 2 5 9 3 1 1 1 1 4 3 2 2 Stroke Bed Capacity * No outliers * 94 14 13
4 3 2 4 1 1 1 6 2 5 5 2 3 3 2 7 9 2 1 4 Trust Bed Capacity * Outliers * % Within Standard Within %
Stroke Patients Spending >90%Timeof on Stroke Unit 1 1 DTOC Breach reasons 2016/2017/2018 and Monthly Stroke position Monthly Stroke and 2016/2017/2018 reasons Breach
17 Operational decision - patient 2 1 2 1 1 1 2 1 1 1 1 3 moved off the unit to accommodate an acute stroke 1 1 1 3 Delay in medical review in ED 29 1 2 1 1 1 1 3 2 1 2 1 1 1 1 1 4 1 1 2 1 Clinical - Appropriate pathway for patient 1 5 4 Difficult presentation 31 3 4 1 3 2 1 1 2 2 2 1 2 2 2 1 1 1 Target 80% Target Medical SpR did not request stroke bed/referred to stroke team 76 2 2 5 6 2 2 2 4 5 2 1 4 3 1 3 2 3 6 3 6 4 1 3 3 1 Delayed diagnosis 1 2 5 2 Clinican's decision to place patient on different ward 33 3 1 1 2 2 1 4 7 2 1 1 1 1 1 3 2 Unclear presentation 15 1 1 1 1 2 1 1 1 4 2 1 Difficult diagnosis 70-79% 12 1 1 1 2 1 1 1 1 1 1 1 Failure to request stroke bed 1 1 Diagnostics not available 499 20 21 27 18 24 27 20 34 17 27 17 14 12 12 18 24 19 13 12 12 10 22 12 25 9 7 7 8 1 8 Number of breaches 60.8% 56.3% 49.1% 80.0% 72.7% 84.1% 56.4% 46.0% 59.2% 52.1% 63.8% 57.1% 84.1% 71.7% 77.0% 84.3% 81.0% 78.2% 73.5% 64.2% 72.4% 67.5% 73.3% 78.2% 83.3% 51.1% 80.0% 78.9% 59.0% 83.3% 0.0%
Month Position (Target 80%) patients. 8 of position breach the to factor contributory main the was (6) beds of Lack = September for achieved was compliance Target • • • • • • Key Actions at at
awaiting confirmation from CCGs from confirmation awaiting is service SU. in the The the beds contain to inability and the issues capacity D the bed C due to Level to Level from further dropped SSNAP submitted recently of the results The found. funding unless occur to be able nolonger would this and Ely area to the of patients amount a large CUH discharge will cease. patch North the therefore forward that risk a is There therapists. the of many of recruitment full prevented has this and Trust the of funding continued The identified. ( Discharge Supported Early the on SU to admission direct 4hrs for focus the improved has decision this of impact The Department. Emergency from admissions direct - ring has Unit Stroke the May, 1st Since Intervention (4) At least daily on - daily At least (4) Intervention to access 24 hours (3) Diagnostics (2) 14 hours within consultation to first Time (a) are standards four The Stroke. for standards Service 7 day the of compliance achieve to means alternative proposed a as post stroke and medical joint a as panel Investment go to the will Consultant Stoke additional case for A revised SU) in stay 90% and ED admission (4hrs measures key performance two of the in reported a SU into bed is being directly patients stroke place to Failure appropriately. forward taken are actions and continues breaches all for undertaken analysis cause root plus place, in remain meetings Taskforce Stroke Brookfields SSNAP
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Maternity dashboard Rosie Maternity Dashboard Sept 18 Sources/ KPI Goa l Red Flag Measure Data Source Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Actions taken for Red/Amber results References Activity Births (Benchmarked to Source - EPIC < 476 > 520 Births per month Rosie KPI's 435 480 448 466 472 458 5716 per annum) Antenatal Care NICE quality Health and social care Booking > 90% < 85% EPIC 98% 97% 98% 99% 98% 96% standard assessment
Workforce WTE(clinical and non- clinical)+ bank/births Midwife/birth ratio (actual) 1:30 >1:34 Finance 1:29.7 1:29:7 1:30:4 1:30:7 1:31:9 1:29.3 Figures produced by Finance Department (12 month rolling average) WTE/births (12 month Midwife/birth ratio (funded) 1:30 >1:34 Finance 1:27.6 1:27:8 1:27:9 1:28:1 1:28:1 1:28.3 Figures produced by Finance Department rolling average) Source - Staff sickness as a whole < 3.5% > 5% MAPS Maps 4.27% 4.56% 6.02% 6.62% 4.85% 6.43% CHEQS Education & Training - Source - attendance at mandatory >92% YTD <75% YTD Training database CHEQs 94% 94% 94% 95% 96% 96% This is reported 1 month behind from CHEQ's CHEQS training (midwives)
35 Integrated Report Page author: Head of Midwifery Maternity dashboard cont.
Maternity Morbidity
Source - QSIS Eclampsia 0 > 1 Risk Report 0 0 0 0 0 0 ITU Admissions in Source - QSIS 1 > 2 Risk Report 0 0 1 0 1 0 Obstetrics PPH equal to or more Source - QSIS PPH => 2L <2.4% >3.5% Risk Report 0.94% 0.42% 0.90% 0.88% 1.29% 1.76% than 2L PPH equal to or more Source - QSIS PPH => 1L < 5% > 8% Risk Report 5.67% 4.43% 5.44% 3.96% 5.61% 4.19% than 1L 3rd/ 4th degree tear rate Source - QSIS < 5% > 7% Risk Report 2.37% 2.99% 3.29% 0.90% 4.06% 1.94% vaginal birth Source - QSIS Maternal Death 0 >1 Risk Report 0 0 1 0 1 0 Risk Source - QSIS Total number of SI's 0 >1 Serious Incidents Datix 0 0 0 2 2 0 Source - QSIS Information Governance 0 >1 Datix 1 0 0 2 1 0 Source - QSIS Clinical 0 >1 Datix 0 0 0 0 1 0 Source - QSIS Never Events 0 >1 DATIX Datix 0 0 0 0 0 0
Neonatal Morbidality Shoulder Dystocia per We have looked at all cases and there Source - EPIC < 1.5% > 2.5% Risk Report 1.01% 1.50% 2.96% 2.14% 2.19% 2.59% vaginal births doesn’t seem to be any themes Unexpected Still Births per Source - EPIC Risk report 4.59 2.08 2.23 2.14 4.23 2.18 1000 Births Injuries to neonate Source - EPIC Number of birth injuries 0 > 1 Risk Report 0 2 0 1 0 0 during delivery Number of term babies Source - EPIC who required therapeutic 0 > 1 Risk Report 1 0 0 1 0 0 cooling Baby born with a low cord Source - EPIC <2% > 3% Risk Report 1.84% 1.14% 0.89% 3% 1.27% 1.31% gas < 7.1(from 1/11/2012) Unexpected/term Percentage of all live Source - EPIC <6.5 >6.5 Risk Report 5.31% 6.90% 6.05% 5.3% 4.89% 3.06 admissions to NICU births Quality Number of times Rosie 0 > 1 All ward diverts includedRosie Diverts 0 1 0 0 1 5 Closed due to staffing and capacity. Maternity Unit Diverted Source - EPIC 1-1 Care in Labour >95% <90% Exlcuding BBA's Rosie KPI's 99% 99% 98% 99% 99% 98% Breast feeding rate at Source - EPIC > 80% < 70% Breastfeeding Rosie KPI's 84% 77% 84% 81% 83% 85% Delivery Source - EPIC VTE >95% < 95% CHEQs 97% 98% 98% 98% 98% 96%
36 Integrated Report Page author: Head of Midwifery Clinical studies Clinical 37 Clinical studies Report Integrated
NIHR Performance in
NIHR Performance in Initiating Research Q1 2018- Q1 Initiating Research in Performance NIHR 14
Delivering 6
12
Research Q 1 2018- 2019 Did not meet target meet not Did target Met Excluded 2019 received the document pack from the Sponsor to the date 1 the date the to Sponsor the pack from document the received date we the days from (70 target initiative and time the abolished has now (NIHR) Research Health for Institute National the While only] update [quarterly Situation at 30/06/2018as reportedto the NIHR
• • • • (Initiating): days 70 timeframe. agreed the in target recruitment met their they whether and months 12 preceding the in recruitment to closed trials for is and unchanged, remains studies commercial for target delivery in performance The open. yet not but selected site CUH are which studies include it will but report, the in are included HRA by are approved which studies Only consistency. it for against performance our on report to continue we recruited), was patient • • • • Delivering target:to • • progressActions in the analysis. analysis. the from excluded are and target the meet to able still are studies 22 analysis. the from 41 exclude will which given been reasons have appropriate target, but the meet not did studies 49 target. outside falling studies more for responsible jointly were we as quarter, this drop or plateau would performance our from in performance Q4 2017 decline slight a is target, which the met (32/40) 80% trials, analysed all Of quarter. this submitted Data on 103 non Nationally, 60.7% of trials met this target as at Q4 2017 Q4 at as target this met trials of 60.7% Nationally, the recruitment number/range agreed. agreed. number/range recruitment the meet to opportunity the having before Sponsor the by withdrawn were target, 85.71% recruitment the meeting not trials the Of performance of 46.15% (12/26). a giving analysed, been have trials target, 26 a having not studies 6 with and quarter, last the since improvement an is There Q1. in trials commercial 32 on submitted was Data need resolving prior to study commencement. commencement. study to prior resolving need issues fundamental as review, for HRA to submitted being studies withproblems causes This diligence. due Trust’sprocesses of the of appreciation proper without dates start arbitrary set funders system, the whereby in tension inherent be to continues There possible. where internally any issues resolving on focusing while trends, developing and issues recruitment of analysis level high their aid to recruit, and studies up set to taken times on information to supply continue will therefore We transparency. on emphasis an with improvement, and reporting measurement, on are focusing NIHR target, the day 70 the matched against longer no is research studies initiating in performance our While
- commercial and commercial clinical trials was was trials clinical commercial and commercial
Page author: Stephen Kelleher Stephen author: Page
- 18. We did anticipate anticipate did We 18.
- 18. st
I&E overview
Month 6 Commentary:
• Year to date Month 6 the Trust had a deficit of Dashboard YTD at Month 6 (August 2018) £m £51.6m, which is £0.0m greater than the planned Direction of Performance deficit of £51.6m. Income and Expenditure Budget YTD Ac tual YTD Variance YTD travel since vs Budget last month • Total income was £5.6m greater than plan. T o t a l Inc o me 419.9 425.5 5.6 Pay 242.8 245.0 2.2 X • Total expenditure was adverse by £5.1m and Capital spend was £8.9m less than plan. Drugs expenditure 60.1 60.9 0.8 X
Other Non Pay expenditure 153.1 155.2 2.1 X • The Trust’s cash position stands at £19m, £15.7m ahead of budget. EBIT DA (36.1) (35.6) 0.5 EBIT DA % (8.6%) (8.4%) 0.2% Net (Defic it) (51.6) (51.6) 0.0 Direction of Variance to Performance Balance Sheet Budget Actual travel since Budget vs target Performance improved last month
Financial Performance Financial Cash at bank 3.3 19.0 15.7 Performance declined Capital expenditure 19.5 10.6 (8.9) Performance maintained Debtor days 36.5 34.7 (1.9) X Creditor days 59.3 68.2 8.8 X Performance not meeting budget Liquidity metric (22.8) (33.5) (10.7) X Performance meeting budget Use of Resources Rating 3 3 0.0
38 Integrated Report Page author: Paul Scott I&E overview by Division Month 6 Commentary:
At the end of Month 6, the Trust’s clinical divisions In month Year to Date excluding Corporate Areas had a total YTD adverse variance of £3.7m, and an in month favourable variance of £0.4m. £millions Variance Variance Divisions B, C, E and corporate areas posted a favourable variance in the month. Division A and D had adverse variances.
Division A (0.4) (1.2) For Division A pay (£0.1m), non-pay (£0.2m) and clinical income (£0.4m) were all adverse variances in month. Drugs £0.2m and devolved income £0.1m were favourable in Division B 0.3 (2.1) month variances.
For Division B Pay (£0.3m) is adverse. Non-pay £0.2m, Division C 0.4 0.1 Devolved income 0.1m, Clinical Income £0.1m and Drugs £0.2m are all favourable. Division D (0.1) (1.5) For Division C non-pay £0.3m, clinical income £0.3m and devolved income £0.1m are favourable. Pay (£0.2m) and Division E 0.2 1.1 Drugs (0.1m) are adverse.
In Division D pay (£0.1m) and clinical income (0.5m) are Financial Performance Financial Corporate Areas 0.4 3.7 adverse variances. Drugs £0.1m, Non-pay 0.2m and devolved income £0.2m are all favourable variances. Net adverse variance 0.8 0.0 In Division E pay £0.2m is a favourable in month variances. Non pay, Drugs, Clinical income and devolved income are all breakeven in month.
Corporate Areas are showing a total favourable variance of £0.4m. Non-pay £1.8m is favourable. Devolved Income (£0.4m), pay (£0.4m) and clinical income (£0.6m) are all adverse.
39 Integrated Report Page author: Paul Scott Cost Improvement Programme
Year to date September 2018 Month 6 Commentary: Budget Actual Variance Workstream £m £m £m Financial Performance Financial Capacity & Demand 6.7 1.6 (5.1) • The table shows the net benefits excluding project management support costs. Diagnostics 0.0 0.0 0.0 Divisional 0.6 1.8 1.2 Estates & Facilities 0.7 0.1 (0.6) • Year to date Cost Improvement Programme (CIP) performance is 0.1m ahead of plan. Income Generation 3.9 5.5 1.6 Outpatients 0.1 2.5 2.4 Pharmacy 1.5 1.6 0.1
Procurement 1.0 1.1 0.1 Surgery 2.0 2.0 (0.0) Unidentified 0.2 0.0 (0.2) Workforce 2.4 3.0 0.6 Net Total 19.1 19.2 0.1
40 Integrated Report Page author: Paul Scott Balance sheet and cash flow Month 6 Commentary £millions Year to date
Budget Actual Variance Non-current assets Debtors/Cash Intangible assets 28.4 31.3 2.9 Property, plant and equipment 336.3 325.1 (11.2) Overall debtors are lower than plan and this is reflected Total non-current assets 364.7 356.3 (8.3) in the improved cash position and reduced borrowing. This is mainly due to commissioners settling prior year Current assets balances earlier than expected and lower levels of in- Inventories 11.8 11.8 (0.0) year over performance, resulting in fewer outstanding Debt ors 83.4 79.1 (4.3) invoices. Cash and cash equivalents 3.3 19.0 15.7 Total current assets 98.6 109.9 11.3 Current Liabilities Current liabilities Trade Creditors (20.6) (21.6) (1.0)
Current liabilities are higher than plan and this is Borrowings (12.5) (10.9) 1.7 reflected in the improved cash position and reduced Other financ ial liabilities (81.9) (101.9) (20.0) borrowing. This is mainly due to normal delays in Provisions (2.5) (0.8) 1.7 liabilities crystallising and falling due for payment. Other liabilities: deferred inc ome (28.1) (32.2) (4.1) Total current liabilities (145.7) (167.4) (21.7)
Net current assets / (liabilities) (47.1) (57.5) (10.4)
Non-current liabilities
Financial Performance Financial Borrowings (345.6) (326.4) 19.2 Provisions (2.4) (2.9) (0.5) Total non-current liabilities (348.0) (329.2) 18.7
Total net assets employed (30.3) (30.3) 0.0
Financed by Public dividend capital 132.9 132.9 0.0 Revaluation reserve 37.7 37.7 (0.0)
Income and expenditure reserve (200.9) (200.9) 0.0
Total taxpayers' and others' equity (30.3) (30.3) 0.0
41 Integrated Report Page author: Paul Scott FTE by staff group Complaint free Workforce
Figure 4.1 Staff in post by staff group Figure 4.2: Staff in post 12000 232 Add Prof Scientific and Technic 8.4% 232 10000 291 Estates and Ancillary 2.2% 296 8000 530 *Healthcare Scientists 7.2% 518 502 6000 Allied Health Professionals 4.0% 492 1,348 Medical and Dental 4.4% 4000 1,313 Additional Clinical Services 1,525 6.2% 1,519 006 165 2000 992 839 153 295 , , , , 10 , 10,078 10,126 10,130 10 , 10,245 10,318 1,952 8,941 9,790 8 9 8,991 9,839 9,079 9,935 9,138 9,995 9 9,211 9,253 9,257 9 9,374 9,448 Administrative and Clerical 5.7% 1,950 0 3,068 Registered Nursing and Midwifery 8.1% 3,054 Jul-18 Jan-18 Jun-18 Oct-17 Apr-18 Feb-18 Sep-18 Dec-17 Aug-18 Nov-17 Mar-18 0 1,000 2,000 3,000 4,000 May-18
Headcount FTE % growth over the last 12 months Sep-18 Aug-18
% growth
Workforce over the Staff Group last 12 FTE Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 months Add Prof Scientific and Technic 214 228 226 231 228 227 225 228 228 229 232 232 8.4% Additional Clinical Services 1,436 1,450 1,449 1,469 1,482 1,480 1,489 1,506 1,501 1,513 1,519 1,525 6.2% Administrative and Clerical 1,846 1,857 1,861 1,889 1,895 1,896 1,910 1,926 1,933 1,937 1,950 1,952 5.7% Allied Health Professionals 482 481 475 483 483 484 475 476 475 481 492 502 4.0% Estates and Ancillary 285 293 291 296 299 293 297 300 298 296 296 291 2.2% *Healthcare Scientists 495 497 503 502 509 511 514 513 510 511 518 530 7.2% Medical and Dental 1,291 1,302 1,300 1,292 1,300 1,300 1,304 1,300 1,298 1,295 1,313 1,348 4.4% of which Doctors in Training 563 570 570 555 559 552 548 540 532 529 546 562 -0.3% of which Career grade doctors 176 178 177 174 169 170 178 181 184 181 181 190 7.9% of which Consultants 552 554 553 563 572 578 579 579 582 585 585 596 8.1% Registered Nursing and Midwifery 2,892 2,884 2,885 2,917 2,942 2,962 2,997 3,004 3,015 3,033 3,054 3,068 6.1% Total 8,941 8,992 8,991 9,079 9,138 9,153 9,211 9,253 9,257 9,295 9,374 9,448 5.7% 42 Integrated Report Page author: David Wherrett Turnover by staff group and monthly Trust trend Complaint free Workforce Overall Trust Turnover Rate Figure 5.1: Turnover by staff Group (Annualised) 25% Add Prof Scientific and Technic
20% Additional Clinical Services Administrative and Clerical 15% Allied Health Professionals
10% DH Benchmark
13.7% % 13.9 14.1% 14.0% 14.0% % 14.3 14.3% 14.3% 13.9% % 14.2 14.0% 13.8% Estates and Ancillary 5% Healthcare Scientists
0% Medical and Dental Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Apr 18 May 18 Jun 18 Jul 18 Aug 18 Sep 18 Nursing and Midwifery Registered
Figure 5.2: Starters & leavers per month 500 100% 450 90% Workforce 400 80% 350 70% 300 60% 250 50% 200 40% 150 30%
100 22 % 24% 23% 19% 22 % 18% 22% 20% 23 % 28% 18% 23% 20% 50 10%
0 0%
*% of Permanent staff leavers that left the Trust within first year of joining Starters *Leavers *Please note that Leavers/Starters figure include both permanent and Fixed term contract staff while the Turnover rate include Permanent staff only
43 Integrated Report Page author: David Wherrett Sickness by staff group Complaint free Workforce
Figure 7.1: Sickness absence Source Target Trust R & D
Division A Division B Division E Corporate Division C Division D
% Sickness absence rate ESR 2.7% 3.15% 3.7% 3.1% 3.1% 2.7% 3.1% 2.4% 3.2%
Number of episodes in 12 months ESR 22,919 4,367 6,199 3,419 2,612 2,802 807 2,713 % of employees with 6 or more short episodes of sickness in the ESR 0.3% 0.3% 0.3% 0.2% 0.3% 0.3% 0.1% 0.2% last six months (<28 days) % of employees with long episodes of sickness in the last six ESR 0.7% 0.8% 0.7% 0.7% 0.6% 0.7% 0.6% 0.7% months (>=28 days) Days lost due to short term sickness in the last 12 months 56,717 11,584 14,700 8,408 5,924 7,023 1,909 7,168 ESR (Percent of time lost in brackets) (1.72%) (1.8%) (1.8%) (1.8%) (1.4%) (1.8%) (1.5%) (1.7%) Days lost due to long term sickness in the last 12 months 47,065 11,354 11,323 6,122 5,324 5,143 1,219 6,579 ESR (Percent of time lost in brackets) (1.43%) (1.8%) (1.4%) (1.3%) (1.3%) (1.3%) (0.9%) (1.5%)
Figure 7.4 Top 6 Sickness Absence reasons 4.0% Figure 7.2: Sickness Absence Rate
Sickness Rate 5.2% 3.5% Back Problems 5.5% CUH Average 5.5% Workforce 3.0% Trust Target 8.7% Injury, fracture 6.9% 2.5% NHS Benchmark 7.0% Other musculoskeletal 9.0% problems 9.0% 8.5% Jul - 18 Jan - 18 Jan Jun - 18 Oct - 17 Apr - 18 Feb - 18 Sep - 18 Dec - 17 Aug - 18 Nov - 17 Mar - 18 May - 18 May 13.6% Gastrointestinal problems 13.2% 13.0% Figure 7.3: Percent sickness rate by staff group 6.0% 14.2% Cold, Cough, Flu - Influenza 15.5% 15.1% 1.95% 0.97% 3.31% 2.88% 1.98 5.39% 4.95% 3.38 1.90% 1.05% 3.24% 2.96% 2.00 4.0% 5.10% 4.82% 3.26 18.6% % % % 2.0% % Anxiety/stress/depression/othe
19.0%
r psychiatric illnesses 0.0% 19.5% Estates and Additional Administrative Nursing and Add Prof Healthcare Allied Health Medical and 0% 10% 20% 30% Ancillary Clinical Services and Clerical Midwifery Scientific and Scientists Professionals Dental Registered Technic Preceding 12Months Preceding 3Months Current Month Prev Month Trust Target Current Month
44 Integrated Report Page author: David Wherrett Temporary Staffing
All staff groups - Weekly bank & agency requests and filled shifts Weekly Registered Nurse requests and filled shifts (excluding Medical) 3000 6000
5000 2500
4000 2000 Total Requests 3000 1500 Total filled 2000 1000 Bank Filled Requests 1000 Agency Filled Filled 500 0 Oct 2017 Oct Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 Apr 2018 May 2018 Jun 2018 Jul 2018 Aug 2018 Sep 2018 0 Oct 2017 Oct Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 Apr 2018 May 2018 Jun 2018 Jul 2018 Aug 2018 Sep 2018
Monthly Medical Temporary staff Requests and Filled Shifts Weekly Admin requests and filled Shifts
Workforce 1600 (including management and estates workers) 1200 1400 1000 1200
1000 800 Total requests Total Requests 800 Total filled 600 600 Bank and Agency Agency filled 400 Admin Filled 400 Bank Admin filled Bank filled 200 200 Unfilled Agency admin filled 0 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 0 Oct 2017 Oct Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 Apr 2018 May 2018 Jun 2018 Jul 2018 Aug 2018 Sep 2018
45 Integrated Report Page author: David Wherrett Mandatory training by Division and staff group Complaint free Workforce Induction Mandatory Training Competency (as defined by Skills for Health)
Non-Medical Medical Prevent Level Conflict Equality & Health & Infection Information Moving & Safeguarding Safeguarding Safeguarding Safeguarding Safeguarding Total Fire Safety Resuscitation Three Corporate Local Corporate Safety Control Adult Lvl 2 Children Lvl 1 Local Induction Resolution Diversity Governance Handling Adults Children Lvl 2 Children Lvl 3 Compliance Induction Induction Induction (WRAP)
Frequency 3 yrs 3 yrs 2 yrs/1yr 3yrs 2 yrs% 2 yrs 2 yrs/1yrs 1year 3 yrs 3 yrs 3 yrs 3 yrs 3 yrs 3 yrs
Delivery Method cl f2f cl/ f2f cl/e/ cl/e/ cl/e/ cl/e/ cl/e/ cl/e/ cl/e/ cl/el cl/e/ cl/el cl/el cl/el cl/el cl Staff Requiring Competency 1,912 1,022 162 161 9,624 9,624 9,624 9,624 9,624 9,624 9,624 6,236 9,624 6,379 9,624 6,292 1,582 1,582
Division A (0)100.0% (11)93.2% (4)90.9% (9)79.1% (28)98.3% (4)98.8% (110)93.4% (4)98.8% (22)98.7% (24)98.6% (133)92.0% (207)86.9% (27)98.4% (70)95.6% (47)97.4% (78)95.1% (5)95.5% (4)96.4% 95.6%
Division B (3)99.5% (24)90.9% (2)93.1% (5)82.8% (26)98.9% (1)99.8% (113)95.2% (1)99.8% (39)98.4% (40)98.3% (128)94.6% (145)88.4% (30)98.7% (79)94.4% (46)98.2% (87)93.4% (10)91.9% (6)95.2% 96.6%
Division C (2)99.2% (15)91.2% (1)96.2% (7)73.1% (21)98.2% (0)100.0% (110)90.7% (0)100.0% (18)98.5% (22)98.1% (107)90.9% (208)82.8% (23)98.0% (88)92.7% (49)96.4% (94)92.2% (20)88.6% (9)94.9% 94.1%
Division D (0)100.0% (2)98.6% (8)80.0% (8)80.0% (25)97.8% (6)98.0% (69)94.0% (6)98.0% (31)97.3% (30)97.4% (86)92.5% (139)85.6% (24)97.9% (66)93.2% (35)97.1% (73)92.4% (28)80.3% (32)77.5% 94.6%
Division E (1)99.5% (7)93.1% (0)100.0% (5)78.3% (14)98.7% (0)100.0% (54)94.9% (0)100.0% (19)98.2% (18)98.3% (73)93.1% (84)91.1% (16)98.5% (38)95.9% (11)99.0% (37)96.1% (70)93.1% (90)91.1% 95.9%
Corporate (6)97.8% (17)87.8% (17)98.5% (1)99.6% (34)97.1% (2)99.3% (17)98.5% (19)98.4% (42)96.4% (16)88.0% (20)98.3% (7)94.7% (46)96.2% (16)88.6% (0)100.0% (0)100.0% 97.2% Compliance by Division
R & D (0)100.0% (5)88.1% (1)99.7% (0)100.0% (11)97.0% (0)100.0% (3)99.2% (3)99.2% (20)94.5% (11)92.4% (1)99.7% (3)97.9% (5)98.7% (7)95.2% 97.9%
Breakdown of Medical staff compliance Consultant (4)92.2% (12)76.5% (22)96.5% (2)96.1% (17)97.3% (2)96.1% (21)96.6% (20)96.8% (19)96.9% (76)88.0% (22)96.5% (30)95.3% (15)97.6% (30)95.3% (8)94.8% (8)94.8% 95.5% Workforce Non Consultant (11)90.1% (22)80.0% (65)81.8% (9)91.9% (79)77.9% (9)91.9% (75)79.0% (78)78.2% (82)77.0% (308)50.6% (66)81.5% (231)62.4% (124)80.3% (175)72.1% (44)65.4% (53)58.3% 73.2%
Add Prof Scientific and Technic (0)100.0% (1)94.4% (0)100.0% (0)100.0% (17)92.7% (0)100.0% (1)99.6% (1)99.6% (25)89.2% (12)86.7% (0)100.0% (4)97.8% (0)100.0% (3)97.0% (0)100.0% (0)100.0% 97.1%
Additional Clinical Services (3)99.3% (17)92.1% (7)99.5% (0)100.0% (131)91.0% (0)100.0% (11)99.2% (11)99.2% (149)89.8% (148)86.6% (12)99.2% (47)96.1% (20)98.7% (66)94.3% (5)96.8% (7)95.5% 95.9%
Administrative and Clerical (4)99.2% (22)90.4% (20)99.0% (1)99.8% (22)98.9% (2)99.6% (24)98.8% (26)98.7% (49)97.5% (1)50.0% (24)98.8% (1)80.0% (62)97.0% (4)60.0% (2)66.7% (2)66.7% 98.3%
Allied Health Professionals (1)99.2% (4)92.2% (2)99.6% (0)100.0% (36)92.9% (0)100.0% (1)99.8% (1)99.8% (35)93.1% (30)94.4% (2)99.6% (2)99.6% (0)100.0% (13)97.6% (1)98.3% (1)98.3% 97.7%
Estates and Ancillary (0)100.0% (2)95.5% (7)97.6% (0)100.0% (14)95.2% (0)100.0% (4)98.6% (5)98.3% (3)99.0% (8)97.2% (10)96.6% 97.7%
Healthcare Scientists (0)100.0% (4)90.7% (0)100.0% (0)100.0% (2)99.6% (0)100.0% (2)99.6% (2)99.6% (13)97.5% (5)94.0% (0)100.0% (2)97.0% (7)98.7% (3)95.5% (13)40.9% (19)13.6% 98.3%
Compliance by Staff Group Staff by Compliance Medical and Dental (15)90.7% (34)78.9% (87)91.1% (11)93.2% (96)90.2% (11)93.2% (96)90.2% (98)90.0% (101)89.7% (384)69.4% (88)91.0% (261)79.1% (139)89.0% (205)83.8% (52)81.5% (61)78.3% 85.7%
Nursing and Midwifery Registered (4)99.4% (31)92.7% (9)99.7% (0)100.0% (183)94.0% (0)100.0% (10)99.7% (12)99.6% (214)92.9% (230)92.7% (7)99.8% (34)98.9% (1)100.0% (98)96.9% (65)93.8% (55)94.8% 97.3%
Trust Total (12)99.4% (81)92.1% (15)90.7% (34)78.9% (132)98.5% (12)99.4% (501)94.4% (13)99.4% (149)98.3% (156)98.3% (589)93.4% (810)87.0% (141)98.4% (351)94.5% (239)97.5% (392)93.8% (138)91.3% (145)90.8% 95.78%
4 Integrated Report Page author: David Wherrett 6 Appraisal compliance / Vacancy rate Staff as Partners
The Annual Appraisal cycle Medical Staff Appraisal Completion rate by Target group Deadline for appraisal completion for all medical staff (excluding By end of March - Tier 1 Executive (Non Medical staff ) junior doctors) is : 100% directors, divisional directors and corporate directors • Round 1 Deadline is the 30th 80% By End of April - Tier 2 Senior of Jun 2018. Appraisal compliance managers bands 8c-9 rate as at 30th of September for By end of May - Tier 3 Managers this group is 99.27% 60% and employees band 7-8b By end of June - Tier 5 Employees • Round 2 Deadline is the 31st of December 2018. 40% band 6
By end of July - Tier 6 Employees 20% •The Deanery is responsible for band 1-5 appraisal compliance for junior medical staff. 0% Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Job Planning – Medical Staff • The Trust’s compliance for Tier 1 actual Tier 2 actual Tier 3 actual Consultant/SAS job planning as at 30th of September 2018 is Tier 5 actual Tier 6 actual Overall 90.3% Tier 1 Target Tier 2 Target Tier 3 Target Self Reported Vacancies for wards and main clinical areas (Pay Band 2-7 inclusive)
Staff as Partners Nursing and Midwifery Vacancy rate by Clinical HCA Vacancy rate by Clinical Division Nursing and Midwifery & HCA Vacancy rate Division 40% 25% 45% 40% 20% 35% 30% 30% 15% 25% 20% 20% 10% 15% 12.8% 11.9% 11.6 % 11.4 % 11.1% 10.2% 29.5% 28.5% 28.8% 29.0 % 28.0 % 28.0% 10% 12.8 % 29.5% 11.9% 28.5 % 11.6% 28.8 % 11.4% 29.0% 11.1% 28.0% 10.2% 28.0% 5% 10%
5% 0% 0% 0% Apr - 18 May - 18 Jun - 18 Jul - 18 Aug - 18 Sep - 18 Apr - 18 May - 18 Jun - 18 Jul - 18 Aug - 18 Sep - 18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 -5% Trust Division A Division B Vacancy rate N&M Vacancy rate HCA Trust Division A Division B Division C Division C Division D Division E N&M Target HCA Target Division D Division E Target Target
47 Integrated Report Page author: David Wherrett Staff Engagement Staff as Partners
5% less than Trust score Equal to or up to 4% more/less than Trust score EIS - Division Comparisons 5% more than Trust score
ENGAGEMENT SURVEY Corporate Division A Division B Division C Division D Division E R&D Trust (EIS is average score of the 6 EIS statements) Overall Q2 Jul-Sep Staff as Partners 2018/19 Participation Rate 35% 18% 23% 19% 21% 22% 26% 22% (actual number of participants) (442) (332) (615) (268) (255) (255) (80) (2376) Engagement Index Scores (EIS) Q2 Jul -Sep 2018/19 82% 81% 79% 78% 80% 82% 76% 80% EIS Q1 Apr - Jun 2018/19 82% 80% 80% 79% 81% 84% 81% 81% EIS Q4 Jan - Mar 2017/18 78% 77% 77% 78% 77% 83% 75% 79% EIS Q3 Oct - Dec 2017/18 78% 76% 81% 82% 80% 84% 79% 80% EIS Q2 Jul - Aug 2017/18 81% 77% 80% 83% 79% 83% 84% 81% EIS Q1 Apr - Jun 2017/18 79% 78% 81% 80% 78% 83% 82% 80% EIS Q4 Jan - Mar 2016/17 80% 77% 81% 78% 77% 81% 82% 79% EIS Q3 Oct - Dec 2016/17 89% 78% 81% 79% 77% 82% 80% 79% EIS Q2 Jul - Aug 2016/17 89% 75% 79% 80% 77% 78% 77% 78% EIS Q1 Apr - Jun 2016/17 77% 77% 79% 79% 78% 79% 82% 78% I would recommend this organisation as a place to work. (EIS) 76% 73% 72% 70% 70% 77% 70% 74% Overall, I enjoy working in this organisation. (EIS) 84% 81% 79% 78% 78% 85% 77% 81% I am proud to work for this organisation. (EIS) 86% 87% 84% 83% 83% 82% 80% 85% I am motivated to make a difference to patients (even if I don't have direct contact with patients). (EIS) 89% 91% 92% 90% 95% 95% 84% 92% I willingly do more than is required of me at work. (EIS) 92% 89% 90% 87% 92% 93% 88% 91% I feel valued and recognised within my area of work. (EIS) 63% 63% 58% 58% 60% 62% 59% 60% Staff FFT -Likelihood to recommend for care or treatment 92% 94% 92% 94% 95% 95% 88% 93% Staff FFT -Likelihood to recommend as a place to work 73% 72% 72% 70% 68% 73% 62% 72% Senior managers here try to involve staff in important decisions. 52% 47% 46% 44% 50% 51% 37% 48% Senior managers act on staff feedback. 48% 47% 45% 43% 44% 49% 38% 46% The support I get from my immediate manager. 77% 73% 70% 73% 72% 77% 80% 73% When errors, near misses or incidents are reported, my organisation takes action to ensure that they do not happen again. 79% 79% 79% 83% 77% 84% 74% 79% I am confident that my organisation would address my concern. 71% 69% 70% 64% 71% 72% 51% 69% 48 Integrated Report Page author: David Wherrett Planned vs. Actual Staff in Post (SIP) Staff as Partners Plan vs Actual WTE by Staff Group Trust Overall Plan vs Actual Staff In Post Jun 18 (WTE) 3,500 5% 9,700 3,000 4% 9,600 2,500 3% 9,500 2,000 9,400 2% 1,500 9,300 1% 1,000 9,200
500 325 0% 9,100 1,323 1,348 2,866 2,899 2,408 2,385 1 , 1,366 502 509 552 556 393 386 0 -1% 9,000 Allied Health Healthcare Medical and Other Qualified *Support to *Total NHS 0.4% 0.7% 0.8% 1.1% 1.2 % 1.2% 1.6 % 1.6% 2.0% 2.4% 2.4% 3.2% 2.7% 3.1% 3.5% 3.9% 4.3 % 4.7 % 8,900 Professionals scientists dental Qualified nursing, clinical staff infrastructure Scientific, midwifery support Therapeutic and health and Technical visiting staff Staff Plan SIP staff Aug 18 Actual SIP staff Aug 18 Planned WTE % increase Actual WTE % Increase Planed WTE %Increase Actual WTE %increase Plan SIP (WTE) Actual SIP (WTE)
Varaiance Adjusted Plan Difference Plan % SIP Plan Actual SIP between Plan *Staff Group Actual Out-turn SIP Mar 19 between Plan Planed WTE Actual WTE *Description increase Mar SIP staff staff Aug vs Actual FTE Mar 18 (WTE) (@ 0.5% vs actual SIP %Increase %increase 19 Aug 18 18 Increase variance) staff (WTE) Aug 18
Include all registered allied health proffesionals exclude pre-
Staff as Partners Allied Health Professionals reg staff 491 512 4.3% 502 509 7 2.1% 3.6% 1.4% Healthcare scientists Include all Healthcare scientists 547 557 1.8% 552 556 4 0.9% 1.6% 0.7% Medical and dental Medical and dental staff 1,300 1,345 3.5% 1,323 1,348 25 1.7% 3.7% 1.9% Other Qualified Scientific, Therapeutic Include other registered scientific, therapeutic and technical and Technical Staff staff 389 396 1.8% 393 386 -6 0.9% -0.7% -1.6% Qualified nursing, midwifery and health Include all registered Nusing and Midwifery staff. Exclude 2,787 2,944 5.6% 2,866 2,899 34 2.8% 4.0% 1.2% visiting staff staff awaiting pin registration include all additional clinical staff group, all clinical staff that are awaiting their professional registration and all admin & *Support to clinical staff 2,333 2,483 6.4% 2,408 2,385 -23 3.2% 2.2% -1.0% clerical and estates & facilities staff group with patient facing roles. E.g. ward clerk, porters, receptionists etc)
*Total NHS infrastructure support Includes all non-patient facing admin & clerical and Estates & facilities staff group and all managers or co-ordinators 1,304 1,345 3.1% 1,325 1,366 41 1.6% 4.7% 3.1%
Total 9,151 9,582 4.7% 9,367 9,448 81 2.4% 3.2% 0.89% * Please note that the workforce plan was based on NHSI staff groups which is slightly different from the way it is grouped for internal/Board reporting. The description for each group is given in the description column. *Adjusted Planned WTE for Sep 18 is derived from the Assumption that there will be equal increase per month based on the overall adjusted increase for the financial year *Overall figures and plan %increase for all groups have changed from previous months due to changes to the grouping as advised by NHSI and DQ changes on ESR 49 Integrated Report Page author: David Wherrett Health and Safety Incidents affecting staff, patients & others ie visitors, contractors and members of the public (Sep 2018)
A total of 1,345 health and safety incidents were reported in the previous 12 months.
653 (51%) incidents resulted in harm. The highest reporting categories were violence and aggression (22%), accidents (21%) and blood/bodily fluid exposure (17%).
75% (1,009) of incidents affected staff, 18% (242) affected patients and 7% (94) affected others ie visitors, contractors and members of the public.
The highest reported incident categories for staff were: violence and aggression (22%), blood exposure (22%) and accidents (18%).
The highest reported incident categories for patients were: accidents (37%), environmental issues (30%) and violence and aggression (20%) .
The highest reported incident categories for others were: violence and aggression (34%), slips, trips and falls (21%) and accidents (18%).
Staff incident rate is 11.3 per 100 members of staff (by headcount) over a rolling 12 month period.
The highest reporting division was Division A with 309 health and safety incidents. Of these, 24% related to accidents.
In the last 12 months, the highest reported RIDDOR category was over 7 day injuries (65%). 65% of RIDDOR incidents were reported to the HSE within the appropriate timescale.
In September 2018, 4 RIDDOR incidents were reported to the HSE:
Over 7 day absence • Tail gate was closed on a staff members hand due to miscommunication.
Dangerous occurrence • Asbestos Insulating Board panel was disturbed. 3 members of staff have potentially been exposed to asbestos.
Specified injury • Patient fall resulting in fractured humerus.
Occupational disease • Occupational dermatitis from wet work.
Appendix – Directorates & Divisions (1st April 2018)
GI Rheumatology MSK Upper GI Digestive ICU/PeriOps Orthogeriatrics Medicine Diseases JF-ICU CSSD Theatres NCCU A Intestinal Lower GI Endoscopy T & O Hand-Plastics Failure ODN (inc MTC) Anaesthetics Pain
Genetics Urology Cancer Labs Imaging Clinical Support HaemOnc Blood Pharmacy Occ Health Onco Plastics Histopathology Virology Radiology B Sciences Outpatients Oncology Nuclear Med Physics Therapies Breast unit Gynae Onc HODS Microbiology Tissue Type medicine /engineering & Dietetics
Acute Medicine GUM Inflammation/ ID Transplant ED Clin Pharm Transplant HPB infection Nephrology Hepatology Acute surgery surgery C Respiratory Medicine Pall care Immunology Allergy DME medicine
Vascular Rehab Ophthalmology Podiatry Cardiovascular – Neuro- ENT/H&N/ Surgery Metabolic Dermatology Oral/maxfax Diabetes/ Medical Neurology science Psychiatry Plastics D Endo Orthotics Haematology Metabolic Neurosurgery Psychology ENT Plastics Stroke medicine Medical Genetics Cardiology
Medical Paediatrics Paediatric Surgery & Critical Care Obstetrics & if andaecology Neonatal Foetal Diabetes/Endo, Acute, ANTS ENT Ophthal Gynaecology E ODN Paed med Maternal Allergy, Resp, Gastro, Neuro, Surgery Medicine Haem/Onc, Rheum, Cardio, PICU NICU Ortho Cleft Obstetrics IVF
51 Integrated Report
Cambridge University Hospitals NHS Foundation Trust
Report to the Board of Directors: 14 November 2018
Agenda item 9a
Title Nurse Safe Staffing
Sponsoring executive director Lorraine Szeremeta, Chief Nurse Lorraine Szeremeta, Chief Nurse Maura Screaton, Deputy Chief Nurse Author(s) Sarah Raper, Roster Support Lead Annesley Donald, Deputy Director of Workforce To provide the Board with the monthly Nurse Safe Purpose Staffing Exception Report. Previously considered by Management Executive, 8 November 2018
Executive Summary The paper sets out the regular nursing and midwifery retrospective staffing report for August 2018 and provides an update on current nurse vacancy levels, including areas of challenge or concern and actions in place.
Improving patient journeys; Strengthening the Related Trust objectives organisation Risk and Assurance Insufficient nursing and midwifery staffing levels Related Assurance Framework BAF ref. 004/18 Entries NHS England & CQC letter to NHSFT CEOs (31.3.14): Hard Truths Commitment regarding the publishing of staffing data. Legal / Regulatory / Equality, NHS Improvement Letter – 22 April 2016. Diversity & Dignity implications? NHS Improvement letter re: CHPPD – 29 June 2018 NHS Improvement – Developing workforce safeguards October 2018 How does this report affect n/a Sustainability? Does this report reference the Trust's values of “Together: safe, Yes kind and excellent”?
Action required by the Board of Directors: The Board is asked to note: • The safe staffing report for September 2018. • Four beds were closed on Lewin ward during September but re-opened on 23 September. • Paediatric RN staffing challenges in ED during September. • The forecast of adult and paediatric ED increasing vacancy rates. • Staffing levels have been increased on N3 and a review is underway. • The impact of the international nurses on the RN actual vacancy factor.
Cambridge University Hospitals NHS Foundation Trust
14 November 2018 Board of Directors Nurse Safe Staffing Lorraine Szeremeta, Chief Nurse
1. Executive Summary
1.1 The Chief Nurse’s Office and Heads of Nursing continue to work together to ensure our wards and departments are safely staffed at Cambridge University Hospitals (CUH). Working closely with divisional and workforce colleagues we continue to look for opportunity for efficiencies within the workforce whilst also monitoring any impact on safety and quality of care.
2. Purpose
2.1 The purpose of this paper is to present the Board of Directors with an overview of nurse staffing capacity for the month of September 2018 in line with the National Institute for Clinical Excellence (NICE) safe staffing and National Quality Board (NQB) standards.
2.2 The report gives an overview of nurse staffing for September 2018 including, actual versus planned hours worked, temporary staffing usage, reports of NICE red flag staffing issues as well as details of care hours per patient day (CHPPD) and cost per care hour (CPCH)
3. Background – National and Local Context
3.1 Since April 2014 all hospitals have been required to publish information about the number of nursing and midwifery staff working on each ward, together with the percentage of shifts meeting safe staffing guidelines. This was in response to the Francis report which called for greater openness and transparency in the health service.
3.2 The Carter report (2016) identified that one of the obstacles to eliminating unwarranted variation in the deployment of nursing and healthcare support workers has been the absence of a single means of recording and reporting how staff are deployed. Care hours per patient day (CHPPD), is the total number of hours worked on the roster (clinical staff), divided by the bed state captured at 23.59 each day. For the purposes of reporting, this is aggregated into a monthly position. CHPPD is now the principal measure of nursing, midwifery and health care support worker deployment and from September 2018, CUH publish data on CHPPD on My NHS and NHS Choices. Data from all hospitals are stored on the model hospital dashboard which allows comparison against our peers to be made.
3.3 October 2018 saw the publication of ‘Developing Workforce Safeguards’ by NHS improvement. Trusts compliance with safer staffing will now be assessed with a triangulated approach which combines evidence based tools (SNCT), professional judgement and outcomes. By implementing the documents recommendations together with strong and effective governance, boards can be assured that workforce decisions will promote patient safety and compliance with regulatory standards. Use of the safer staffing tool, SNCT, and procedure for establishment setting is currently being reviewed at CUH with input from NHS Improvement and reference to current
Board of Directors: 14 November 2018 Monthly Nurse Safe Staffing Exception Report Page 2 of 22
guidance. A revised policy for establishment setting will be tabled at a future Board meeting for discussion and agreement.
3.4 Recruitment and retention of nurses and midwifes remains high on the national agenda. Nationally there are more nurses and midwifes leaving the NMC register than there are joining requiring organisations to develop strategies to build their workforce.
3.5 CUH continues to work closely with local Academic Higher Education Providers Anglia Ruskin University (ARU) and University of Suffolk (UoS) on recruitment to pre- registration nursing programmes. In September 2018, ARU reported to the Nursing & Midwifery Executive Committee at CUH that there was a drop in Adult Nursing applicants. This drop is mitigated by the CUH apprenticeship programme, with 61 recruited this year to date to the Nursing Apprenticeship Pathway (2 + 2 model, Assistant Practitioner Higher Apprenticeship and Pre-Registration Nursing Degree Apprenticeship. CUH are also piloting seven pre-registration nursing students on placement from the University of East Anglia (UEA). There has been an increase in Paediatric pre-registration Nursing applicants, from 20 to 33, who will be on placement at CUH in November.
3.6 CUH has supported 5 staff to undertake Nursing Associate training and they are due to qualify in January 2019. Once qualified, they will be registered with the NMC. There is a task and finish group consisting of Nursing and Workforce colleagues, actively reviewing the role and strategy for Nursing Associates at CUH going forward. A report will be presented to Nursing & Midwifery Executive Committee in November 2018.
3.7 The NMC has reported an 86% increase in the number of nurses and midwife’s joining the NMC register from outside the EU due to changes in processes. The most recent change being that the NMC has removed the requirement of international nurses needing to work for 12 months after achieving their qualification. This change brings applicants from outside the EU into line with many of their EU counterparts. International nurses continue to be part of RN pipeline at CUH.
3.8 At CUH there are currently 52 international nurses awaiting successful completion of OSCE programme. The current success rate is 99% for this group. Unsuccessful candidates, after three attempts, are required to leave the trust due to breach of visa requirements. In September no nurse was required to leave the Trust due to unsuccessful OSCE attempts.
3.9 There are currently a further 52 international (European) nurses awaiting successful completion of English language tests. The pass rate at CUH is 54% at one year (nationally 11-20%). Whilst awaiting successful completion of language tests the recruited European nurses are working as Band 3 HCSW’s, however the uncertainty of when candidates are ready to join the register makes it difficult to predict accurate recruitment pipelines and poses a certain level of risk. From the 52 international nurses awaiting completion of language tests, it is predicted that 11 may not succeed.
3.10 Recruitment of HCSW’s remains a challenge for CUH with a vacancy rate of 28%. Overseas and EU nurses working in a HCSW capacity whilst awaiting NMC registration helps to mitigate this to a vacancy level of 12.7%. This is further mitigated by the large Bank of HCSW’s. Further work is required to help with recruitment of substantive HCSW’s.
3.11 The current RN vacancy rate in August 2018 is 10.17%, which is a slight improvement on August.
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3.12 The current RM vacancy rate in September 2018 is 4.27%. This is a reduction on the August position due to the number of newly qualified midwives joining the organisation.
4. Actual and Planned Staffing Report for August 2018
4.1 Appendix 1 gives an overview of the planned versus actual coverage in hours for the calendar month of September 2018. To ensure that the Board is given sight of the staffing within all areas the planned versus actual staffing hours are included within the relevant divisional table.
4.2 The report includes additional shifts that have been worked due to increased workload (activity, patient dependency and/or acuity) or 1:1 patient supervision (specialling). As the requirement for additional shifts is not static and fluctuates, these shifts are not planned in advance (i.e. when the rota is published), it is possible for a rota to have >100% fill (as seen particularly in the care worker fill within this report).
4.3 Throughout the data monitoring period, for wards with an overall rota fill of <90%, or where the trained nursing rota was <90%, or the ward had been a concern to the Divisional Head of Nursing; an individual written summary is reported. The threshold for reporting these exceptions is not agreed nationally and remains unique to CUH within this report.
4.4 The overall RN/RM fill rate in September was 94.03%
4.5 Seven wards reported <90% fill rate for registered nurses (RN) and 5 wards reported <90% fill rate overall for RN’s and HCSW’s. This is an improving position due to the reduction in number of RN vacancies in the Trust. Further detail analysis and outcome measures are included in the exception report, appendix 2.
4.6 Night shift planned versus actual RN/RM fill for September was 95.9% which is an improvement on the August picture (94.4%). Five wards reported <90% fill rate for RN/RM compared to six in August.
4.7 Trend data is included in charts below.
Chart 1
Number of wards reporting < 90% rota fill Overall < 90% 18 16 RN < 90% 14 HCSW < 90% 12 10 8 6 4 2 0 Sep Oct Nov Dec Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18
Board of Directors: 14 November 2018 Monthly Nurse Safe Staffing Exception Report Page 4 of 22
Chart 2
Overall RN/RM fill RN/M fill
100 95 90 85 80 75 70 65 60 55 50 Sep Oct Nov Dec Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18
Chart 3
Paediatric Rota Fill % RN HCSW 125 Overall 120
115
110
% 105 100
95
90
85 Aug Sep Oct Nov Dec Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18
Board of Directors: 14 November 2018 Monthly Nurse Safe Staffing Exception Report Page 5 of 22
Chart 4
Rosie Rota Fill % RM MSW 105 Overall 100
95
90 % 85
80
75
70 Sep Oct Nov Dec Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18
Chart 5 Adult ED % fill rate
100%
90%
80%
70% Average Reg fill Average unreg fill 60% Overall fill 50%
40% ED Adult ED Adult ED Adult ED Adult ED Adult ED Adult ED Adult ED Adult ED Adult January February March April May June July August Sept
Board of Directors: 14 November 2018 Monthly Nurse Safe Staffing Exception Report Page 6 of 22
Chart 6 Paediatric ED %fill rate 105% 100% 95% 90% 85% 80% 75% Average Reg fill 70% Average unreg fill 65% Overall fill 60% PAED PAED PAED PAED PAED PAED PAED PAED PAED EAU EAU EAU EAU EAU EAU EAU EAU EAU January February March April May June July August Sept
Source: CUH MAPS data.
4.8 Adult Critical Care Units
• John Farman Critical Care Unit – 95.76% RN fill • Neuro Critical Care – 97.77% RN fill
The Critical Care units have consistently remained compliant with Intensive Care Services guidelines (ICS).
4.9 PICU & NICU
The RN fill rate for PICU was 95.99% & NICU was 91.67%. The fill rate for these two areas has improved from August (88%). There were no breaches of PICU or NICU staffing standards in September.
4.10 Emergency Department (ED)
Adult ED had an overall RN fill rate of 92.62 which is better than August (91.88%). Whilst Adult ED staffing was maintained in September the department are reporting a vacancy factor of 34 WTE for October.
Paediatric ED had an RN fill rate of 80% which is worse than previous month of 89%. Provision of paediatric RN cover in ED has been affected as a result of the percentage of paediatric nurse vacancies (38%). Mitigations for this risk are in place including training of adult RN’s in paediatric competencies and by moving paediatric nurses from paediatric ward areas where possible to support. A task group has been set up within the division working on addressing recruitment & retention of adult and paediatric ED nurses. An update on this work will be included in Decembers Board paper.
Board of Directors: 14 November 2018 Monthly Nurse Safe Staffing Exception Report Page 7 of 22
Recruitment of HCSW’s in ED has improved in October. There has been no impact on quality indicators and all shifts in paediatric ED in September were covered by RCN from ED.
5. Operational Exceptions
5.1 Four beds on Lewin ward were closed until 24 September 2018 due to inadequate staffing levels. Staffing has improved on Lewin ward as international nurses have got their NMC registration and staff have returned from long term sickness. There were four beds closed on M4 for refurbishment.
5.2 The Board is asked to note the frequency of using contingency beds. These are beds that require to be opened generally out of hours to accommodate increased capacity. The average number of patients in contingency beds when required was 10 patients per day in September.
5.3 There were four occasions in September when patients were bedded in ED at night due to capacity constraints. On one occasion there were seven, one occasion of three and two occasions of one patient bedded.
5.4 The contingency areas are supported by the bed management bank rota and through the movement of staff from ward areas.
6. Safety and risk
6.1 The trend in Safety Learning Reports (SLRs) completed in relation to nurse staffing is shown in chart below. All incidents continue to be reviewed via the safety and quality processes.
Chart 7 – Incidents reported relating to nurse staffing
Staff Shortage - Nursing Feb 2016 - Sep 2018
Count Mean LCL UCL Linear (Count)
120
100
80
60
40
20
0 Jul 2016 Jul 2017 Jul 2018 Jan 2017 Jan 2018 Jun 2016 Jun 2017 Jun 2018 Oct 2016 Oct 2017 Apr 2016 Apr 2017 Apr 2018 Feb 2016 Feb 2017 Sep 2016 Feb 2018 Sep 2017 Sep 2018 Dec 2016 Dec 2017 Aug 2016 Aug 2017 Aug 2018 Nov 2016 Nov 2017 Mar 2016 Mar 2017 Mar 2018 May 2016 May 2017 May 2018
Board of Directors: 14 November 2018 Monthly Nurse Safe Staffing Exception Report Page 8 of 22
6.2 A daily escalation plan is used in line with the Safer Staffing Policy to mitigate wards with inadequate fill rates, and to ensure support is directed on a shift by shift basis as required in line with patient acuity and activity demands. Maintaining safe staffing continues to compromise the senior sister ability to maintain a supervisory capacity, and includes the Matrons and the Divisional Heads of Nursing supporting the wards clinically over the month.
6.3 Staffing on N3 has been increased to support the ward following an increase in incidents related to care of NIV patients. A full review of staffing numbers and skill mix is underway.
6.4 Movement of staff across wards to support safe staffing can be seen in chart 8 with further detail on Chart 9. It shows that 4299 nursing hours reallocated in the month of September (equivalent to circa. 573 shifts at 7.5 hours).
6.5 The detail of staff movements is reviewed and tracked by the Heads of Nursing; the data is also shared with the ward managers and is managed locally to ensure fairness in terms of staff moving to other areas. Staff moving to other wards does have a negative effect on morale and presents a risk to retention.
6.6 Staff movement has seen a slight reduction this month and as staffing levels increase we should see a reduction in the need to move staff on a shift by shift basis which will help with our plans for staff retention.
Chart 8 - Percentage of staff moved to other areas
% staff movement into alternative ward 1.8 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0 Jul/17 Aug/17 Sep/17 Oct/17 Nov/17 Dec/17 Jan/18 Feb/18 Mar/18 Apr/18 May/18 Jun/18 Jul/18 Aug/18 Sep/18
Board of Directors: 14 November 2018 Monthly Nurse Safe Staffing Exception Report Page 9 of 22
Chart 9
Redeployed staff inbound to wards in hours (includes Substantive and Bank staff who are moved, excludes BM staff) 2500 6000 Div A wards Div B wards Div C wards Div D wards Div E wards Total (on right axis) 5000 2000
4000
1500 3000 Hours 1000 2000
500 1000
0 0 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18
*BM = Bed Management allocation of staff
7. Red Flags
Red flag report 2018 KPI No Jan-18 Feb-18 Mar-18 Q4 Apr-18 May-18 Jun-18 Q1 Jul-18 Aug-18 Sep-18 Q2 Number of wards reporting < 1 90% RN fill 5 8 8 21 13 13 12 38 12 9 7 28 Number of wards reporting SLRs relating to medicine 2 administration 31 27 26 84 23 32 26 81 31 27 22 80 Number of wards with compliance with intentional 3 rounding < 90% 2 2 3 7 2 1 1 4 2 0 1 3 Number of wards reporting > 15% of their shifts with > 25% 4 down in RN cover 4 8 11 23 6 6 6 18 14 38 30 82 Number of ward completing SLRs regarding staffing 5 levels/workload 21 19 26 66 18 13 16 47 17 22 14 53 Number of wards reporting an avoidable patient fall resulting in 6 harm 24 17 19 60 23 20 18 61 20 25 21 66
Number of wards reporting an avoidable hospital acquired 7 pressure ulcers (≥ grade 2) 5 4 9 18 6 5 4 15 4 4 8 16 Number of ward < 95% compliance with vital signs completed at the frequency 8 indicated 2 2 3 7 2 4 5 11 5 3 7 15 Total number 94 87 105 286 93 94 88 275 105 128 233
7.1 This will be monitored via the Patient Safety Group.
7.2 There was an increase in the number of wards reporting where patients have developed pressure ulcers. A quality improvement initiative in relation to pressure ulcers is being led by the tissue viability team. All incidents are investigated at ward and department level and any concerns escalated as appropriate.
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8. Care Hours per Patient Day (CHPPD) & Cost per Care Hours (CPCH)
8.1 The CHPPD metric is calculated by adding the hours of registered nurses to hours of nursing assistants and dividing the total by every 24 hours of inpatient admissions. NHS Improvement began collecting care hours per patient day formally in May 2016 as part of the Carter Programme. All trusts are required to report this figure externally
8.2 The overall CHPPD for the month of September was 9.66. This is a slight decrease from August (9.92).
8.3 Chart 10 shows how we compare to our peers within Shelford and to the National average (note this model hospital data is a month in arrears).
8.4 CHPPD at CUH in August was 9.92 with the Shelford group average at 9.0. It is noted that the CHPPD for HCSW’s at CUH has increased since June 18. This is thought to be due to increased demand for specialling. This could explain the increase CHPPD at CUH in comparison to the Shelford group.
8.5 Cost per care hour (Chart 11) shows CUH as being closely aligned to the Shelford group and national median for August.
Chart 10
Care Hours per Patient Day - Total Nursing & Midwifery Staff 10.3
9.8
9.3
8.8
8.3
7.8
7.3
CHPPD CUH CHPPD National Median CHPPD Shelford group
Board of Directors: 14 November 2018 Monthly Nurse Safe Staffing Exception Report Page 11 of 22
Chart 11
Cost per Care Hours - Total Nursing & Midwifery Staff £27.50
£27.00
£26.50
£26.00
£25.50
£25.00
£24.50
£24.00
CUH National Median Shelford group
9. Forecast of Nurse Staffing Position
Chart 12
35
30 Vacancy rates % for RN and HCSW’s Vacancy Rate % 25 Nurse
20 Vacancy Rate % 15 HCA
10
5
0
Board of Directors: 14 November 2018 Monthly Nurse Safe Staffing Exception Report Page 12 of 22
9.1 Chart 12 shows the nurse vacancy rate for both RNs and HCSWs. The vacancy rate for RN’s continues to fall however the HCSW vacancy rate remains similar to previous months (28%). Appendix 3 provides detail of nurse recruitment numbers via source (newly qualified, international recruitment etc. against the number of Band 5 leavers in month. The confirmed vacancy rate as at September 2018 was 12.7% with a drop anticipated in October to 8.6%. However, it must be noted that the number of international nurses awaiting NMC registration and, therefore, working as HCSW rather than nurses (168 in September) does impact on the overall actual and available RN’s. Therefore excluding the international recruits without registration the actual RN vacancy rate for September is 22%.
Chart 13
WTE gap RN and HCSW 3000
2500
2000 Establishment WTE Nursing 1500 Establishment WTE HCA 1000 In Post WTE Nursing 500 In Post WTE HCA
0 Jul-16 Jul-17 Jul-18 Jan-17 Jan-18 Sep-16 Sep-17 Sep-18 Nov-16 Nov-17 Mar-17 Mar-18 May-17 May-18
9.2 Chart 13 shows the WTE gap yet to be filled for both RNs and HCSWs. There are 467 Nurses in the pipeline (those who have been made offers); 437 international and 20 from the UK. In line with the proactive focus on recruitment, the actual vacancy rate and trajectory of new starters is an improving picture for RN’s.
9.3 The current vacancy rate for HealthCare Support Workers (HCSW) is currently circa 28% which is an improving picture. International recruits who have not yet secured their registration are rostered as substantive HCSWs, which reduces the impact to circa 8%. A focused recruitment and retention plan for HCSW is in place; however substantive recruitment to these vital roles remains challenging.
9.4 Appendix 3a provides detail on the forecasted position in relation to the number of RN vacancies based on FTE and included UK and international recruits up to March 2019. Numbers based on those interviewed and offered positions. Expected numbers of recruits from international campaigns that have been planned but not yet implemented are also included.
10. Temporary Staffing
Bank Fill Rate
10.1 The Trust’s Staff Bank continues to support the clinical areas with achieving safe staffing levels. During September, the total number of requests for RN Bank shifts
Board of Directors: 14 November 2018 Monthly Nurse Safe Staffing Exception Report Page 13 of 22
was 8,355 (3-30 September 2018) with an average fill rate of 72% (5,975 shifts filled with 2,380 unfilled). This is an increase of 3% over average fill rates in August. The total number of requests for HCSW Bank shifts was 7,966 (3-30 September 2018) with an average fill rate of 82% (6,554 shifts filled with 1,412 unfilled). This is an equivalent average fill rate to August.
Chart 14
RN Bank fill rate
HCSW Bank fill rate
Board of Directors: 14 November 2018 Monthly Nurse Safe Staffing Exception Report Page 14 of 22
Agency usage
10.2 We continue with the use of agency nurses to support safe staffing across the Trust.
10.3 In September the total number of hours worked by agency nurses was equivalent to 32.94 WTE based on total number of hours worked, which is a small increase over August’s figure.
10.4 In theatres agency Operating Department Practitioners (ODPs) were used to support lists equating to 14.68 WTE based on the number of hours worked. ODPs are classified as Allied health professionals but important to note within this report.
10.5 In line with increased permanent recruitment, we undertook a review to ensure continued agency RN use in agreed areas was still required, and this will continue to be monitored on an on-going basis. We have also provided the Operational Matrons with details of where agency RNs are generally placed to work to assist them with the appropriate placement of agency RNs when booked, and therefore reallocated, via Bed Management in line with patient safety and quality of care.
11. Recommendations
11.1 The Board of Directors is asked to note:
• The safe staffing report for September 2018. • Four beds were closed on Lewin ward during September but re-opened on 23 September. • Paediatric RN staffing challenges in ED during September. • The forecast of adult and paediatric ED increasing vacancy rates. • Staffing levels have been increased on N3 and a review is underway. • The impact of the international nurses on the RN actual vacancy factor.
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Appendix 1: Actual and Planned Staffing Report (September 2018)
The data used within this report is pulled retrospectively from our Healthroster, and includes the % of hours (registered nurse and care staff) that were filled against the planned (baseline) number of hours (required number of rostered hours for the calendar month. This data set is the same as our national submission to UNIFY.
Please note, areas with > 100% fill is due to additional hours filled to care for patients who require 1:1 supervision (specialling). Greater than 100% does not mean that all planned hours were filled, just that once totalled the actual hours planned and unplanned are greater than simple planned hours.
Division A Day Night Sep-18
Night - Night - Total % hours Day - Average Day- Average RN/RM Care staff average fill average fill filled Main Speciality fill rate RN / fill rate care average average fill rate RN / rate care (registered RM (%) staff (%) fill rate rate RM (%) staff (%) and care staff)
C8 Trauma and Orthopaedics 90.4% 128.6% 90.2% 106.4% 90% 119% 101% D8 Trauma and Orthopaedics 94.4% 159.9% 96.7% 151.2% 95% 156% 119% IDA Intermediate Critical care Unit 101.0% 152.6% 100.5% 145.4% 101% 150% 109% JOHN FARMAN ICU Critical Care 95.9% 98.2% 95.7% 96.8% 96% 98% 96% L2 23 hour Stay Day Surgery 87.0% 80.9% 92.7% 123.9% 88% 85% 87% L4 Colorectal Surgery 94.0% 117.4% 97.5% 117.4% 95% 117% 103% M4 Gastroenterology 93.2% 132.3% 96.0% 167.2% 94% 148% 112% NCCU Neuro Critical Care 97.9% 110.8% 97.7% 113.1% 98% 112% 99% OIR Overnight Intensive Recovery 100.0% 100% 100% Overall divisional fill 95% 121% 97% 128% 96% 123% 102%
Division B Day Night Sep-18
Total % Day - Day- Night - Night - RN/RM Care staff hours filled Main Speciality Average fill Average fill average fill average fill average fill average (registered rate RN / RM rate care rate RN / RM rate care rate fill rate and care (%) staff (%) (%) staff (%) staff)
C10 Haematology 98.9% 122.9% 89.0% 99.1% 95% 110% 99% C9 Teenage Cancer Trust 98.9% 96.8% 96.0% 90.0% 98% 93% 96% D6 HAEM Haematology 84.1% 211.7% 85.9% 138.7% 85% 190% 103% D9 Oncology 91.7% 146.7% 92.0% 97.0% 92% 123% 103% Overall divisional fill % 93% 143% 91% 99% 92% 122% 101%
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Division C Day Night Sep-18
Total % Day - Night - Day- Average Night - average RN/RM Care staff hours filled Main Speciality Average fill average fill fill rate care fill rate RN / average fill average (registered rate RN / RM rate care staff staff (%) RM (%) rate fill rate and care (%) (%) staff)
AME (C4) Geriatric Short Stay Medicine 96.2% 146.0% 96.2% 193.8% 96% 163% 121% C5 Nephrology 92.9% 138.1% 92.6% 168.9% 93% 149% 114% C6 Geriatric Medicine 93.9% 144.7% 98.2% 183.2% 96% 160% 124% C7 Hepatobilary 92.0% 109.3% 96.3% 108.6% 94% 109% 99% D10 Infectious Diseases 94.9% 104.3% 100.0% 100.9% 97% 103% 99% D5 Hepatology 92.9% 135.9% 91.8% 153.0% 92% 143% 109% D7 General Medicine 89.9% 178.8% 98.6% 193.3% 93% 185% 124% F&G5 Transplant and HDU 93.3% 100.7% 96.3% 102.8% 94% 102% 96% F4 Geriatric Medicine 94.5% 169.0% 97.7% 147.0% 96% 159% 120% G3 Discharge Unit Geriatric Medicine 95.5% 132.1% 98.9% 202.7% 97% 156% 122% G4 Geriatric Medicine 92.4% 153.8% 99.7% 233.2% 95% 180% 131% G6 Geriatric Medicine 95.3% 139.0% 101.1% 191.3% 97% 157% 122% MDU Medical Decisions Unit 88.2% 104.3% 86.0% 117.2% 87% 110% 96% MSEU Medical Emergency Short Stay Unit 86.9% 175.7% 100.0% 147.1% 92% 161% 110% N2 Infectious Diseases 87.5% 109.7% 100.8% 121.1% 93% 114% 103% N3 Respiratory Medicine 93.3% 96.8% 96.0% 111.7% 95% 102% 97% Overall divisional fill % 92.1% 130.8% 96.3% 150.9% 94% 139% 110%
Division D Day Night Aug-18
Night - Night - Total % hours Day - Average Day- Average RN/RM Care staff Main Speciality average fill average fill filled fill rate RN / fill rate care average fill average fill rate RN / RM rate care staff (registered RM (%) staff (%) rate rate (%) (%) and care staff)
A3 DoSA 90.4% 114.9% 92.8% 92.8% 91% 107% 98% A4 Neurology 90.3% 225.7% 95.0% 200.3% 92% 214% 136% A5 Neurosurgery / oncology 94.7% 189.4% 95.5% 204.9% 95% 196% 138% D6 Neuro Neurology 88.6% 194.7% 92.7% 291.3% 90% 222% 143% F6 Diabetes and General Medicine 98.6% 128.9% 95.3% 195.0% 97% 151% 120% J2 Neuro Rehabilitation 90.1% 267.7% 95.8% 176.9% 93% 223% 154% K3 Cardiology incl. CCU 97.9% 105.6% 98.3% 132.6% 98% 112% 101% L5 Vascular Surgery 97.5% 119.4% 98.3% 116.8% 98% 118% 105% LEWIN Stroke Rehabilitation 91.6% 91.9% 97.8% 100.7% 94% 95% 94% M5 ENT & Ophthalmology 94.7% 120.2% 91.9% 119.6% 94% 120% 103% R2 Acute Stroke Unit 93.4% 121.7% 97.8% 163.6% 95% 136% 107% Overall divisional fill % 94.2% 154.1% 95.9% 161.9% 95% 157% 118%
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Maternity Day Night Sep-18
Day- Night - Total % hours Day - Night - Average average RN/RM Care staff filled Main Speciality Average average fill fill rate fill rate average average (registered fill rate RN rate RN / care staff care staff fill rate fill rate and care / RM (%) RM (%) (%) (%) staff)
Daphne Gynaecology incl. Oncology 97.9% 97.8% 101.6% 101.7% 99% 99% 99% Delivery Unit Obstetrics 87.7% 85.2% 85.4% 84.1% 86% 85% 86% Lady Mary Ward Obstetrics 89.0% 90.8% 91.5% 93.6% 90% 92% 91% RBC Obstetrics 94.9% 93.4% 92.7% 110.0% 94% 101% 95% Sara Obstetrics (antenatal) 85.0% 85.9% 87.5% 82.2% 86% 84% 85% Overall divisional fill % 90% 90% 89% 92% 90% 91% 90%
Childrens Day Night Sep-18
Day- Night - Total % hours Day - Night - Average average RN/RM Care staff filled Main Speciality Average average fill fill rate fill rate average average (registered fill rate RN rate RN / care staff care staff fill rate fill rate and care / RM (%) RM (%) (%) (%) staff)
C2 Paediatric Oncology 92.3% 99.3% 96.4% 80.9% 94% 95% 94% Paediatric medicine & surgery C3 80.8% 98.1% 92.7% 74.4% 85% 94% 87% (babies) Charles Wolfson Ward Mother and Babies 100.2% 122.0% 100.3% 97.9% 100% 113% 105% D2 Paediatric medicine & surgery 86.9% 96.8% 90.1% 90.8% 88% 94% 90% F3 Paediatric DoSA 97.3% 142.1% 65.4% NA 92% 137% 108% Neonatal Unit Neonatal Critical Care 91.3% 108.2% 92.0% 99.5% 92% 105% 93% PICU Paediatric Critical Care 95.4% 97.7% 96.6% 94.3% 96% 96% 96% Overall divisional fill % 91% 108% 93% 93% 92% 103% 94%
Emergency Department Day Night Sep-18
Day- Night - Total % hours Day - Night - Average average RN/RM Care staff filled Main Speciality Average average fill fill rate fill rate average average (registered fill rate RN rate RN / care staff care staff fill rate fill rate and care / RM (%) RM (%) (%) (%) staff)
CDU Clinical Decisions Unit 89.1% 99.4% 94.1% 94.5% 91% 97% 94% EAU3 Assessment Assessment 91.3% 86.4% 91% 86% 90% ED Adult ED 91.4% 94.2% 94.0% 0.0% 93% 55% 82% ENP ED 97.9% 98% NA 98% Paed ED ED 80.3% 93.1% 78.2% NA 80% 93% 82% Overall divisional fill % 91% 94% 92% 21% 91% 67% 84%
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Appendix 2: Staffing Exception report (2018)
Throughout the data monitoring period, wards with an overall rota fill of <90% or where the trained nursing rota was <90%, or the ward had been a concern to the Head of Nursing for any other reason, an individual written summary is reported. The nursing KPIs are analysed and used to inform the report.
Sep-18 Report from the Divisional Head of Nursing Division A Speciality % fill registered % fill care staff Overall filled % Analysis of gaps Impact on Quality / outcomes Actions in place 14.48% RN unavailbility and sickness. 33% vacancy FFT response rate remains good with positive Daily review of staffing by Matron and DHON and ops L2 Day surgery 88% 85% 87% HCSW. Adverts currently out. feedback.100% recommender score. team. Escalation against Theatre numbers.Staff moved from recovery / and other division A areas to support. Division B Speciality % fill registered % fill care staff Overall filled % Analysis of gaps Impact on Quality / outcomes Actions in place 30% of staff in an RN post do not currently have RN Patients needing chemotherapy are being streamed Assigned 1 WTE agency RN. Recruitment - targetting registration. 75% of RNs in the establishment have elswhere, this is sub-optimal care. Turnover is high. RNs with post-registration experience. Frequent moves D6 haem haematology 85% 190% 103% been qualified less than one year. within Division to even out risks. Band 7 to maintain supervisory time. Use of CNSs to support care provision. Skill mix issues within the RN establishment. 66% HCA Concern for chemotherapy, specialsit and end of life Recruitment - targetting RNs with post-registration C9 TYA 98% 86% 95% vacancy. 25% of staff in a RN post do not currently care as patients cannot be streamed to another area. experience. Frequent moves within Division to even out have RN registration. risks. Band 7 to maintain supervisory time. Division C Speciality % fill registered % fill care staff Overall filled % Analysis of gaps Impact on Quality / outcomes Actions in place 32 WTE vacancies (RN) and 30.4% unavailability. 1.64 Elements of safety checks are not fully compliant but Bank enhancments in place and will be reviewed to see WTE B7 on secondment, 3 RNs supporting Paeds ED. have mostly improved from the previous month. No if they need to be increased. Recruitment meeting held Accident & HCA vacancy is 33.8% other areas of concern with nursing KPIs to plan a focussed campaign across all ED areas. Staff ED Adult 93% 55% 82% Emergency allocated from bed management and divisions to mitigate high risks on a shift by shift basis.
8.35 WTE vacancies (RN) and 35% unavailability. HCA Recent meeting with recruitment and Paeds to look at vacancies are 1.42%. There is a local and naional recruitment campaigns. Risk assessment in place with recruitment issue in paediatric ED nursing generally. mitigation to cover from paeds wards or recovery areas in the first instance. Bank enhancements in place. Agency CVs requested and currently being Accident & Paed EAU 80% 93% 82% reviewed for possible start dates in November. ED Emergency adult nurses with PILS skills identified to move and support roster. Risk assessment added this month to reflect the vulnerable staffing position with RSCNs and potential to not have cover oneach shift. Chief Nurse office aware of plans. 29.59% vacancy (RN) within a very small Bank shifts filled by own staff. Division C bleep holder Arrivals & establishment. moves staff from within division when needed. Discharge Lounge 89% 73% 81% Discharge Discharge lounge will close early if it cannot be safely staffed. 2.36 WTE vacancies (RN) and 30.9% unavailability Elements of safety checks are not fully compliant and Number of additional duty hours allocated for wrong GENERAL with 3 nurses on secondment and 3 nurses working have worsened from last month. Only 1 hand hygiene reason that need to be utilised for specialling shifts MDU 87% 110% 96% MEDICINE without PIN's. HCA vacancies mitigated by nurses audit submission in the month but no other areas of out to bank. Division C bleep holder moves staff from working in HCA B3 roles. concern from nursing KPIs. within division when needed.
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Division E Speciality % fill registered % fill care staff Overall filled % Analysis of gaps Impact on Quality / outcomes Actions in place Current shortfall 6.2 WTE RNc, total establishment gap Positive patient safety metrics and improvements in of 22%. This will improve in October with newly most NQM. Minimal complaints or concerns raised. Daily staffing review within the service. Enhanced C3 PAEDIATRICS 85% 94% 87% qualified intake, resulting in 2.2 WTE vacancy. Plans for staff support due to prolonged period of staff rates for bank. shortage. Current shortfall of 11.5 WTE RNc, total establishment Positive patient safety metrics and maintained good gap of 34%. This will improve slowly from October results in most NQM. Complaints increased Daily staffing review within the service. Enhanced D2 PAEDIATRICS 88% 94% 90% with 6.1 WTE vacancies. Appointment to 3 band 6 concerning nursing care. Plans for staff support due to rates for bank. Appointment of PD nurse for general posts to support teams. Junior skill mix with 8 new prolonged period of staff shortage paediatrics to support team starters. Current postion for vacancies for midwives at 6.92 Small improvements in NQM. Safety checks audits stll Daily review of staffing - results sent to operational WTE. No MCA vacancies . Recruitment on going. Junior need some work on them. centre. Extra payments for bank up until the end of Delivery Unit Delivery Unit 86% 85% 86% skill mix - 10 WTE started in October. October. New starters will then not be supernumerary. Head of Midwiferyis arranging weekly meetings to review rotas. Current postion for vacancies for midwives at 6.92 small improvements in NQM. Safety checks audits stll Daily review of staffing - results sent to operational WTE. Midwives. No MCA vacancies. Recruitment on need some work on them centre. Extra payments for bank up until the end of Sara Ward Obstetrics 86% 84% 85% going .Junior skill mix 10 wte started in October October. New starters will then not be supernumerary. Head of Midwifery is arranging weekly meetings to review rotas.
SCN = Senior Clinical Nurse FFT = Friends and Family Test ST = Safety Thermometer NQMs = Nursing Quality Metrics NMC = Nursing and Midwifery Council ONP = Overseas Nurses Programme WTE = Whole Time Equivalent
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Appendix 3a
Band 5 RN position based on predictions and established FTE with additional capacity added in
Total New ESR Actual Vacancy rate based on Staff in post Month UK Exp. UK NQ EU Overseas Starters Leavers FTE Establishment required additional agreed needs FTE FTE FTE FTE FTE not current established
Apr 18 6 12 9 39 64 18 1,636 1,895 1,895 13.7%
May 18 9 1 7 19 36 25 1,638 1,900 1,900 13.8% Jun 18 3 1 7 25 36 17 1,633 1,899 1,899 14.0% Jul 18 7 0 8 36 51 26 1,652 1,911 1,911 13.6%
Aug 18 5 0 11 26 42 17 1,670 1,913 1,913 12.7% Sep 18 14 13 10 12 49 35 1,669 1,913 1,913 12.7% Oct 18 5 65 12 20 102 23 1,748 1,913 1,913 8.6%
Nov 18 6 4 6 18 34 31 1,751 1,913 1,938 9.6% Dec 18 7 0 7 23 37 38 1,750 1,913 1,938 9.7% Jan 19 6 0 0 23 29 23 1,756 1,913 1,938 9.4%
Feb 19 9 2 2 24 37 22 1,772 1,913 1,938 8.6%
Mar 19 5 9 2 26 42 22 1,792 1,913 1,938 7.5%
TOTAL 82 107 81 291 559 297 1,792 1,894 1,938 7.5%
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Appendix 3b
Likely dates when international nurses will have NMC registration
Vacancy rate Productive Productive ESR Actual UK UK Leavers based Month EU Overseas Starters Staff in Establishment required Exp. NQ FTE on Productive FTE post FTE FTE FTE actual starter FTE leaver variance Apr 18 6 12 3 11 32 18 1,436 1,895 1,895 24% 14 May 18 9 1 2 32 44 25 1,455 1,900 1,900 23% 19 Jun 18 3 1 1 14 20 17 1,467 1,899 1,899 23% 3 Jul 18 7 0 4 22 32 26 1,476 1,911 1,911 23% 6 Aug 18 5 0 4 31 40 17 1,487 1,913 1,913 22% 23 Sep 18 14 13 4 15 46 35 1,501 1,913 1,913 22% 11 Oct 18 5 65 5 20 95 23 1,573 1,913 1,913 18% 72 Nov 18 6 4 4 29 43 31 1,585 1,913 1,938 18% 12 Dec 18 7 0 4 21 32 38 1,579 1,913 1,938 19% -6 Jan 19 6 0 5 10 21 23 1,577 1,913 1,938 19% -2 Feb 19 9 2 5 16 32 22 1,587 1,913 1,938 18% 10 Mar 19 5 9 6 14 35 22 1,600 1,913 1,938 17% 13 TOTAL 82 107 48 235 472 297 1,600 1,894 1,938 17% 176
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Cambridge University Hospitals NHS Foundation Trust
Report to the Board of Directors: 14 November 2018
Agenda item 9.5 Title Finance Report Sponsoring executive director Paul Scott, Chief Finance Officer Author(s) Tim Glenn, Deputy Director of Finance To update the Trust Board on the financial Purpose position of the Trust in 2018/19. Previously considered by n/a
Executive Summary The Trust has, at the end of month 6, a year to date deficit in line with its financial plan. This is mainly due a clinical income position which is £6.4m favourable year to date, offset by overspends mainly in non-pay areas.
Related Trust objectives Strengthening the organisation The paper provides assurance on the Risk and Assurance delivery of the Trust’s financial plan for 2018/19. Related Assurance Framework Entries BAF ref: 009/18 Legal implications/Regulatory requirements n/a How does this report affect Sustainability? n/a Does this report reference the Trust's values of “Together: safe, kind and n/a excellent”?
Action required by the Board of Directors The Board is asked to note the report of the Chief Finance Officer.
Cambridge University Hospitals NHS Foundation Trust
14 November 2018 Board of Directors Finance Report Paul Scott, Chief Finance Officer
1. Introduction/Background
1.1 This report outlines the Trust’s financial position at the end of month 6 of the financial year 2018/19.
2. Month 6 – September 2018
2.1 The Trust posted a deficit of £5.8m in month 6, which is £0.8m favourable to the Trust’s budget. This result does not include any Sustainability and Transformation Funding (STF) income as the Trust has not been able to agree a control total with NHS Improvement.
2.2 Clinical income was £0.6m adverse in month 6, but remains favourable year to date (with a favourable variance of £6.4m). The year to date position reflects windfall gains following the successful conclusion of negotiations in relation to contract queries from 2017/18.
2.3 Year to date pay expenditure stands at £245m which is £2.2m adverse to plan. This is mainly due to the pay award for Agenda for Change (AfC) staff which came into effect on 1 April 2018 and to increased use of agency and bank staff.
2.4 Year to date non-pay expenditure is £138.2m, which is £4.1m higher than budget. This overspend includes a £1.5m non-recurrent cost incurred in relation to energy recharges.
2.5 The Trust’s year to date deficit stands at £51.6m, which is on plan.
3. Recommendation
3.1 The Board of Directors is asked to note the report of the Chief Finance Officer.
Board of Directors: 14 November 2018 Finance Report Page 2 of 2
Cambridge University Hospitals NHS Foundation Trust
Report to the Board of Directors: 14 November 2018
Agenda item 10 2018-19 Workforce Influenza Vaccination Title Programme Sponsoring executive director David Wherrett, Director of Workforce Giles Wright, Head of Service – Health and Author(s) Wellbeing To receive a summary of the 2017/18 Purpose programme and the plan for this season’s programme. Previously considered by Management Executive, 1 November 2018
Executive Summary This paper sets out the performance and learning from last season’s workforce influenza vaccination programme and the approach for the current season (2018/19). NHS England provided guidance to all trusts in September 2018 (see Appendix 1). This paper responds to that guidance and proposes specific actions.
Improving patient journeys; Strengthening Related Trust objectives the organisation The paper provides assurance on the Risk and Assurance Trust’s plans for staff flu vaccination. Related Assurance Framework Entries n/a Legal / Regulatory / Equality, Diversity & Regulatory – National mandate and CQUIN. Dignity implications? How does this report affect Sustainability? n/a Does this report reference the Trust's values of “Together: safe, kind and n/a excellent”?
Action for the Board of Directors The Board is asked to note the report and the guidance from NHS England and endorse the proposed actions set out in Section 4 of the paper.
Cambridge University Hospitals NHS Foundation Trust
14 November 2018 Report to the Board of Directors 2018-19 Workforce Influenza Vaccination Programme Giles Wright
1. Introduction/Background
1.1 CUH has for many years provided the influenza vaccination to its workforce. Since the introduction of the CQUIN connected to this programme in 2016, and the additional investment in this annual campaign, uptake across the Trust has increased significantly. The programme is increasingly high profile and has energy and participation across a broad spectrum of specialities and corporate functions.
1.2 In 2016/17 CUH saw a ‘step-change’ in the way in which it resources and delivers the campaign, and achieved an uptake of 75.4% of frontline workers receiving their vaccination. This change set the tempo for subsequent campaigns. Last year (2017/18) CUH achieved 84.3% of frontline workers choosing to receive the vaccination, equating to approximately 6,600 colleagues. The CQUIN target of 70% uptake was achieved by week five of the launch of the campaign. CUH was awarded ‘Best Flu Fighter Team’ by NHS Employers at the national awards ceremony, being recognised for the multi-disciplinary approach to the planning, delivery and the strength of commitment and engagement from the organisation.
1.3 CUH finished the programme with the highest uptake among the Shelford Group of teaching hospital trusts. It should be recognised that the programme is complex, run at significant pace – a key component to success - and requires investment. This year (2018/19) the CQUIN target is 75%.
1.4 In September 2018, NHS England sent a guidance letter to all Chief Executives of NHS trusts and NHS Foundation trusts (see Appendix 1). The letter outlines NHS England’s ambition: “… for 100% of healthcare workers with direct patient contact to be vaccinated.” The guidance contains specific recommendations formed from NICE guidelines and attributes of other successful programmes nationally. In this letter, boards of directors are asked to specifically assess the position of their trusts against a best practice management checklist. A number of the checklist recommendations are already incorporated within the Trust’s approach and plan. The remainder are discussed further in Section 4 of this paper.
2. 2017/18 campaign performance and learning
Uptake
2.1 Table 1 summarises the uptake data submitted to Public Health England in February/March 2018. It should be noted that headcounts are specifically for those deemed to be ‘frontline – with direct patient care’. The challenges associated with this are described below.
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Table 1: 2017/18 uptake
No. Doses % Doctors Nurses (Qualified) Other All Involved given doses doses given prof. support with given qualified staff direct staff (direct patient doses care) care given doses given 7,946 6,696 84.3 1,012 2,876 1,664 1,144 (78.8%) (97.2%) (67.9%) (91.4%)
Successes
2.2 Accessibility – the CUH flu team (through the support of a CUH-commissioned external vaccination provider) was able to provide clinics centrally 11 hours a day for six weeks.
2.3 Engaged local vaccinators delivered over 1,000 vaccines and drove momentum at a ward/department level.
2.4 Speed of uptake/momentum – it is known from trusts who achieve high levels of uptake that momentum is a key factor. The pandemic in the southern hemisphere certainly added to the urgency for members of staff last year. Also, the high profile nature of the CUH programme/campaign drives great footfall through the clinics early in the season.
2.5 High visibility (including a great communications and programme brand) – CUH is fortunate to have an engaged Communications team who are core members of the flu team each year.
2.6 Incentives – as discussed further in this paper, incentives did resonate with the workforce and created opportunities for communications and engagement which boosts momentum, particularly towards the end of the first six week period.
2.7 Support at all levels – CUH has excellent support from all levels and groups within the organisation (and partner organisations including Compass Group).
Challenges
2.8 The primary challenge is around data capture, categorisation and live reporting.
2.9 In the context of vaccinating 250-300 members of staff daily through a mix of centrally-managed clinics and a team of local vaccinators (approximately 60 people) across multiple locations, the capture and matching of data accurately by staff group, role and location details at pace is challenging. Not least because individuals complete paper consent forms, to varying quality, which then has to be matched with Trust headcount by staff groups and the Occupational Health database ‘Cohort’.
2.10 Public Health England provides guidance on which staff groups/professions should be included in the denominator. PHE guidance categories of staff groups do not directly correspond with ESR workforce groups. Employers have to make a judgement on grouping and the level of patient contact each role may or may not
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have. Then, as completed forms are received in volume, the CUH flu team have to manually sort and again match to the denominator categories using best judgement. The final stage is then for all the forms to be entered onto ‘Cohort’, a separate Occupational Health electronic patient record system. This is a time consuming, manual process and therefore has a lead time. Only once this part of the process is complete can reports be run for individual departments, wards, etc. An example of the complexity is illustrated here:
“[Denominator] Also includes clerical & administrative staff and maintenance & works staff working specifically in clinical areas but not clerical & administrative staff - maintenance and works staff working in areas such as laundry or staff working in IT”
2.11 One example would be clerks or secretaries. Some clerks, such as ward clerks, are based in clinical areas and would be ‘included’. Others are in central functions and not permitted to be included under PHE guidance. Interpreting this level of detail and making the necessary judgement is extremely difficult based on the information available and with complexity of CUH. While every effort is made to ensure accuracy of recording it should be noted that the process has multiple possible variables.
2.12 Public Health England guidance states that staff bank members should be included if they work one or more shifts within the vaccination period. This would be incredibly difficult and time consuming to calculate in a practical way. Also, a large portion of our staff bank nursing colleagues are permanent staff. As such, CUH does not include staff bank, honorary contract holders or volunteers within either the denominator or uptake. CUH does of course vaccinate all who work for CUH in any capacity. Adjustment also has to be made during the campaign to allow for joiners to and leavers from the Trust.
2.13 The nature of the virus and its ability to potentially spread within all areas of the hospital does not of course discriminate against members of staff who undertake particular roles. The primary aim should be to vaccinate as many of the workforce as possible, especially given that approximately 50% of us could be carrying and transmitting the influenza virus and be asymptomatic.
Key learning from previous programme
2.14 Essentially, the key learning has been to continuously build on the model created in 2016. Managing the programme as a defined project with its own budget, resource allocation, MDT and focus within the Trust’s plans has enabled its successful performance. Logistics and mobilisation is always a challenging phase and each year new issues present themselves.
2.15 This year (2018/19) there was a European shortage of (one brand of) the vaccine leading up to the programme start date. Last year CUH experienced difficulties with fridge storage prior to go-live. The CUH flu team acknowledges and reflects on each of these detailed issues and include them in planning for the subsequent season.
2.16 Incentives such as a free pen and weekly prize draw undoubtedly led to engagement among colleagues. The pens and badges, etc. were visible in Trust meetings and daily work life. The investment for the peer-to-peer publicity this generated was minimal.
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2.17 Being able to operate 11 hours a day (central clinics) within the concourse also had a significant impact on uptake and the speed of uptake.
2.18 Off-campus teams and facilities – working with local vaccinators, the OH nursing team and neighbouring trusts, CUH hopes to improve the ‘reach’ into these groups of CUH staff. This aspect does present a communication and resourcing challenging. However, it is not insurmountable.
3. 2018/19 plan and current performance
3.1 Table 2 sets out the key campaign phases for 2018/19.
Table 2: 2018/19 campaign phases
Phase When What Who 1 April-May Planning and Flu team concept design 2 May-Sep Mobilisation and Flu team (inc. local preparedness vaccinators training and PGD draft and signoff) 3 Oct-Nov (first 6 Programme live – Flu team, external weeks) Central clinics and vaccinators and local vaccinators local vaccinators (from week 2) 4 Mid Nov* Evaluate progress. Flu team, local Continue with local vaccinators and vaccinators and OH OH nursing team nursing team to (external support target higher risk at additional cost if and hard to reach required) areas. 5 Dec-Feb 2019 Continue progress Flu team et al and final reporting 6 March Close down, Flu team et al evaluate and celebrate successes *additional element proposed for this year (section 4.2)
3.2 This season (2018/19) there is a different vaccination protocol for those aged 65+. In February/March 2018 the CUH flu team/OH service had to make a decision about how the two vaccination protocols would be managed, given the complexity of our programme and delivery model.
3.3 It was decided that having two vaccines in circulation could pose a risk. Given that the vaccine is available free of charge to all in the 65+ age group via their GP, it was felt it was safest and most appropriate for those in our workforce aged 65 and over (135 members of staff) to receive their vaccine elsewhere and report to the Trust once they had had it. The CUH OH service wrote to the individuals affected to explain the reasoning and offer advice on how and where to receive the vaccine. The CUH flu team will, however, continually review this during the campaign and if uptake becomes an issue in this community there is the option to provide the alternative protocol via pre-booked OH clinics.
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3.4 In addition to leading the CUH workforce flu vaccination programme, the OH Occupational Health and Wellbeing team also supports the delivery of the flu vaccination programme to Royal Papworth Hospital and West Suffolk NHS Foundation Trusts.
4. Specific approach in relation to NHS England guidance
4.1 CUH has had an ever increasing focus on vaccinating its workforce against influenza over recent years. CUH seeks to have a culture where all members of its workforce (for whom the vaccine is not contraindicated) take-up the vaccination. As part of the continual improvement in vaccination rate, it is proposed that attention is paid to the following measures, while maintaining the positivity associated with the campaign and its brand. A further step will be to better utilise data to target areas where the rate is lower. The letter from NHS England attached as Appendix 1 includes a number of recommendations:
4.2 ‘Opt out data capture / published monthly – it has been recommended that we use a form to capture (anonymously) the reason why an individual is not having their flu vaccination’. It is strongly felt by the CUH flu team that promoting this opt out and mechanism for recording particularly during phase 3 (as outlined above) would put a negative light on the programme. The forms are available at the central clinic locations and will be used if someone turns down a direct approach and is willing to complete the form.
It is proposed that during phases 4-5 the forms are more readily used, specifically in ‘higher-risk’ areas (see Section 4.3). The focus should remain on improving uptake rather than solely recording why the vaccine is not being taken up.
4.3 ‘In these higher-risk areas, staff should confirm to their clinical director / head of nursing / head of therapy whether or not they have been vaccinated. This information should be held locally so that trusts can take appropriate steps to maintain the overall safety of the service, including considering changing the deployment of staffing within clinical environments if that is compatible with maintaining the safe operation of the service.’
It is proposed that CUH defines the following areas as ‘higher-risk’:
• Oncology • Haematology • Neonatal Intensive Care Unit (NICU) • All other Intensive Care Units • Medicine for the Elderly and Stroke • Transplant and Infectious Diseases • Areas designated as ‘flu wards’
It is proposed that the CUH flu team will generate a report on uptake within these areas in mid-November and then approach the areas and seek to work with their leadership to improve uptake if required. Where this is not achieved, a risk assessment should be completed by the areas’ leadership to manage any potential risk and consider appropriate control measures, which may include changing staff deployment.
4.4 ‘Weekly feedback on % by directorate, teams and professional groups’ – for reasons outlined above this is virtually impossible to achieve within CUH currently. However, weekly updates on overall performance is given at the 08.27
Board of Directors: 14 November 2018 2018/19 Workforce influenza vaccination programme Page 6 of 7
meeting and shared via the Trust Communications team. We have a good spread of uptake across all areas and staff groups.
It is proposed that this is the continued approach, moving to sharing more detailed breakdown as soon as is practicable, starting with higher-risk areas.
4.5 ‘Schedule for 24 hour mobile vaccinations’
It is proposed that CUH continues with the model of central clinics (starting early and ending late) plus the large group of local vaccinators. Should it be required there is the opportunity to dedicate additional resource to vaccinate at night specifically. This can be explored in phase 5.
4.6 ‘By February 2019 we (NHS England) expect each trust to use its public board papers to locally report their performance on overall vaccination uptake rates and numbers of staff declining the vaccinations, to include details of rates within each of the areas you designate as ‘higher risk’. This report should also give details of the actions that you have undertaken to deliver the 100% ambition for coverage this winter.’
It is proposed that a further paper is provided to the Board of Directors in January 2019.
5. Recommendations
5.1 The Board of Directors is asked to note the report and the guidance from NHS England and endorse the proposed actions set out in Section 4 of the paper.
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Wellington House 133-155 Waterloo Road Friday 7 September 2018 London SE1 8UG [email protected]
To: Chief Executives of NHS Trusts and Foundation Trusts
Dear Colleague
Health care worker flu vaccination
We know you appreciate the importance of all healthcare workers protecting themselves, their patients, their colleagues and their families by being vaccinated against seasonal flu, because the disease can have serious and even fatal consequences, especially for vulnerable patients. Your leadership, supported by the Flu Fighter campaign and the CQUIN has increased take-up of the flu vaccine, with some organisations now vaccinating over 90% of staff. Our ambition is for 100% of healthcare workers with direct patient contact to be vaccinated.
In February, the medical directors of NHS England and NHS Improvement wrote to all Trusts to request that the quadrivalent (QIV) vaccine is made available to all healthcare workers for winter 2018-19 because it offers the broadest protection. This is one of a suite of interventions that can and should be taken to reduce the impact of flu on the NHS.
Today we are writing to ask you to tell us how you plan to ensure that every one of your staff is offered the vaccine and how your organisation will achieve the highest possible level of vaccine coverage this winter.
Healthcare workers with direct patient contact need to be vaccinated because:
a) Recent National Institute for Health and Care Excellence (NICE) guidelines1 highlight a correlation between lower rates of staff vaccination and increased patient deaths;
b) Up to 50% of confirmed influenza infections are subclinical (i.e. asymptomatic). Unvaccinated, asymptomatic (but nevertheless infected) staff may pass on the virus to vulnerable patients and colleagues;
c) Flu-related staff sickness affects service delivery, impacting on patients and on other staff – recently published evidence suggests a 10% increase in vaccination may be associated with as much as a 10% fall in sickness absence;
d) Patients feel safer and are more likely to get vaccinated when they know NHS staff are vaccinated.
1 https://www.nice.org.uk/guidance/ng103
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In order to ensure your organisation is doing everything possible as an employer to protect patients and staff from seasonal flu we ask that you complete the best practice management checklist for healthcare worker vaccination [appendix 1] and publish a self-assessment against these measures in your trust board papers before the end of 2018.
Where staff are offered the vaccine and decide on the balance of evidence and personal circumstance against having the vaccine, they should be asked to anonymously mark their reason for doing so by completing a form, and you should collate this information to contribute to the development of future vaccination programmes. We have provided an example form [appendix 2] which you may wish to tailor and use locally, though we suggest you use these opt out reasons to support national comparisons.
We specifically want to ensure greatest protection for those patients with specific immune- suppressed conditions, where the outcome of contracting flu may be most harmful. The evidence suggests that in these ‘higher-risk’ clinical environments more robust steps should be taken to limit the exposure of patients to unvaccinated staff and you should move as quickly as possible to 100% staff vaccination uptake. At a minimum these higher-risk departments include haematology, oncology, bone marrow transplant, neonatal intensive care and special care baby units. Additional areas may be identified locally where there are a high proportion of patients who may be vulnerable, and are receiving close one-to-one to clinical care.
In these higher-risk areas, staff should confirm to their clinical director / head of nursing / head of therapy whether or not they have been vaccinated. This information should be held locally so that trusts can take appropriate steps to maintain the overall safety of the service, including considering changing the deployment of staffing within clinical environments if that is compatible with maintaining the safe operation of the service.
We would strongly recommend working with your recognised professional organisations and trade unions to maximise uptake of the vaccine within your workforce; to identify and minimise any barriers; to discuss and agree which clinical environments and staff should be defined as ‘higher-risk’; and to ensure that the anonymous information about reasons for declining the vaccine is managed with full regard for the dignity of the individuals concerned. Medical and nurse director colleagues will need to undertake an appropriate risk assessment and discuss with their staff and trade union representatives how best to respond to situations where clinical staff in designated high risk areas decline vaccination.
It is important that we can track trusts’ overall progress towards the 100% ambition. Each trust shall continue to report uptake monthly during the vaccination season via ‘ImmForm’. However from this year you are also required to report how many healthcare workers with direct patient contact have been offered the vaccine and opted-out. This information will be published monthly by Public Health England on its website.
By February 2019 we expect each trust to use its public board papers to locally report their performance on overall vaccination uptake rates and numbers of staff declining the vaccinations, to include details of rates within each of the areas you designate as ‘higher- risk’. This report should also give details of the actions that you have undertaken to deliver the 100% ambition for coverage this winter. We shall collate this information nationally by
2
asking trusts to give a breakdown of the number of staff opting out against each of the reasons listed in appendix 2.
You can find advice, guidance and campaign materials to support you to run a successful local flu campaign on the NHS Employers Flu Fighter website www.nhsemployers/flufighter
Finally we are pleased to confirm that NHS England is once again offering the vaccine to social care workers free of charge this year. Independent providers such as GPs, dental and optometry practices, and community pharmacists, should also offer vaccination to staff. There are two parallel letters to primary care and social care outlining these proposals in more detail.
Yours sincerely
- signed jointly by the following national clinical and staff side professional leaders -
Prof Stephen Powis ...... National Medical Director, NHS England ...... and on behalf of National Escalation Pressures Panel
Prof Paul Cosford .. Medical Director & Director of Health Protection, Public Health England
Prof Jane Cummings ...... Chief Nursing Officer, NHS England
Sara Gorton (Unison)...... Co-chair, National Social Partnership Forum
Prof Dame Sue Hill ...... Chief Scientific Officer, NHS England
Dame Donna Kinnair. Acting Chief Executive & General Secretary, Royal College of Nursing
Prof Carrie MacEwen ...... Chair of the Academy of Medical Royal Colleges
Ruth May ...... Executive Director of Nursing, NHS Improvement
Dr Kathy Mclean ...... Executive Medical Director NHS Improvement
Danny Mortimer (NHS Employers) ...... Co-chair, National Social Partnership Forum
Pauline Philip ...... National Director of Urgent and Emergency Care
Suzanne Rastrick ...... Chief Allied Health Professions Officer, NHS England
Keith Ridge ...... Chief Pharmaceutical Officer, NHS England
John Stevens ...... Chairman, Academy for Healthcare Science
Gill Walton ...... Chief Executive, Royal College of Midwives
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Appendix 1 - Healthcare worker flu vaccination best practice management checklist – for public assurance via trust boards by December 2018
A Committed leadership Trust self- (number in brackets relates to references listed below the table) assessment A1 Board record commitment to achieving the ambition of 100% of front line healthcare workers being vaccinated, and for any healthcare worker who decides on the balance of evidence and personal circumstance against getting the vaccine should anonymously mark their reason for doing so. A2 Trust has ordered and provided the quadrivalent (QIV) flu vaccine for healthcare workers (1). A3 Board receive an evaluation of the flu programme 2017-18, including data, successes, challenges and lessons learnt (2,6) A4 Agree on a board champion for flu campaign (3,6) A5 Agree how data on uptake and opt-out will be collected and reported A6 All board members receive flu vaccination and publicise this (4,6) A7 Flu team formed with representatives from all directorates, staff groups and trade union representatives (3,6) A8 Flu team to meet regularly from August 2018 (4) B Communications plan B1 Rationale for the flu vaccination programme and myth busting to be published – sponsored by senior clinical leaders and trade unions (3,6) B2 Drop in clinics and mobile vaccination schedule to be published electronically, on social media and on paper (4) B3 Board and senior managers having their vaccinations to be publicised (4) B4 Flu vaccination programme and access to vaccination on induction programmes (4) B5 Programme to be publicised on screensavers, posters and social media (3, 5,6) B6 Weekly feedback on percentage uptake for directorates, teams and professional groups (3,6) C Flexible accessibility C1 Peer vaccinators, ideally at least one in each clinical area to be identified, trained, released to vaccinate and empowered (3,6) C2 Schedule for easy access drop in clinics agreed (3) C3 Schedule for 24 hour mobile vaccinations to be agreed (3,6) D Incentives D1 Board to agree on incentives and how to publicise this (3,6) D2 Success to be celebrated weekly (3,6)
Reference links 1. http://www.nhsemployers.org/-/media/Employers/Documents/Flu/Vaccine-ordering-for-2018-19-influenza-season- 06022018.pdf?la=en&hash=74BF83187805F71E9439332132C021EFA3E6F24C 2. http://www.nhsemployers.org/-/media/Employers/Publications/Flu-Fighter/Reviewing-your-campaign-a-flu-fighter- guide.pdf 3. http://www.nhsemployers.org/-/media/Employers/Documents/Flu/Flu-fighter-infographic-final-web-3-Nov.pdf 4. http://www.nhsemployers.org/-/media/Employers/Publications/Flu-Fighter/good-practice-acute-trusts-TH-formatted- 10-June.pdf 5. http://www.nhsemployers.org/-/media/Employers/Publications/Flu-Fighter/good-practice-ambulance-trusts-TH- formatted-10-June.pdf 6. https://www.nice.org.uk/guidance/ng103/chapter/Recommendations
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Appendix 2 – Example opt out forms for local adaptation and use
Form to be potentially co-branded by NHS organisation and key trade unions
Dear colleague,
Did you know that 7 out of 10 front line NHS staff had the flu vaccine last year, and in some departments more than 9 out of 10 staff were vaccinated?
The flu jab gives our body the information it needs to fight the flu, which stops us from contracting and spreading the virus. For those of us who work in care settings, getting the flu jab is an essential part of our work. In vaccinating ourselves we are protecting the people we care for, and helping to ensure that we are able to provide the safest environment and effective care for patients.
We want everyone to have the jab. The sooner you get it, the more people you can protect. We hope that you will agree to having the vaccine – this really helps to protect patients, you and your family. But, if you choose not to have the flu vaccine, we want to understand your reasons for that by filling in this anonymous form.
Signed
Chief Executive, Medical Director, Director of Nursing, and Trade Union representative
Please tick to confirm that you have chosen not to have the vaccine this year:
I know that I could get flu and have only mild symptoms or none at all; and that because of this I could give flu to a patient. I know that vaccination is likely to reduce the chances of me getting flu and of me passing it to my patients. But I still don't want the vaccine.
Please tick each of the boxes below that apply to your decision not to have the jab.
I DON’T WANT TO BE FLU VACCINATED BECAUSE:
I don’t like needles I don’t think I‘ll get flu I don’t believe the evidence that being vaccinated is beneficial I’m concerned about possible side effects I don’t know how or where to get vaccinated It was too inconvenient to get to a place where I could get the vaccination The times when the vaccination is available are not convenient Other reason – please tell us here
______Thank you for completing this form.
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Cambridge University Hospitals NHS Foundation Trust
Report to the Board of Directors: 14 November 2018
Agenda item 11 Title Cambridge Transition Programme Nicola Ayton, Director of Strategy and Sponsoring executive director Major Projects Author(s) Allison Warn, CTP Programme Lead, CUH Purpose To provide a programme update. Previously considered by Management Executive, 8 November 2018 Executive Summary On 27 June 2018 Royal Papworth Hospital announced that its move to the new hospital on the Cambridge Biomedical Campus would be delayed. A revised move date commencing on 23 April 2019 has subsequently been announced. The purpose of this paper is to update the Board of Directors on progress since the last update, highlight key areas of joint working and outline critical issues, risks and interdependencies in relation to the successful transition of Royal Papworth Hospital onto the Cambridge Biomedical Campus.
Related Trust objectives Working with our communities Risk and Assurance Risks are detailed in the paper Related Assurance Framework Entries BAF risk 001/18 Legal / Regulatory / Equality, Diversity & n/a Dignity implications? How does this report affect Sustainability? n/a Does this report reference the Trust's values of “Together: safe, kind and excellent”? n/a
Action required by the Board of Directors The Board is asked to note: • The revised date for the opening of new Royal Papworth Hospital on the Cambridge Biomedical Campus. • The progress made since the last update. • The key risks, areas of concern and actions being taken to mitigate these.
Cambridge University Hospitals NHS Foundation Trust
14 November 2018
Board of Directors Cambridge Transition Programme Allison Warn, CTP Programme Lead, CUH
1. Purpose
1.1 The paper provides the Board of Directors with an overview of the joint work being undertaken between Cambridge University Hospitals (CUH) and Royal Papworth Hospital (RPH) to support the opening of the new RPH on the Cambridge Biomedical Campus (CBC).
1.2 Since the last update to the Board, RPH have announced a delay to the handover of the new building on the CBC which has resulted in the need to postpone the opening of the hospital. Subsequently, RPH have announced that relocation to the CBC will commence on 23 April 2019 and is planned to be completed on 13 May 2019.
1.3 Despite the delay, where possible, the CTP work programme has continued with some activities being re-ordered to respond to the new timelines and minimise the impact of the new relocation date.
1.4 Overall, significant progress continues to be made. Our collective focus remains on ensuring critical services are agreed and in place ready for the opening of the new hospital. Additionally, work on changes to clinical services to enhance patient experience, access and quality has continued and a revised timetable was discussed and agreed by the Joint Transition Group (JTG) in October 2018.
1.5 Risks to the delivery of the programme continue to be monitored closely and at the current time the most highly rated risks relate to: histopathology; travel and transport; and workforce.
2. Background information
2.1 The programme of work is known as the Cambridge Transition Programme (CTP). CTP is a core programme under the ‘Working with our communities’ priority as part of our overall CUH Strategy. The programme was first established in July 2014 to ensure that the mutual benefits from improved patient pathways, service efficiencies and research opportunities are realised.
2.2 Oversight of the programme delivery is through a fortnightly CEO-led JTG, which has been meeting regularly since May 2017.
3. Programme governance
3.1 In order to manage the complexity of the move of RPH onto the CBC, a master commissioning programme has been developed and documented. In light of the delay to RPH’s move to the CBC, the master commissioning programme has now been fully reviewed and updated. The focus of the master commissioning programme is the safe opening of the new hospital. The tasks and workstreams that are within the CTP constitute approximately 15% of the entire programme.
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3.2 The CTP activities are managed through a suite of jointly staffed steering groups and working groups and are reported internally through CUH’s monthly CTP Steering Group. Any CTP activities that are falling behind plan are managed at an operational level or escalated to the JTG for guidance and decision making. The programme provides reports to both Boards on a four-monthly basis or more frequently if requested. Regular reports are also provided to the CUH Management Executive to ensure oversight of the programme.
4. Areas of joint work critical to the opening of the new Royal Papworth Hospital
Overall progress
4.1 Since the signing of the overarching Shared Services Agreement (SSA) on 4 September 2017 five further variations have been signed to progressively include additional services into the agreement. The agreement currently includes 18 services that are either provided from one trust to the other or will be joint services. The focus for the remaining months, before opening, is on the operationalisation of the agreed services, to ensure they are in place ready for the opening of the new hospital.
4.2 Table 1 below highlights the areas of joint working and those that are now being developed by RPH as an internal solution. These have been grouped into phases associated with their incorporation into the SSA. It should be noted that the RPH only solutions are planned to be short term measures of 12-18 months and it is our joint intention that these services are provided by CUH in the longer term.
Table 1: CTP Phases Joint Solution Royal Papworth Only Solution Phase 1 (Incorporated into SSA dated 4 September 2017) Estates Services including linen, waste Blood Transfusion (building and service management provision) Tunnel Maintenance Research and Tissue Bank Beaker Interface Switchboard and Telephony Emergency Consultant Cover Service: Sterile Services CUH to Papworth’ Emergency Thoracic and Cardiac Scope Washing Surgical cover service from Papworth to CUH Variation 1 (1 October 2017) Occupational Health Variation 2 (10 January 2018) Information and Communication Technology (ICT) rack space Phase 2 (26 March 2018) Mortuary Chaplaincy and Bereavement Radiology Medical Physics Planned Medical Services Phase 3 (25 June 2018) Communication Antennae connection (DAS base station hotel) Blood Sciences Radiopharmacy
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Phase 3 (anticipated inclusion in November 2018) Blood Transfusion (workforce only) Car Parking Management Histopathology (interim – pre-LMB) Patient Courtesy Bus pilot Histopathology LMB
Phase 3 services
4.3 Services being developed as part of phase three are of greater complexity than those already specified and signed off. These have been split into two variations with the first set signed off on 25 June 2018 and the second set due to be signed in November 2018. An update on the remaining phase 3 services is provided below.
Transfusion services
4.4 Although RPH will initially be providing blood transfusion services from within a modular building co-located with the new hospital, the longer-term solution remains the provision of an integrated service within the CUH laboratory facilities. This interim service is, therefore, expected to be in place for 12 – 18 months only. In order to deliver the interim RPH service laboratory staff will be seconded from CUH to RPH until such time as the two services come together. A service level agreement and managerially responsible matrix is agreed and ready for signing.
Histopathology
4.5 The intention is for a fully integrated histopathology service for both Trusts. However, the current facilities at CUH are insufficient to accommodate the RPH activity. Work has commenced on the first stage of refurbishment of a University of Cambridge building that will provide facilities for the combined service. The timeframe for completion of the full refurbishment programme is early 2019. These facilities will therefore not be ready in time for the opening of new RPH.
4.6 The teams have worked collaboratively to identify an interim solution for the RPH service. This service has now been agreed and the supporting service level agreement is ready for signing. At the time of writing the planned relocation of the RPH service to begin integration with the CUH service is June 2019. In the meantime, orientation of laboratory staff is underway.
Car parking management
4.7 The provision of 645 car parking spaces is a pre-occupation planning condition for new RPH and both organisations recognise the significant risk that not providing the spaces represents to the opening of the new hospital. The planning condition for new Royal Papworth is that 608 spaces, plus 37 disabled spaces, are to be allocated for use by their patients, visitors and staff. This planning condition has now been discharged. A service level agreement for the provision of car park management services has been agreed and is ready for signing.
4.8 Wider campus discussions are continuing to progress with strategies for addressing access issues to the CBC.
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Patient courtesy bus pilot
4.9 It has been agreed that the courtesy bus currently serving the CUH campus will include stops outside new RPH. This has been achieved by reviewing the current usage of the courtesy bus and modifying the timetable. This service will run as a pilot initially to allow an opportunity to review any impact from the modifications to the timetable.
5. Areas where we are working together to deliver improved patient outcomes, experience and value
Clinical services
5.1 The most significant improvements to patient care, in relation to our collaboration, will result from developing new ways of working and enhanced patient pathways for cardiology and respiratory services, with the aim of improving patient outcomes experience and value for money. Clinical groups have been meeting on a regular basis since September 2014.
5.2 Programme planning for the implementation of changes to clinical pathways or services had previously been based on a start date of six months after new RPH opens. However, due to the additional planning time afforded by the delayed moving date, this assumption has been reviewed and brought forward where clinically appropriate. The areas of service under discussion will be discussed with commissioning colleagues during November.
5.3 Safe and timely transfer of the care of patients between organisations depends on the right supporting workflows and access to appropriate clinical patient information. In October 2018 a workshop to map the thoracic oncology patient pathway took place. This is one of the most complex and rapid pathways currently spanning both trusts. The purpose was to identify the information needs for safe decision making and timely care at each step of the patient pathway and, in particular, where care transfers between trusts.
Cardiology
5.4 Work within cardiology continues to focus on pathways of care, providing a seamless and consistent service for patients and ensuring that transfers of patient care between Trusts is timely. Examples of proposals being developed include a strategy for the use of the catheter laboratories across the two Trusts; the development of a joint cardiac physiology provided out of hours service for patients experiencing problems with implanted devices; and closer integration of the cardiac physiology services to deliver resilient services for both Trusts and improve the development opportunities for staff within the service. All proposals are being discussed through the joint cardiology steering group.
Respiratory medicine
5.5 Within respiratory medicine five sub-specialty areas have been identified where there is either duplication or an overlap of services between the two trusts. Business proposals are being developed to support the service proposals with interstitial lung disease being the first service planning to make changes, once approved. Much of the focus in respiratory has been on outpatient based services however it is anticipated that once RPH has opened safely further progress will be made on proposals to transfer appropriate inpatients from CUH to RPH.
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Other clinical services
5.6 Throughout the course of discussions within CTP there have been services identified where there would be potential benefit in closer working between CUH and RPH. This has often been driven by expertise or skills within one Trust that would benefit the patients of the other Trust. These include the reporting of paediatric sleep studies, the insertion of percutaneous endoscopic gastrostomy tubes for complex patients and increased thoracic surgical input for patients within the major trauma service.
6. Key areas of concern
6.1 The critical milestones for delivery of the programme are on track against the updated programme. However, there remain a small number of areas of risk that are being closely monitored and actively managed. These relate to the programme of work to refurbish a University of Cambridge building for the provision of histopathology; access to the campus; and recruitment and retention of staff.
6.2 The delay to the opening of new RPH has given the joint programme teams the opportunity to review the governance structure for the programme specifically in the context of the critical dependencies that had been identified and any emerging risks.
6.3 The review has identified that all areas for concern had been captured within the existing governance structure and that no unexpected risks within the CTP programme emerged that would have prevented safe opening of new RPH. The learning from this review and the governance structure within CTP is being shared with the Director of Strategy and Major Projects to inform the design and implementation of CUH’s Major Projects regime.
7. Recommendations
7.1 The Board of Directors is asked to note:
• The revised date for the opening of new Royal Papworth Hospital on the Cambridge Biomedical Campus. • The progress made since the last update. • The key risks, areas of concern and actions being taken to mitigate these.
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Cambridge University Hospitals NHS Foundation Trust
Report to the Board of Directors: 14 November 2018
Agenda item 12 Multi-professional Education, Learning, Title Development and Training Sponsoring Executive Director David Wherrett, Director of Workforce Arun Gupta, Director of Post Graduate Medical Education; Maura Screaton, Author(s) Deputy Chief Nurse; Karen Clarke, Associate Director of Workforce To provide the Board of Directors with an Purpose update on education, learning, training and development across CUH. Previously considered by Management Executive, 1 November 2018
Executive Summary This paper provides an update on multi-professional education, learning and development, activity. The content of this paper sets out progress since the last Board report aligned to the key themes set out in the Trust’s Education, Learning & Development Strategy.
Related Trust objectives Strengthening the organisation The report provides assurance on Risk and Assurance education, learning, development and training activities across the Trust. Related Assurance Framework Entries BAF ref: 004/18 Legal / Regulatory / Equality, Diversity & n/a Dignity implications? How does this report affect Sustainability? n/a Does this report reference the Trust's values of “Together: safe, kind and Yes excellent”?
Action required by the Board of Directors The Board is asked to receive the report.
Board of Directors: 14 November 2018 Report from the Multi-professional Education, Learning, Development & Training group Page 1 of 10
Cambridge University Hospitals NHS Foundation Trust
14 November 2018 Board of Directors Multi-professional Education, Learning, Development and Training Dr Arun Gupta, Maura Screaton, Karen Clarke
1. Introduction/Background
1.1 This paper provides an update on education, learning and development. Its purpose is to provide information about a number of key developments since the last report in July 2018. It uses the eight themes of the Multi-professional Education, Learning and Development Strategy (MELDS) work plan to set out a range of developments since the last Board report.
1.2 The eight strategy themes are:
Theme 1: Good learning experience for all students/learners
Theme 2: Sustainable Continuous Professional Development and multi- disciplinary learning
Theme 3: Maximise the opportunities of the Apprenticeship Levy
Theme 4: Great leadership and management development
Theme 5: Innovation leading to new roles and routes to training and employment
Theme 6: Modern fit for purpose education facilities and resources
Theme 7: Opportunity to learn and develop speciality skills in a world leading environment
Theme 8: Strong partnership working with education providers
2. Theme One: Good learning experience for all students/learners
2.1 Postgraduate Medical Education
2.1.1 GMC Trainee Survey
The results of the latest General Medical Council (GMC) were discussed at the Workforce and Education Committee in October 2018. This section provides the Board with an update on the results and plan.
The GMC national training survey is an annual survey to monitor the quality of medical education and training in the UK. The survey asks all doctors in training for their views about the training they are receiving. In 2018 the survey ran between March and May. The GMC uses red and green colour coding to highlight results that are significantly above or below the average to help identify areas for investigation. Positive (green) outliers represent scores in upper quartile nationally. Negative (red) outliers represent scores in the lowest quartile nationally.
Board of Directors: 14 November 2018 Multi-professional Education, Learning, Development and Training Page 2 of 10 The survey consists of 18 domains. There is an additional domain in the 2018 survey on rota design.
The domains are: Overall satisfaction, Clinical supervision, Clinical supervision out of hours, Induction, Handover, Workload, Reporting systems, Educational supervision, Adequate experience, Feedback, Local teaching, Regional teaching, Study Leave, Supportive Environment, curriculum coverage, rota design, educational governance and teamwork.
Work continues to reduce the number of red outliers in the GMC trainee survey. The GMC Working Group chaired by the Director of Postgraduate Medical Education met with the Educational Leads and College Tutors with specialties that have three or more red outliers. Action plans for specialties with red outliers have been developed, and returned to HEEoE as part of the HEEoE response.
2.1.2 Summary of results
Local results
• A comparison between the 2017 to the 2018 data for CUH showed 52 red outliers in 2018 compared to 45 in 2017. The new domain of Rota Design accounted for four red outliers.
• There has been an increase in the number of green outliers – 36 in 2018 compared to 14 in 2017.
2.1.3 Most improved specialties
Specialty 2018 red 2018 2017 red outliers green outliers outliers Cardiology 3 9 Clinical Oncology 0 2 6 Clinical Pharmacology* 0 5 Endocrinology and diabetes 0 2 GP Programme Medicine 0 3 Obstetrics & Gynaecology 0 3 Ophthalmology 0 1 1 (2016 = 8) Plastic Surgery 0 4 Surgery F1 0 2
2.1.4 Specialities requiring support The majority of red outliers are in the specialties of: Neurosurgery, Surgery F2, Anaesthetics and Clinical Radiology.
Specialty 2018 red 2017 red outliers outliers Neurosurgery 7 2 Surgery F2 10 0 Anaesthesia 6 4 Clinical Radiology 4 0
Board of Directors: 14 November 2018 Multi-professional Education, Learning, Development and Training Page 3 of 10 There were two patient safety and four undermining comments raised during the survey; these were investigated, actions taken and responses sent to HEE.
2.1.5 Shelford Group In 2018 CUH ranked 6 out of 10 hospitals in the Shelford Group for overall satisfaction – Central Manchester did not report an overall satisfaction result in 2018.
In 2018, out of the 40 programmes showing results for CUH, the following eight Programme Groups ranked number 1 in the Shelford Group ranking: CMT, Geriatric Medicine, Histopathology, Clinical Genetics, Clinical Pharmacology and Therapeutic Medicine, Obstetrics and Gynaecology F2, Surgery F1, Vascular Surgery.
2.1.6 Actions The GMC Trainee Survey Working Group, chaired by the Director of Postgraduate Medical Education, met with the Educational Leads and College Tutors on 9 August to discuss the results of the GMC trainee survey. The Director of Postgraduate Medical Education and senior members of the Education team had individual meetings with the trainees in those specialties with three or more red outliers. Action plans have been received for those specialties with three or more red outliers and returned to Health Education England, East of England (HEE EoE). HEE EoE has requested a summary of the outcomes from the 2018 survey, with a response date of 14 September 2018. The response to HEE EoE including the individual action plans is attached.
2.1.7 Guardian of Safe Working – Exception Reports Since the start of the new Contract in December 2016, there have been 777 Exception Reports with 42 relating to education and training. The issues raised in the survey are aligned to the concerns raised through the education and training exception reports, as the majority of the issues relate to workload and rotas. Rota design is a new domain in the 2018 survey and accounts for four red outliers.
2.2 Pre-registration Nursing
The Trust continues to monitor student experience and triangulate data to ensure we provide high quality clinical learning environments. We are working in partnership with Trusts and HEIs across the Midlands and East to develop a coordinated approach to learner assessment in clinical practice. This positive initiative will be launched in September 2019.
2.3 National Education and Training Survey (NETS) The Trust has been invited to participate in the National Education and Training Survey (NETS) that has been developed by Health Education England (HEE) with the help of an academic partner, to supports its 2016-2020 Quality Strategy. The NETS is aimed at all healthcare learners, including postgraduate medical trainees and learners from other allied healthcare professions. It comprises a series of questions, aligned to HEE’s multi-professional standards for education and training as set out in the HEE Quality Framework. The focus of the survey is the clinical learning environment and will be sent to learners on clinical placements at the time the survey is open.
Board of Directors: 14 November 2018 Multi-professional Education, Learning, Development and Training Page 4 of 10 The NETS will provide a comprehensive source of evidence and provide HEE with assurance about the quality of clinical learning environments. The results will support trusts to identify and develop excellence in clinical practice learning from a multi-professional perspective. The survey opens on 12 November and closes on 14 December. Following data analysis, trusts will receive reports on the results in January 2019.
2.4 The Board is asked to receive and note:
• The results of GMC Trainee Survey • The increase in the number of green outliers • The action plans submitted to HEE EoE in response to the red outliers • The commencement of the Internal Medical Training (IMT) programme from 1 August 2018 • The Trust’s participation in the new National Education and Training Survey (NETS).
3. Theme Two: Sustainable continuous professional development and multi- disciplinary learning
3.1 Medical
3.1.1 Internal Medical Training (IMT) A new IMT programme will commence nationally from 1 August 2019. The IMT programme will run for three years and replace the previous two-year Core Medical Training (CMT) programme. IMT trainees must spend at least ten weeks in the Intensive Treatment Unit (ITU) and four months in Care of the Elderly in the first two years of the programme. The resultant transfer of some trainees to ITU is likely to require a significant degree of backfill for medical posts.
3.1.2 August changeover The August changeover of 346 junior doctors went well (229 doctors new to the Trust and the remainder changing jobs internally); with no issues reported. Almost all gaps were filled, although there were gaps in the neurosciences junior rota in August but these are now filled.
3.1.3 Foundation Doctors The Preparing for Professional Practice (PfPP) week held in July for the 51 new Foundation Year 1 (FY1) doctors went well, with no issues reported. No gaps have been reported in the FY1 and FY2 recruitment.
3.2 Non-Medical Preceptorship course for nurses The multi professional preceptorship programme continues to be well evaluated and both a committee and a steering group have been established to regularly review and update the programme in line with national, Trust and staff requirements. It continues to be widely publicised as a recruitment and retention incentive.
3.3 Pharmacy The Pharmacy Education and Training team has been working to proactively embed support for emotional and physical wellbeing for pharmacy trainees within our training programmes. This has included a ‘Refocus and Recharge’ workshop during trainee induction, wellbeing noticeboards and tutor prompts to routinely discuss wellbeing with trainees. The above work and future plans in relation to supporting wider wellbeing across the department have been shared with the HEE Wellbeing Commission.
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3.4 Continuous Professional Development (CPD) funding update In addition to the Trust’s designated recurring budget of £800k for CPD, the Trust received a one-off allocation of £178k from HEE to support nursing modules at Anglia Ruskin University (ARU) in advanced clinical practise and 2 ICU ACP modules at King’s College London.
3.5 The Board is asked to receive and note: • Continued development of inter-professional preceptorship programmes • Embedding of support for emotional and physical wellbeing within the training programmes for pharmacy trainees • CUH CPD funding update
4. Theme Three: Maximise the opportunities of the Apprenticeship Levy
4.1 Apprenticeship Levy Update A detailed update of progress was provided in the last Board report
In September 2018 the Trust led a review of approaches, pay models and schemes across the Shelford Group to share learning and best practice. There is also joint work in place with trusts across Cambridgeshire.
The Trust keeps abreast of Apprenticeship Standards being developed and ensures communication and dialogue with professional leads about scope and potential for future workforce supply.
There has been communication across manager networks to provide further information about direct entry apprenticeships and opportunities for existing staff and new pages have been made available on Connect/HR Consult for managers and employees.
4.2 The Board is asked to note: • Continued development of embedding the Apprenticeship Levy, on-going communication with line managers and sharing best practice across the Shelford Group and across Cambridgeshire.
5. Theme Four: Great leadership and management development
5.1 Trust wide Leadership and Organisational Development
5.1.1 CUH Senior Leaders Programme The Senior Leaders Programme continues with Team 7 of 9 (cohort 3) commencing on 2 October. Cohorts 1 and 2 are currently with the Cambridge Judge Business School (CJBS) element of the programme. We will develop, refine and deliver a plan to commission a successor to the CUH Senior Leaders Programme the next stage in our journey to improving Culture, Climate, Leadership and Engagement.
5.1.2. Coaching Both the ILM level 5 and 7 have been well evaluated with the first level 5 course just finishing their qualification. The second ILM level 5 course commenced on 3 October and the second level 7 course is also full.
5.1.3 Mary Seacole Programme Working across the Cambridgeshire and Peterborough Sustainability and Transformation Partnership (STP) CUH has trained seven facilitators to deliver this leadership academy programme locally. To date there have
Board of Directors: 14 November 2018 Multi-professional Education, Learning, Development and Training Page 6 of 10 been 4 cohorts organised with another four in train for quarter 4. CUH has 24 staff on the current programmes with a healthy waiting list for the subsequent programmes. This bridges the gap in development for staff taking up their first leadership role.
5.2 Medical Leadership Programmes
5.2.1 Medical Trainee Leadership Development Programme Development of leadership training for junior medical staff in the East of England is progressing with a provisional programme planned to pilot in Luton, Cambridge and West Suffolk over the next 12 months. Further faculty development days are planned in Norwich and Chelmsford.
5.2.2 The Chief Resident Programme Following the favourable findings of the Faculty of Education review, HEE EoE has confirmed funding for the 2018/19 programme. The 2018/2019 programme commenced in September at the Moller Centre with a total of 65 Chief Residents across the East of England.
5.2.3 Learning to Lead The Learning to Lead 2018 programme continues with Day 5 taking place on 25 September. Delegate feedback for the first four days has been largely very positive. Course members are currently working together in groups to prepare their Healthcare Challenge presentations as part of the Day 6 programme.
5.2.4 CUH Senior Leadership Development Programme The programme is progressing well and discussions are underway to extend the programme from two cohorts to three cohorts.
5.3 Nursing Leadership The Trust continues to deliver the supervisory band 7 development programme and theatres band 7 programme, with excellent feedback. Four cohorts have completed the programmes. To ensure on-going development, those that have completed the programme have ‘keep in touch’ days - where a structured agenda is in place to enable networking, development and priority updates. The programme is currently being reviewed and evaluations and feedback are being sought from delegates and managers prior to cohort 5 commencing early in 2019.
5.4 Pharmacy A number of pre-registration trainee pharmacists have recently undertaken their week-long leadership rotations. This rotation aims to develop leadership skills and to deepen trainee understanding of wider issues affecting the department and the Trust. The rotation includes a significant element of project work and this has recently included designing a medicines optimisation strategy poster, supporting department CQC readiness, ward stock list reviews and coordinating tours for a group of Chinese Chief Pharmacists that visited the Trust in August.
5.5 The Board is asked to receive and note: • The Trust wide leadership programmes • Programmes in place for specific staff groups: medical and nursing. • Confirmation of funding from HEE EoE for the Chief Residents programme
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6. Theme Five: Innovation leading to new roles and routes to training and employment
The Workforce and Education Committee discussed the Trust’s approach to new roles and routes to training in October. This section updates the board on two particular areas.
6.1 Nursing Associates 6.1.1 The Nursing Associate (NA) programme continues on a pilot phase both within CUH and nationally. The CUH pilot cohort is due to complete in December 2018, with five trainees on the programme from the original eight. On completion they will have a role as a Nursing Associate within the Trust paid at AfC band 4 upon qualification and they will be placed on the NMC professional register.
6.1.2 The NA standards are currently being developed by the NMC and are due later in 2018. This will set out the requirements of Higher Education Institutions (HEIs) in delivering the course programme, and provide further direction on roles and responsibilities within their scope of practice.
6.1.3 The NMC register on which the NA will be placed on qualification is still under development and current approximations state that this register will not be implemented until Spring 2019; pending this it is likely NAs will be on a voluntary register. CUH have set up a task group to ensure processes are in place to support and integrate the nurse associate role into the organisation. The group will also make recommendations to Nursing and Midwifery Executive Committee (NMEC) as to the future strategy of nurse associates.
6.2 Overseas nurses 6.2.1 There has been an increase in numbers of new starters from overseas requiring the Objective Structured Clinical Examination (OSCE) programme. There are currently 98 nurses in the pipeline awaiting successful completion of their OSCE programme. This has created additional challenges for course facilitation leading to a fall in the pass rate at the first attempt. However, our overall pass rate continues to be successful at 98%.
6.2.2 The failures in first attempt at OSCE extend the time for candidates to be successfully registered with the NMC, and thus have an impact on the availability of nurses with NMC registration. In order to mitigate this temporary extra resources have been put in place with an investment case being developed to address the longer term.
6.2.3 New European recruits commencing at CUH since April 2018, will undertake the Occupational English Test (OET) in place of the International English Language Testing System (IELTS) programmes. Early indications are that the OET candidates found this route professionally more relevant than IELTS. There are 81 European nurses currently studying for IELTS examinations. Our current pass rate with both examinations remains in the region of 50% where the national pass rate is 22%.
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6.3 Celebration event Lorraine Szeremeta, Mike More and David Wherrett welcomed staff to a celebration event to recognise achievement of the following: • Apprenticeships, Diplomas in Health Care, preceptorship, completion of IELTS (EU nurses) and completion of OSCE and registration with the NMC
6.4 The Board is asked to note: • The on-going Nursing Associate pilot • An update on international and EU recruitment and training outcomes • The celebration event held on 11 October, 2018
7. Theme Six: Modern fit for purpose education facilities and resources
7.1 Medical The Evelyn Cambridge Surgical Training Centre A feasibility study to identify an alternative site for the Centre was undertaken. Currently there is interest in a site at Great Chesterford Park. An option appraisal summary is being written which will form part of the discussions with Estates and Facilities at CUH around negotiating a favourable leasing agreement.
7.2 Multi-Professional Education Centre Working Group The first meeting of the Multi-professional Education Centre Working Group has taken place; it has agreed terms of reference and set itself a deadline of January 2019 to prepare a report for the Commercial Services Committee setting out next steps to move forward the ambition for a multi-professional education centre.
7.3 The Board is asked to receive and note: • Update on the alternative site for the Evelyn Cambridge Surgical Training Centre • Developments towards a multi-professional education centre
8. Theme Seven: Opportunity to learn and develop specialist skills in a world leading environment
8.1 The Advanced Clinical Practitioner (ACP) Training Programme This programme continues to evolve. CUH has worked closely with ARU to develop a robust Masters programme and continue to support our staff to undertake these opportunities through HEE funding. The ACP programme in Acute Medicine Services continues to develop. A successful recruitment process has taken place with six trainee ACPs for Acute Medicine/DME and two further trainee ACPs for the Emergency Department. There is interest from across the divisions to develop their workforce with ACPs in Acute Oncology, Neurosciences and Acute Paediatrics. Currently ACPs are supporting the workforce in acute medicine, NCCU and ED. The terms of reference for the group are being reviewed.
8.2 The Board is asked to note: • The continued development of the ACP Training programme
9. Theme Eight: Strong Partnership working with education providers
9.1 Pre-registration Nursing The NMC has published the Future Nurse Standards of Proficiency for Registered Nurses (May, 2018), we are working collaboratively with our partners to ensure a smooth transition to the new model in autumn 2019. The standards will ensure
Board of Directors: 14 November 2018 Multi-professional Education, Learning, Development and Training Page 9 of 10 that the clinical skills that pre-registration nurses enter the register with include more advanced practice skills, for example cannulation. The change will redefine the role of the mentor, and we are working with HEIs to shape the delivery of this new programme. A strong working relationship continues with University partner, ARU, with involvement in programme content, and strategic development of clinical education pathways.
9.2 Pharmacy The CUH Pharmacy Education and Training Team has taken a lead role in the development of a Cambridgeshire and Peterborough Pharmacy Education and Training Group. The group has recently successfully secured funds form HEE Midlands & East for a scoping project to explore cross sector rotational posts for pharmacists and pharmacy technicians. Sectors to be explored for the proposed rotational posts will include secondary care, general practice and community pharmacy.
9.3 Recommendation
The Board is asked to receive and note: • Continued partnership working with ARU to ensure smooth transition to the new model as set out in the Future Nurse Standards of Proficiency for Registered Nurses (May, 2018) • CUH Pharmacy Education and Training team’s involvement in the development of a Cambridgeshire and Peterborough Pharmacy Education and Training Group.
10. Recommendation
10.1 The Board of Directors is asked to receive the report.
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Cambridge University Hospitals NHS Foundation Trust
Report to the Board of Directors: 14 November 2018
Agenda item 13 Title Learning from deaths Sponsoring executive director Ashley Shaw, Medical Director
Jane Nicholson, Head of Patient Safety Improvement; Giles Thorpe, Director for Author(s) Clinical Quality; Dr Sue Robinson, Deputy Medical Director for Safety and Quality Improvement
To receive assurance on implementation of Purpose nationally-mandated guidance. Previously considered by Management Executive, 1 November 2018
Executive Summary In March 2017 the National Quality Board published guidance to ensure all NHS trusts implement a policy to learn from deaths within their organisations. The main purpose is to promote learning and improve how trusts support and engage with the families and carers of those who die in our care. NHS Improvement has emphasised that the purpose is not to count and classify deaths.
Improving patient journeys Related Trust objectives To provide assurance on implementation of Risk and Assurance the guidance. Related Assurance Framework Entries n/a Legal / Regulatory / Equality, Diversity & Dignity implications? National Quality Board guidance. How does this report affect Sustainability? n/a
Does this report reference the Trust's values of “Together: safe, kind and Yes excellent”?
Action required by the Board of Directors The Board is asked to receive the report for the period to October 2018. Cambridge University Hospitals NHS Foundation Trust
Learning from Deaths: Quarterly performance report April 2018 – October 2018 update
SJR overdue (SJR must be submitted Red within 25 days of the date of death)
1. Summary of learning from deaths KPIs SJR not yet submitted but within 25 day Amber timeframe
Sections in 2 3 4 5 6 7 report
Potentially SJR No. of Compliance Potentially SJRs PFD No. of avoidable % avoidability of % avoidability of all training deaths with in- avoidable triggered issued KPI deaths deaths deaths reviewed deaths compliance in- scope death SIs by family to in month identified (by deaths ‘in scope’) (by total deaths in month) (from SJR scope SJRs reported / carers CUH from SJR form) 100% 5% 0.8% 71% Apr-18 130 21 1 1 1 0 (21/21) (1/21) (1/130) (15/21)
94% 6% 4% 0.8% 0.6% 47% May-18 118 18 1 2* 3 0 (17/18) (1/17) (2/51) (1/118) (2/355) (8/17)
87% 0% 0% 46% Jun-18 107 15 0 2* 3 0 (13/15) (0/13) (0/107) (6/13)
95% 0% 0% 68% Jul-18 126 20 0 0 1 0 (19/20) (0/19) (0/126) (13/19)
81% 5% 2% 0.7% 0.3% 71% Aug-18 145 26 1 0* 0 0 (21/26) (1/21) (1/51) (1/145) (1/371) (15/21)
79% 0% 0% 55% Sep-18 100 14 0 1* 0 0 (11/14) (0/11) (0/100) (6/11)
33% 0% 0% 0% 0% 67% Oct-18 101 18 0 0 1 0 (6/18) (0/6) (0/6) (0/101) (0/101) (4/6)
* There are four discrepancies between the number of potentially avoidable deaths identified from the SJR and potentially avoidable deaths reported as serious incidents (SI). May 2018 SLR51444 – SJR was scored 4 – unavoidable, however on receipt of the post mortem report the case was reviewed and an SI commissioned via SIERP. The Mortality Surveillance Committee is to discuss how we reference a potential change in avoidability scores, where the original SJR original score no longer reflects the final avoidability assessment. June 2018 SLR51284 – Patient with subarachnoid haemorrhage secondary to a ruptured PCA aneurysm suffered a significant complication during the procedure when part of a coil became detached during insertion. Following submission of a clinical incident a 24 hour review was requested (ahead of SJR request) and an SI commissioned via SIERP. Consequently the SJR has not been undertaken as the information has already been collated through the 24 hour review and SI process. Agreed by the Mortality Surveillance Committee. SLR55103 – Patient died while in Custody and so a 24 hour review was completed and an SI commissioned at SIERP. There remains some discrepancy in process between 24 hour reviews and SJR which is under review and will be refined moving forward to minimise duplication.
Board of Directors: 14 November 2018 Learning from Deaths Page 1 of 16 Cambridge University Hospitals NHS Foundation Trust
September 2018 SLR55137 – SJR will be completed for this Stillbirth at the Perinatal Mortality Review Meeting in November 2018. A 24 hour review was completed and an SI commissioned at SIERP.
2. Number of deaths in month
There were 803 ED and inpatient deaths in April to August 2018, of which 44 were in the ED and 759 were inpatient deaths. The data in the graphs below monitors deaths, the data is taken from Epic via CHEQS. Graph 1 shows total CUH deaths (inpatients and Emergency Department (ED)) from April 2016 to October 2018. There is special cause variation in January 2017 and January 2018. There is special cause variation from April 2018 to October 2018.
Graph 1. ED and inpatient deaths XMR SPC 200
180
160
140
120
100
80
60 Jul-18 Jul-17 Jul-16 Oct-18 Apr-18 Oct-17 Apr-17 Oct-16 Apr-16 Jun-18 Jan-18 Jun-17 Jan-17 Jun-16 Mar-18 Feb-18 Mar-17 Feb-17 Nov-17 Dec-17 Aug-18 Sep-18 Nov-16 Dec-16 Aug-17 Sep-17 Aug-16 Sep-16 May-18 May-17 May-16 Number of ED and patient deaths UCL LCL Mean
Board of Directors: 14 November 2018 Learning from Deaths Page 2 of 16 Cambridge University Hospitals NHS Foundation Trust
Graph 2 shows Emergency Department deaths from April 2016 to October 2018. There is no special cause variation.
Graph 2. ED deaths XMR SPC 16 14 12 10 8 6 4 2 0 -2 -4 Jul-18 Jul-17 Jul-16 Oct-18 Apr-18 Oct-17 Apr-17 Oct-16 Apr-16 Jun-18 Jan-18 Jun-17 Jan-17 Jun-16 Mar-18 Feb-18 Mar-17 Feb-17 Nov-17 Dec-17 Aug-18 Sep-18 Nov-16 Dec-16 Aug-17 Sep-17 Aug-16 Sep-16 May-18 May-17 May-16 Number of ED deaths UCL LCL Mean
Graph 3 shows inpatient deaths only, from April 2016 to October 2018. There is special cause variation in January 2017 and January 2018. There is special cause variation from April 2018 to October 2018.
Graph 3. Inpatient deaths XMR SPC 180
160
140
120
100
80
60 Jul-18 Jul-17 Jul-16 Oct-18 Oct-17 Apr-18 Oct-16 Apr-17 Apr-16 Jan-18 Jun-18 Jan-17 Jun-17 Jun-16 Mar-18 Mar-17 Feb-18 Feb-17 Nov-17 Dec-17 Nov-16 Dec-16 Aug-18 Sep-18 Aug-17 Sep-17 Aug-16 Sep-16 May-18 May-17 May-16 Number of inpatient deaths UCL LCL Mean
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3. Structured judgement review (SJR) compliance 3.1. Deaths in-scope There were 803 ED and inpatient deaths in April to October 2018, of which 132 were in- scope for a structure judgement review (SJR); the in-scope criteria triggered are detailed in graph 4:
Graph 4. Pareto of SJR in-scope criteria April 2018 - October 2018 Total % 80 100 70 90 80 60 70 50 42 41 60 40 50 30 40 15 30 20 11 9 8 8 8 7 20 10 4 3 1 1 10 0 0 Stillbirth ED death Other deaths Maternaldeath Neonatal death Paediatric death Post-natal death Learning disability significant concerns Families/carers raised Elective admission death AlertTrust raised the with Unexpected trauma deaths Severe mental healthSevere mental illness
Staff raised significant concerns 132 patient deaths were in-scope for a structured judgement review, of which 24 deaths triggered multiple in-scope criteria; these are listed in the table below: In-scope trigger Total Alert raised with the Trust 1 Alert raised with the Trust, Severe mental health illness, Staff raised significant concerns 1 Alert raised with the Trust, Staff raised significant concerns 1 ED death 32 ED death, Alert raised with the Trust 1 ED death, Learning disability 1 ED death, Paediatric death 3 ED death, Paediatric death, Learning Disability 1 ED death, Post-natal death 3 ED death, Staff raised significant concerns 1 Elective admission death 10 Elective admission death, Families/carers raised significant concerns 2 Elective admission death, Staff raised significant concerns 2 Families/carers raised significant concerns 6 Families/carers raised significant concerns, Staff raised significant concerns 1 Learning disability 4 Learning disability, Staff raised significant concerns 1 Maternal death 1
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Neonatal death 7 Other deaths 1 Paediatric death 7 Post-natal death 3 Post-natal death, Elective admission death 1 Severe mental health illness, Staff raised significant concerns 2 Staff raised significant concerns 29 Staff raised significant concerns, Neonatal death 1 Staff raised significant concerns, Post-natal death 1 Stillbirth 7 Stillbirth, Staff raised significant concerns 1 Total 132
Of the 132 in-scope deaths, 108 SJRs have been completed to date; therefore compliance with completion of SJR for patients who died in April to October 2018 is currently 82%. The compliance by the thresholds for completion and by divisions is shown in the table below:
SJR SJR KPI compliance compliance A B C D E within 5 days by day 25
33% 76% N/A 100% 100% 100% 100% Apr-18 (7/21) (16/21) (0/0) (1/1) (14/14) (2/2) (4/4) 56% 78% 100% 100% 92% N/A 100% May-18 (10/18) (14/18) (2/2) (2/2) (12/13) (0/0) (1/1) 40% 73% N/A 100% 88% 0% 100% Jun-18 (6/15) (11/15) (0/0) (1/1) (7/8) (0/1) (5/5) 10% 50% N/A 100% 90% 100% 100% Jul-18 (2/20) (10/20) (0/0) (2/2) (9/10) (3/3) (5/5) 42% 62% 100% 0% 100% 33% 80% Aug-18 (11/26) (16/26) (2/2) (0/2) (14/14) (1/3) (4/5) 29% 79% 100% 100% 86% 100% 33% Sep-18 (4/14) (11/14) (2/2) (1/1) (6/7) (1/1) (1/3) 17% 33% 0% 0% 44% N/A 33% Oct-18 (3/18) (6/18) (0/1) (0/2) (4/9) (0/0) (2/6)
3.2. Length of time taken to complete SJRs (April 2018 to October 2018) Graph 5 reflects the average length of time taken (see Appendix 1) to complete an SJR between April 2018 and October 2018. The average length of time is 2.64 hours N.B. One SJR completed in GI medicine took 8 hours (see appendix 1).
Board of Directors: 14 November 2018 Learning from Deaths Page 5 of 16 Cambridge University Hospitals NHS Foundation Trust
Graph 5. Average length of time taken (hours) April 2018 - October 2018
Average time taken (hours) Mean 9.00 8.00 8.00
7.00
6.00
5.00 4.27 4.00 4.00 4.00 3.67 3.00 3.00 3.00 2.50 2.33 2.50 2.00 2.00 1.67 1.82 2.00 1.40 1.00 1.16 1.17 1.00 0.75
0.00 DME PICU NICU Urology JVF ICU Lower GI Lower Oncology Obstetrics Cardiology Hepatology Nephrology GI Medicine Gynaecology Orthopaedics Acute Medicine Vascular Surgery Respiratory Medicine Emergency Department Emergency Diabetes/Endocrinology
4. Potentially avoidable deaths 4.1. Cases identified and commissioned as SI – April 2018 - October 2018 There have been seven cases identified as a potentially avoidable death commissioned as a Serious Incident between April and October 2018. All seven cases were commissioned as SIs by the SI Executive Review Panel and reported to the CCG. Three of the seven cases originated from an SJR scored 1-3. Date of STEIS SI Sub Ward / Ref SI Title Div. Specialty occurrence categories Department Sub-optimal care of Disconnection from Respiratory SLR47991 28/04/2018 the deteriorating C Ward N3 non-invasive ventilation Medicine patient Suboptimal care of Department Sub-optimal care of deteriorating patient of Medicine SLR48762 06/05/2018 the deteriorating C Ward G3 resulting in peri-arrest for the patient call Elderly Complication during Surgical/invasive Angiography SLR51284 28/06/2018 B Radiology coiling procedure procedure incident Neuro Diagnostic incident Potentially missed including delay Emergency Emergency SLR51444 30/04/2018 diagnosis of aortic meeting (including C Department Medicine dissection failure to act on test – Adult results) Diagnostic incident including delay Missed diagnosis of Histopatholo SLR51908 17/07/2014 meeting (including B Pathology SCC gy failure to act on test results) Malignant melanoma ENT/HN/Pl SLR55103 07/08/2017 Treatment delay D Dermatology (death in custody) astics Maternity/Obstetric SLR55137 11/09/2018 Intrapartum still birth E Obstetrics Delivery Unit incident: baby only
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4.2. Percentage of avoidable deaths The percentage of avoidability of all deaths in April 2018 - October 2018 is 2.3% (3/132 SJRs completed to date). The distribution of avoidability scores of the deaths reviewed in the SJR are shown in the table below:
Possibly Definitely Evidence of Probably Slight evidence avoidable, Definitely not avoidable avoidability avoidable of avoidability not very avoidable (6) (1) (2) (3) (5) likely (4)
Apr-18 1 0 0 1 5 14
May-18 0 0 1 1 4 11
Jun-18 0 0 0 0 2 11
Jul-18 0 0 0 4 2 13
Aug-18 0 0 1 4 4 13
Sep-18 0 0 0 2 2 7
Oct-18 0 0 0 0 1 5
4. Structured judgement reviews triggered by family/carers
There have been nine SJRs initiated by this route for deaths between April 2018 and October 2018:
Reference Source of referral Subject Sub-subject Speciality Div.
Neighbour contacted PAC9243 / Neglect in Emergency member of CUH staff Patient care C PAC9580 hospital Medicine who raised concerns Slips trips and PAC9513 Letter Patient care falls - C DME unwitnessed Clinical Haem- PAC10584 Email Other B Treatment Oncology
Care needs not PAC9653 Letter Patient Care C DME adequately met
Clinical Information / Haem- PAC9595 Letter B Treatment Advice request Oncology Communication Vascular PAC10431 Email Communications with relatives / D Surgery carers Failure to PAC10763 Letter Patient care provide D Rehabilitation adequate care
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Discharge Admissions and Arrangements PAC9662 Letter A GI Medicine discharges (inc lack of or poor planning) Clinical Information / Transplant PAC10783 Email C Treatment Advice request Surgery
5. Consultant training compliance Of the SJRs completed (108/132) for patients who died between April 2018 and October 2018, 62% of SJRs in total were reviewed by a consultant who had completed the SJR training. This data was taken from the information on the SJR form.
Graph 6. SJRs reviewed by Consultant who completed SJR training
% trained Mean 80 70 60 50 40 30 20 10 0 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18
On average, 61% of SJRs are completed by a Consultant who has completed the SJR training.
6. Prevention of future death reports issued to Cambridge University Hospitals
There have been no Prevent Future Death orders for CUH between July 2018 and October 2018.
7. Learning
7.1. Learning from SIs There have been 19 unexpected/potentially avoidable death serious incidents reported to our commissioners in the last two years (November 2016 - October 2018); incidence is shown in graph 7.
Board of Directors: 14 November 2018 Learning from Deaths Page 8 of 16 Cambridge University Hospitals NHS Foundation Trust
Graph 7. Unexpected/potentially avoidable death SIs October 2015 - October 2018 4
3
2
1
0 Jul-18 Jul-17 Jul-16 Oct-18 Apr-18 Oct-17 Apr-17 Oct-16 Apr-16 Oct-15 Jun-18 Jan-18 Jun-17 Jan-17 Jun-16 Jan-16 Mar-18 Feb-18 Mar-17 Feb-17 Mar-16 Feb-16 Nov-17 Dec-17 Aug-18 Sep-18 Nov-16 Dec-16 Aug-17 Sep-17 Nov-15 Dec-15 Aug-16 Sep-16 May-18 May-17 May-16 Data Median
Quarterly incidence of unexpected/potentially avoidable death SIs in the last 12 months is shown in table 1. Table 1. Number of SIs reported to the CCG in quarter. Quarter 2017/18 2018/19
Q1 4 2 Q2 1 2 11 4 Q3 5 0 Q4 1
The highest reported SI subcategory (unexpected/potentially avoidable death), in the last 12 months, remains the ‘suboptimal care of the deteriorating patient’ at 50% (5/10). The incidence of subcategories is shown in graph 8 below.
Graph 8. Subcategory of potentially avoidable SIs (November 2017- October 2018)
Sub-optimal care of the deteriorating patient 5
Maternity/Obstetric incident: baby only (this includes foetus, neonate and infant) 2
Surgical/invasive procedure incident 1
HCAI/Infection control incident 1
Diagnostic incident including delay meeting (including failure to act on test results) 1
0 2 4 6
Board of Directors: 14 November 2018 Learning from Deaths Page 9 of 16 Cambridge University Hospitals NHS Foundation Trust
Completed unexpected/potentially avoidable death serious incidents reports submitted in April 2018 to October 2018 are listed in the table below:
Date of STEIS SI Sub Ward / Ref SI Title Div. Specialty occurrence categories Department Neurosurgical Sub-optimal care management of SLR37795 31/03/2015 of the deteriorating D Neurosurgery Ward A5 cerebral patient empyema Sepsis management - Sub-optimal care Acute MDU - Medical SLR39552 27/11/2017 delay in of the deteriorating C Medicine Decision Unit administration of patient antimicrobials Maternity/Obstetric SLR40354 14/12/2017 Stillbirth E Obstetrics Clinic 23 incident: baby only NIV patient - Sub-optimal care Inflammation SLR47991 28/04/2018 interruption of of the deteriorating C Ward N3 Infection NIV patient Suboptimal care Sub-optimal care of deteriorating Acute SLR48762 06/05/2018 of the deteriorating C Ward G3 patient resulting Services patient in peri-arrest call Complication Surgical/invasive Angiography SLR51284 28/06/2018 during coiling B Imaging procedure incident Neuro procedure Diagnostic incident including delay Missed diagnosis Histopathology SLR51908 17/07/2014 meeting (including B Pathology of SCC Laboratory failure to act on test results)
The causal factors from the above listed reports are summarised in the table below:
Causal factor classification* Serious Incident Domain Category Component
SLR37795 Communication factors Communication Communication strategy Sub-optimal care of the management & policy not defined deteriorating patient Staff factors Cognitive factors Overload Neurosurgical management of cerebral Task factors Procedural design Appropriate automation empyema not available Task factors Guidelines & procedures Unavailable
Wok environment Administrative factors unavailable
Organisational Safety culture Disempowerment of staff to escalate issues
Staff factors Cognitive factors Overload
Work environment Staffing Inappropriate skill mx
Board of Directors: 14 November 2018 Learning from Deaths Page 10 of 16 Cambridge University Hospitals NHS Foundation Trust
Team Support Failure to seek support
Education & training Supervision Inadequate supervision
SLR39552 Communication Lack of effective Communication factors Sub-optimal care of the management communication of risks deteriorating patient Team & Social factors Role congruence Lack of shared Sepsis management - understanding delay in administration of Communication Lack of effective antimicrobials orating Communication factors patient management communication of risks
SLR40354 Work environment Staffing Low staff to patient ratio Maternity/Obstetric incident: baby only - Stillbirth Work environment Environment Facility not available
Design of physical Poor or inappropriate Work environment environment area design SLR47991 Sub-optimal care of the deteriorating patient NIV patient - interruption of NIV Lack of risk management Organisational Safety Culture plans
SLR48762 Inappropriate target Sub-optimal care of the Education & Training Appropriateness deteriorating patient audience
Suboptimal care of deteriorating patient Education & Training Appropriateness Inappropriate content resulting in peri-arrest call
SLR51284 Surgical/invasive procedure incident No causal factors identified – known complication of procedure Complication during coiling procedure
Perception / viewpoint SLR51908 Staff Factors Cognitive factors affected by information or Diagnostic incident mindset including delay meeting Work load and hours of Work Conditions Excessive working hours Missed diagnosis of SCC work
*National Patient Safety Agency (NPSA) Contributory factors classification framework
Board of Directors: 14 November 2018 Learning from Deaths Page 11 of 16 Cambridge University Hospitals NHS Foundation Trust
7.2. Learning from phases of care
Scores allocated to the SJR section ‘Overall quality of care’ are displayed in the graph below for all completed SJRs between April 2018 and October 2018:
Graph 7. Overall quality of care April 2018 - October 2018 60 49 50
40 37
30
20 10 10 7 0 0 Very poor care Poor care (2) Adequate care Good care (4) Excellent care (1) (3) (5)
N.B. Poor care does not automatically indicate the avoidability of death score allocated
Rates of care scored during phase 1 – admission and initial management 3 - 5 - 1 – very 2 - poor 4 - good adequate excellent poor care care care care care
Apr-18 5 5 9
May-18 1 3 4 8
Jun-18 3 9
Jul-18 1 1 3 14
Aug-18 1 1 9 9
Sep-18 2 2 7
Oct-18 2 4
Board of Directors: 14 November 2018 Learning from Deaths Page 12 of 16 Cambridge University Hospitals NHS Foundation Trust
Rates of care scored during phase 2 – ongoing care 3 - 5 - 1 – very 2 - poor 4 - good adequate excellent poor care care care care care
Apr-18 2 5 1 6
May-18 2 4 3
Jun-18 5 4
Jul-18 2 2 10
Aug-18 1 1 4 5
Sep-18 1 2 5
Oct-18 1 3
Rates of care scored during phase 3 – care during a procedure
3 - 5 - 1 – very 2 - poor 4 - good adequate excellent poor care care care care care
Apr-18 2 3 2
May-18 2 1 2
Jun-18 1 2
Jul-18 1 2 7
Aug-18 4 2
Sep-18 4 5
Oct-18 1 2
Board of Directors: 14 November 2018 Learning from Deaths Page 13 of 16 Cambridge University Hospitals NHS Foundation Trust
Rates of care scored during phase 4 – perioperative care 3 - 5 - 1 – very 2 - poor 4 - good adequate excellent poor care care care care care
Apr-18 1 4
May-18 1 1
Jun-18
Jul-18 2 3
Aug-18 2
Sep-18 1 1
Oct-18
Rates of care scored during phase 5 – end of life care 3 - 5 - 1 – very 2 - poor 4 - good adequate excellent poor care care care care care
Apr-18 1 4 9
May-18 3 4 6
Jun-18 3 9
Jul-18 6 11
Aug-18 1 2 11
Sep-18 3 8
Oct-18 4
7.3 Themes of care Quantification of the learning themes emerging from the Phases of care section of the SJR is at present difficult. This may be resolved with the new mortality module in Datix Cloud IQ which may support data extraction and reporting of themes (work began in September 2018 on the mortality module). Key themes for improvement emerging from standards of care in Q2 are similar to those identified in Q1, 2018/9 SJRs: • DNACPR management – good and poor examples identified • Inadequate frequency of vital signs monitoring (acutely ill patients) • Ineffective recognition of deterioration of acutely ill patients
Board of Directors: 14 November 2018 Learning from Deaths Page 14 of 16 Cambridge University Hospitals NHS Foundation Trust
Listed below are some excerpts from SJRs (Q1, 2018/19) illustrating good care:
• The care delivered was of a very high standard, from initial evaluation and management to an overall management plan, through to treatment, as complications of advanced liver failure progressed. Escalation of care was appropriately performed and, in the final phase of patient’s illness, recognition of need to palliative care support. Excellent multi- disciplinary team working. Conclusions: High quality care Good multi-disciplinary involvement in care regarding assessment and listing for liver transplantation. Good liaison with Intensive Care Strong working with Palliative Care (Enhanced Supportive Care) team
• This was a rare case of xxxx that received excellent antenatal and neonatal care. Parents’ wishes were respected and supported by both obstetric and neonatal team. A final diagnosis was made from clinical examination, genetic and radiology tests and review from different specialties (including teams from other centres). Parents were well supported by the clinical and psychology teams. The care provided to infant and parents was excellent. There was clear record of the events and plans and the team was compassionate and kind.
8. Next Steps
The learning from deaths programme has been established for 12 months as of October 2018 and it has been agreed with the Mortality Surveillance Committee that this would be the appropriate time to review the effectiveness of the programme in conjunction with key stakeholders. The detail from this review will be presented to the Mortality Surveillance Committee in December 2018 and the Quality Committee in January 2019.
A Medical Examiner has been appointed to review all deaths in CUH from 1 April 2019. A pilot phase will begin locally from 5 November 2018 in JVF ICU, NCCU and the Rosie (obstetrics). During this phase, all deaths (excluding stillbirths) in these clinical areas will be reviewed by the Medical Examiner.
The Medical examiner is working closely with the Coroner to develop an effective process for appropriate SJR’s to be shared with the Coronial service. It is currently the case that all SJR’s scored equal to or less than 4 will be shared with the Coroner.
Good progress is being made with the appointment of a lay member to the Mortality Surveillance committee with 15 applications received. It is the intention the appointment process will be completed by 31 December 2018.
Board of Directors: 14 November 2018 Learning from Deaths Page 15 of 16 Cambridge University Hospitals NHS Foundation Trust
Appendix 1: Length of time taken to complete SJRs (April 2018 to October 2018)
Number of Total time Average Minimum Maximum April - October 2018 SJRs taken time taken time taken time taken completed Acute Medicine 2 5 hours 2.5 hours 2 hours 3 hours Cardiology 1 1 hour 1 hour 1 hour 1 hour Diabetes/Endocrinology 3 11 hours 3.67 hours 3 hours 4 hours DME 5 7 hours 1.4 hours 1 hour 2 hours Emergency Department 39 45.10 hours 1.16 hours 10 minutes 2 hours GI Medicine 1 8 hours 8 hours 8 hours 8 hours Gynaecology 1 3 hours 3 hours 3 hours 3 hours Hepatology 6 10 hours 1.67 hours 1 hour 2.5 hours JVF ICU 2 1.5 hours 45 minutes 30 minutes 1 hour Lower GI 2 4 hours 2 hours 1 hour 3 hours Nephrology 3 7 hours 2.33 hours 2 hours 3 hours NICU 11 47 hours 4.27 hours 2 hours 10 hours Obstetrics 6 7 hours 1.67 hours 3 hours 4 hours Oncology 6 15 hours 2.5 hours 3 hours 4 hours Orthopaedics 1 2 hours 2 hours 2 hours 2 hours PICU 4 12 hours 3 hours 2 hours 5 hours Respiratory Medicine 11 20 hours 1.82 hours 1 hour 3 hours Urology 1 4 hours 4 hours 4 hours 4 hours Vascular Surgery 2 8 hours 4 hours 2 hours 8 hours
Board of Directors: 14 November 2018 Learning from Deaths Page 16 of 16
Cambridge University Hospitals NHS Foundation Trust
Report to the Board of Directors: 14 November 2018
Agenda item 14 Title Board Assurance Framework Sponsoring executive director Ian Walker, Director of Corporate Affairs Author(s) As above
To receive the latest version of the Board Purpose Assurance Framework. Previously considered by Risk Oversight Committee, 25 October 2018
Executive Summary The Board Assurance Framework (BAF) provides a structure and process which enables the Board of Directors to focus on the principal risks which might compromise the achievement of the Trust’s strategic objectives. The BAF should identify the key controls which are in place to manage and mitigate those risks and the sources of assurance available to the Board regarding the effectiveness of the controls.
The April 2017 external review of Board governance concluded that the BAF should be reframed to focus on a smaller number of key strategic risks, alongside the development of a Corporate Risk Register (CRR) for the organisation. A revised version of the BAF was received and approved on this basis by the Board in October 2017 and it was agreed that the Board should in future receive the BAF on a quarterly basis, with Board committees reviewing the respective risks assigned to them at each meeting. The latest version of the BAF, for October 2018, is attached for review by the Board. It was reviewed by the Risk Oversight Committee at its meeting on 25 October 2018.
All objectives Related Trust objectives The report sets out the principal risks to Risk and Assurance the achievement of the Trust’s strategic objectives. Related Assurance Framework Entries All BAF entries. The BAF is a key document which informs Legal implications/Regulatory requirements the Annual Governance Statement. How does this report affect Sustainability? n/a Does this report reference the Trust's values n/a of “Together: safe, kind and excellent”?
Action required by the Board of Directors The Board is asked to receive and approve the latest version of the Board Assurance Framework.
Cambridge University Hospitals NHS Foundation Trust
14 November 2018
Board of Directors Board Assurance Framework Ian Walker, Director of Corporate Affairs
Introduction
1. The Board Assurance Framework (BAF) provides a structure and process which enables the Board of Directors to focus on the principal risks which might compromise the achievement of the Trust’s strategic objectives. The BAF should identify the key controls which are in place to manage and mitigate those risks and the sources of assurance available to the Board regarding the effectiveness of the controls.
2. The April 2017 external review of Board governance concluded that the BAF should be reframed to focus on a smaller number of key strategic risks, alongside the development of a Corporate Risk Register for the organisation. It also recommended the development of a new Risk Management Strategy and Policy and the establishment of an Executive-led Risk Oversight Committee to review risks on both the CRR and the BAF.
3. The following progress has been made over the past 18 months:
• The new Risk Management Strategy and Policy was approved by the Board of Directors in June 2017, with minor revisions and an updated risk appetite statement approved by the Board on 12 September 2018. • The Risk Oversight Committee, chaired by the Chief Executive and comprising all members of the Management Executive, held its first meeting in June 2017 and has met on a monthly basis since. • A Corporate Risk Register (risks which cannot be managed at divisional/corporate directorate level) has been produced and continues to develop. It is reviewed on a monthly basis by the Risk Oversight Committee. • The revised version of the BAF was approved by the Board of Directors at its meeting on 11 October 2017 and it was agreed that the Board should receive the BAF on a quarterly basis, with Board assurance committees reviewing the respective risks assigned to them at each meeting (which has taken place). • The annual Internal Audit review of the BAF and risk management (May 2018) provided an overall assessment of “significant assurance with minor improvement opportunities”.
Development and review of the BAF
4. Each BAF risk is assigned an Executive Lead and a Board oversight committee (either one of the Board committees or the Board itself). A key responsibility of the committees, as embodied in their terms of reference, is to ensure that their work programmes are informed by the relevant BAF risks and that they are able to satisfy themselves, and in turn the Board of Directors, that appropriate assurance is being sought and provided on the controls in place to manage the risk, and actions to address gaps in control or assurance are being implemented.
Board of Directors: 14 November 2018 Board Assurance Framework Page 2 of 3
5. Since October 2017, monthly reviews have been undertaken of each BAF risk – and CRR risks – with the respective lead Executive Director. Proposed updates have then been presented for review to the Risk Oversight Committee on a monthly basis and the BAF entry has been updated accordingly.
6. The October 2018 version of the BAF is attached at Appendix 1. It incorporates updates from monthly reviews undertaken in September and October 2018. These have been reviewed by the respective Board assurance committees.
7. There are currently 13 risks on the BAF, unchanged from the April 2018 version received by the Board in May 2018. One risk has been added (by dividing the previous IT risk into two) and one was closed (relating to quality governance) in September 2018.
8. A detailed log of monthly amendments and updates to the BAF as reviewed by the Risk Oversight Committee is available to Board members on request. In summary, the key issues and changes since the BAF was last received by the Board of Directors in September 2018 are as follows:
• 008/18: to amend the formulation of the risk relating to decisions on estates and infrastructure investment. It is proposed to change the cause of the risk to capital constraints rather than the lack of a well-developed estates strategy.
• 011a/18: there was a discussion at the Audit Committee in October 2018 regarding the scoring of risk 011a/18 on cyber security – in relation to whether the likelihood should be higher than currently scored. Following further review with the Director of Improvement and Transformation and discussion at the Risk Oversight Committee, it is proposed to retain the current score of 15 (I5 x L3).
9. Of the 13 current BAF risks, there are eight rated at 20, 16 or 15 as follows:
• Capacity to manage patient flow (20) • Fire safety (20) • Estates backlog maintenance and statutory compliance priorities (20) • Redesign of models of care and patient pathways (16) • Sustainable workforce – recruitment and retention (16) • Structural deficit support (16) • IT infrastructure resilience (16) • Cyber security (15)
10. The Trust's risk scoring matrix is appended to the BAF for reference.
Recommendation
11. The Board of Directors is asked to receive and approve the latest version of the Board Assurance Framework.
Board of Directors: 14 November 2018 Board Assurance Framework Page 3 of 3 Cambridge University Hospitals NHS Foundation Trust Board Assurance Framework: October 2018
BAF overview – ranked by current (proposed) risk rating
Risk Current Risk description Lead Board monitoring committee ref. rating Executive
007/18 20 A failure to address estate backlog maintenance and statutory compliance priorities (including infection) Chief Finance Performance Committee caused by insufficient capital funding and decant capacity impacts on safety and continuity of clinical service Officer Quality Committee delivery. 007a/18 20 Inadequate fire safety management arrangements and plans impact on patient and staff safety and continuity Chief Finance Board of Directors of clinical service delivery. Officer 002/18 20 The Trust has insufficient capacity to sustain timely and effective emergency and elective patient flow through Chief Operating Performance Committee its hospitals which impacts on waiting times, safety and patient experience. Officer 004/18 16 As a result of recruitment and retention challenges, the Trust does not have adequate staffing which impacts Director of Workforce and Education on the delivery of safe and responsive services for our patients. Workforce Committee 001/18 16 The Trust does not work sufficiently effectively with partners to organise and redesign models of care and Director of Strategy Board of Directors patient pathways which impacts on continuity of service delivery and the ability to manage demand for and Major Projects hospital services. 010/18 16 As a result of not achieving system-wide service redesign and securing support for the structural element of Chief Finance Performance Committee the financial deficit, the Trust does not achieve a position of financial sustainability by 2020 which impacts on Officer its ability to improve services for patients. 011b/18 16 There is insufficient resilience in the Trust’s IT network and technology platform given the reliance on Director of Quality Committee electronic patient information to cope with IT infrastructure failures which impacts on the delivery of safe and Improvement and effective services for patients. Transformation 011a/18 15 There is insufficient protection in the Trust’s IT network and technology platform given the reliance on Director of electronic patient information to cope with a cyber attack which impacts on the delivery of safe and effective Improvement and Audit Committee services for patients. Transformation 009/18 12 As a result of slippage against its activity and CIP plans, the Trust does not achieve its financial plan for Chief Finance Performance Committee 2018/19. Officer 003/18 12 As a result of insufficient planning and testing, the Trust is not adequately prepared to deal with a major Chief Operating Performance Committee incident or emergency. Officer 006/18 12 The culture and climate of the organisation is not conducive to high levels of staff engagement and Director of Workforce and Education empowerment which impacts on staff morale, staff-led quality improvement and patient experience. Workforce Committee 008/18 12 As a result of capital and capacity constraints, decisions on estates and infrastructure investment are delayed Chief Finance Board of Directors and/or sub-optimal for the long term despite having an estates strategy and masterplan aligned with the Officer Trust’s organisational and clinical strategy. 012/18 12 The Trust does not maximise the opportunities of working with Campus partners and other stakeholders to Director of Strategy Board of Directors harness the benefits of the biomedical campus and life sciences for its patients and the wider NHS. and Major Projects
Note: 005/18 was removed from the BAF in September 2018 Cambridge University Hospitals NHS Foundation Trust Board Assurance Framework: October 2018
BAF risk 001/18 The Trust does not work sufficiently effectively with partners to organise and redesign models of care and patient Current risk pathways which impacts on continuity of service delivery and the ability to manage demand for hospital services. rating:
Strategic theme ST2: Working with our communities Lead Executive Director of Strategy and Major (ST 2.1, 2.2) Projects 16 Latest review date October 2018 Board monitoring committee Board of Directors
Risk rating Impact Likelihood Total Change Related BAF and Corporate Risk Register entries since last ID Score Summary risk description month Initial (Sep 17) 3 3 9 BAF 002/18 20 Capacity to manage patient flow Current (Oct 18) 4 4 16 BAF 012/18 12 Maximise benefits of Biomedical Campus and life sciences Target (Mar 19) 4 3 12 CR 18 12 Cambridge Transition Programme (Papworth)
Key controls Assurances on controls What are we already doing to manage the risk? How do we gain assurance that the controls are working? 1. STP participation through Delivery Groups, Clinical Advisory Group and 1. STP Board meetings in public from October 2018. Health and Care Executive. 2. Health and Care Executive meetings. 2. STP Interim Chair in post from April 2018. 3. Monthly A&E Delivery Board with partners, with reporting to Performance 3. STP Interim Accountable Officer appointment, 6-9 months from July 2018. Committee and Board of Directors via Integrated Report. 4. STP Board comprising Chairs, Chief Executives and elected members. 4. Reports to Board of Directors on STP (quarterly) and Papworth (four-monthly). 5. Focus on key priorities for 2018/19: DTOC, ED, finance and locality model 5. Oversight of progress on workforce redesign plans by Workforce and Education (including development of north and south alliances with partners). Committee. 6. Working with partners on local delivery mechanisms for local populations. 6. STP progress rating by NHS England: ‘Category 2’. 7. Fortnightly meetings with Papworth chaired by the two Chief Executives.
Gaps in control Gaps in assurance Actions to address gaps in controls and assurances Due date C1. Increase clinical engagement. A1. Need for clear C1. Engage clinicians (inc. primary and community care) in co- Ongoing C2: Agree and communicate longer-term leadership success criteria and design and implementation, specifically through alliances. and governance arrangements. metrics. C2. CUH input to STP Board discussions with NHSI/NHSE. December 2018 C3: Develop vision, remit and priorities for north C3: To be developed by delivery groups. December 2018 and south alliances. A1. Develop and implement evaluation methodology. November 2018
Risk score Mar 18 Apr 18 May 18 Jun 18 Jul 18 Aug 18 Sep 18 Oct 18 Nov 18 Dec 18 Jan 19 Feb 19 Mar 19 12 16 16 16 - 16 16 16
2
Cambridge University Hospitals NHS Foundation Trust Board Assurance Framework: October 2018
BAF risk 002/18 The Trust has insufficient capacity to sustain timely and effective emergency and elective patient flow through its Current risk hospitals which impacts on waiting times, safety and patient experience. rating:
Strategic theme ST1: Improving patient journeys (ST 1.1) Lead Executive Chief Operating Officer Latest review date October 2018 Board monitoring committee Performance 20
Risk rating Impact Likelihood Total Change Related BAF and Corporate Risk Register entries since last ID Score Summary risk description month Initial (Sep 17) 5 4 20 CR 05/08 20/16 Insufficient capacity across the Trust/adequacy of winter plans Current (Oct 18) 4 5 20 BAF 007a/18 20 Fire safety Target (Dec 18) 4 4 16 BAF 004/18 16 Recruitment and retention challenges
Key controls Assurances on controls What are we already doing to manage the risk? How do we gain assurance that the controls are working? 1. Physical Capacity Plan for 2018/19 based on Trust and STP modelling. 1. Paper on 2018/19 capacity plan to Board in March 2018. 2. 2018 Winter Plan (inc. flu plan) being developed – inc. lessons from 2017. 2. Monthly meetings of Board Performance Committee to seek assurance on all 3. Detailed escalation plans in response to capacity shortages. aspects of operational performance. 4. ED streaming service in place. 3. Monthly review of Integrated Performance Report by Board of Directors. 5. Length of stay/stranded patients reduction programme. 4. Bi-monthly Performance Review Meetings with NHSI. 6. System-wide DTOC plan with oversight at chief executive level. 5. A&E Delivery Board chaired by Chief Executive with system partners. 7. Development of capacity plan for 2019/20 and beyond. 6. Oversight by Physical Capacity Steering Group chaired by COO. 8. Capital bids submitted via STP underpinned by system capacity plan. 7. DTOC peer-review – October 2018.
Gaps in control Gaps in Actions to address gaps in controls and assurances Due date assurance C1. DTOCs not reduced to trajectory (target score for July not C1. Refreshed system DTOC plan being implemented. December 2018 achieved - reset based on reduction by Dec 18). C2 and C3. Funding bid submitted through STP and awaiting C2. Funding for modular build to maintain capacity during fire outcome in November 2018 – Board decision will then be improvement works not yet agreed. required on next steps including scope to maintain services. December 2018 C3. Funding of medium-term capacity plans not yet identified. C4. Programme in place to deliver trajectory. December 2018 C4. Trajectory for stranded patients still to be achieved.
Risk score Mar 18 Apr 18 May 18 Jun 18 Jul 18 Aug 18 Sep 18 Oct 18 Nov 18 Dec 18 Jan 19 Feb 19 Mar 19 20 20 20 - 20 20 20 20
3
Cambridge University Hospitals NHS Foundation Trust Board Assurance Framework: October 2018
BAF risk 003/18 As a result of insufficient planning and testing, the Trust is not adequately prepared to deal with a major incident or Current risk emergency. rating:
Strategic theme ST1: Improving patient journeys (ST 1.2) Lead Executive Chief Operating Officer Latest review date October 2018 Board monitoring committee Performance 12
Risk rating Impact Likelihood Total Change Related BAF and Corporate Risk Register entries since last ID Score Summary risk description month Initial (Sep 17) 4 3 12 BAF 011/18 15 IT resilience Current (Oct 18) 4 3 12 Target (Mar 19) 4 2 8
Key controls Assurances on controls What are we already doing to manage the risk? How do we gain assurance that the controls are working? 1. Emergency Preparedness, Resilience and Response (EPRR) Strategy. 1. EPRR Steering Group chaired by the Director of Operations. 2. Major Incident Plan (MIP) and Critical Incident Procedure. 2. Nominated Non Executive Director with oversight of EPRR. 3. Trust Resilience Manager in post. 3. Annual assurance reports to the Board’s Performance Committee. 4. Training for Gold, Silver and Bronze commanders on roles and 4. Report to Board of Directors in July 2017 following London/Manchester responsibilities - all Gold Directors have attended NHSE Regional Training incidents. and one-to-one session with Trust Resilience Manager. 5. External review of EPRR commissioned by COO and undertaken in March 2017. 5. Exercises (internal and system wide) to test resilience of plans. 6. Annual EPRR Core Standards assurance process including external visit by 6. Regular liaison meetings with system partners to ensure learning and NHSE/NHSI – latest took place on 10 October 2017. 2018 review underway and sharing of best practice. CCG peer review undertaken on 7 September 2018.
Gaps in control Gaps in assurance Actions to address gaps in controls and assurances Due date C1. Full ‘end-to-end’ major incident exercise to be C1. COO to identify resourcing and timetable. tbc undertaken subject to resourcing. C2. Review of support arrangements across Divisions and C2. External review identifies need to review resourcing within trauma network. December 2018 to support Resilience Manager post.
Risk score Mar 18 Apr 18 May 18 Jun 18 Jul 18 Aug 18 Sep 18 Oct 18 Nov 18 Dec 18 Jan 19 Feb 19 Mar 19 12 12 12 - 12 12 12 12
4
Cambridge University Hospitals NHS Foundation Trust Board Assurance Framework: October 2018
BAF risk 004/18 As a result of recruitment and retention challenges, the Trust does not have adequate staffing which impacts on the Current risk delivery of safe and responsive services for our patients. rating:
Strategic theme ST3: Strengthening the organisation (ST 3.1) Lead Executive Director of Workforce Latest review date October 2018 Board monitoring committee Workforce and Education 16
Risk rating Impact Likelihood Total Change Related BAF and Corporate Risk Register entries since last ID Score Summary risk description month Initial (Sep 17) 4 4 16 BAF 001/18 16 Working with partners on models of care and pathways Current (Oct 18) 4 3 16 BAF 002/18 20 Capacity to manage patient flow Target (Mar 19) 4 3 12 BAF 006/18 12 Staff engagement and empowerment CR 17 12 Skilled workforce
Key controls Assurances on controls What are we already doing to manage the risk? How do we gain assurance that the controls are working? 1. Continued multi-channel recruitment – local, national and overseas, with 1. Monthly nursing/midwifery safe staffing report to Board of Directors, including nursing pipeline currently delivering as anticipated driven by reliance on tracking of progress against nursing pipeline through safe staffing Board report overseas recruitment (7.5% nursing vacancy rate (inc. non-productive) by from Chief Nurse. March 2019, although productive vacancy rate remains high into 2019 due 2. Monthly data in Integrated Performance Report on turnover, vacancies, to 6-9 month lag effect from overseas recruitment). bank/agency fill rates/etc. reviewed by Performance Committee and Board. 2. Payment of retention and other premia for specific staff groups (e.g. 3. Staff Survey (annual and quarterly FFT) feedback on retention issues. Theatre ODPs), linked to training and development. 4. Quarterly reporting to the Board by the Guardian of Safe Working in respect of 3. Scrutiny of agency costs and other premium pay spend arising from junior doctors. vacancy position. 5. Workforce and Education Committee oversight (quarterly). 4. Short-term reductions in capacity as required to maintain patient safety 6. NHSI Performance Review Meetings (bimonthly). where there are staffing shortages, e.g. Lewin Ward. 7. Quarterly reporting to the Board on Cambridge Transition Plan (Papworth 5. Travel and transport programme on staff travel to work. move). 6. Prioritisation of education and training within constrained budgets. 8. Board Seminar in November 2017 on Sustainable Workforce. 7. Provision of support to staff non-UK staff in context of Brexit concerns. 8. Active membership of NHSI group on nursing recruitment and retention. 9. Joint working with Papworth to minimise recruitment and retention risks associated with Papworth’s move to the Campus in autumn 2018. 10. Establishment of Sustainable Workforce Improvement Team including 2-5 year programme on enhancing supply, including use of Apprenticeship
5
Cambridge University Hospitals NHS Foundation Trust Board Assurance Framework: October 2018
Levy. Launch of Nurse Apprenticeship Degree Programme. 11. Partnership working on transport links and affordable housing.
Gaps in control Gaps in assurance Actions to address gaps in controls and assurances Due date C1. No recognition in national pay C1. Ongoing discussions at national level. Ongoing framework for regional variations in C2. Discussions to take place at Improvement Steering Group. December 2018 cost of living. C3. Development of workforce plans through business Ongoing C2. Need to agree resourcing for and planning processes. engagement in Sustainable Workforce programme (5-10 year horizon). C3. Development of 3-5 year workforce plans for staff groups other than nursing.
Risk score Mar 18 Apr 18 May 18 Jun 18 Jul 18 Aug 18 Sep 18 Oct 18 Nov 18 Dec 18 Jan 19 Feb 19 Mar 19 16 16 16 16 16 16 16 16
6
Cambridge University Hospitals NHS Foundation Trust Board Assurance Framework: October 2018
BAF risk 006/18 The culture and climate of the organisation is not conducive to high levels of staff engagement and empowerment Current risk which impacts on staff morale, staff-led quality improvement and patient experience. rating:
Strategic theme ST3: Strengthening the organisation (ST 3.1, 3.2) Lead Executive Director of Workforce Latest review date October 2018 Board monitoring committee Workforce and Education 12
Risk rating Impact Likelihood Total Change Related BAF and Corporate Risk Register entries since last ID Score Summary risk description month Initial (Sep 17) 4 3 12 BAF 004/18 16 Recruitment and retention Current (Oct 18) 4 3 12 CR 12 12 Equality and diversity Target (Mar 19) 4 3 12
Key controls Assurances on controls What are we already doing to manage the risk? How do we gain assurance that the controls are working? 1. Leadership and development programmes across the organisation. 1. Annual staff survey results. 2. Start Well/Stay Well plans for staff experience. 2. Quarterly Staff FFT results inc local questions – improvement in 2018/19Q1. 3. Strategy awareness and programme of staff-led improvement. 3. Monitoring by Equality, Diversity and Dignity Steering Group. 4. Application of workforce policies and procedures. 4. Oversight by Workforce and Education Committee. 5. Internal communications and engagement channels. 5. Biannual updates on improvement strategy to Board of Directors. 6. Visits by Executive Team to wards and departments and Exec ‘drop-ins’. 6. Biannual reporting to the Board of Directors on Freedom to Speak Up. 7. Workforce Race Equality Plan approved by Board in September 2018 with 7. CQC Well-led internal assessment in 2018/19. plan to identify additional actions and increase pace and focus. 8. Accountability Framework approved by Board in May 2018. 9. Freedom to Speak Up Guardian role.
Gaps in control Gaps in assurance Actions to address gaps in controls and assurances Due date C1. Issues of harassment and bullying and equality C1. Implementation of staff survey action plan including Ongoing of opportunity highlighted in staff survey, including action plans on bullying and WRES; agreement by Board to as they relate to BME staff. take further actions to improve opportunities for BME staff. C2. Consistently tackling inappropriate behaviours C2. Management Executive to discuss follow up from Senior and demonstrating this is happening. Leaders’ Programme ‘Open Space’ event and agree actions. December 2018
Risk score Mar 18 Apr 18 May 18 Jun 18 Jul 18 Aug 18 Sep 18 Oct 18 Nov 18 Dec 18 Jan 19 Feb 19 Mar 19 12 12 12 12 12 12 12 12
7
Cambridge University Hospitals NHS Foundation Trust Board Assurance Framework: October 2018
BAF risk 007/18 A failure to address estate backlog maintenance and statutory compliance priorities (including infection) caused by Current risk insufficient capital funding and decant capacity impacts on safety and continuity of clinical service delivery. rating:
Strategic theme ST3: Strengthening the organisation (ST 3.3) Lead Executive Chief Finance Officer Latest review date October 2018 Board monitoring committee Performance 20 Quality
Risk rating Impact Likelihood Total Change Related BAF and Corporate Risk Register entries since last ID Score Summary risk description month Initial (Sep 17) 5 4 20 CR 03 15 Water quality Current (Oct 18) 5 4 20 CR 07 20 Infection control Target (Mar 19) 5 4 20 CR 09 12 Health and Safety engagement BAF 002/18 20 Capacity to manage patient flow
Key controls Assurances on controls What are we already doing to manage the risk? How do we gain assurance that the controls are working? 1. Estate Condition Survey completed and documented with risk ratings. 1. Capital Advisory Board approved the risk based backlog maintenance Oversight by externally-appointed Authorising Engineers. investment plan in July 2018. 2. Introduction of the Premises Assurance Model (PAM) within the 2. Three monthly reporting on backlog spend (November 2018) and risk reduction department being piloted with a view to roll out in late 2018. to Capital Advisory Board. 3. Six Facet survey commissioned. 3. Capital Advisory Board reports to Management Executive. 4. Capital programme for 2018/19 prioritised. 4. Biannual assurance reports to the Board’s Performance Committee on estate 5. STP capital proposals submitted to NHSI/NHSE in July 2018. and facilities services (first scheduled for December 2018). 6. Immediate works on fire compartmentation in high risk areas (007a/18). 5. Fire safety – see BAF 007a/18. 7. Water quality mitigations in place including water safety plan, testing and 6. Infection control and health and safety – assurance reports to the Board’s targeted flushing. Quality Committee. 8. Improved governance relating to water quality, asbestos, medical gases 7. Deep dive by the Patient Safety team in the water quality risk in July 2018 through established governance groups reporting to the Health and Safety reported to the Risk Oversight Committee in August 2018. Committee via the estates and Facilities health and safety Group.
Gaps in control Gaps in assurance Actions to address gaps in controls and assurances Due date C1. Only the highest risks are addressed C1. Ongoing dialogue with NHSI to secure funding. Board Ongoing agreement to proceed with essential spend.
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Cambridge University Hospitals NHS Foundation Trust Board Assurance Framework: October 2018
C2. Six Facets survey required. C2. Commission and deliver Six Facet Survey. December 2018 C3. More work underway to improve the overall C3. Targeted work continues to improve the governance, Ongoing governance, data quality and pace of the statutory supported by external authorising engineers. compliance groups to improve the overall environment.
Risk score Mar 18 Apr 18 May 18 Jun 18 Jul 18 Aug 18 Sep 18 Oct 18 Nov 18 Dec 18 Jan 19 Feb 19 Mar 19 20 20 20 20 20 - 20 20
9
Cambridge University Hospitals NHS Foundation Trust Board Assurance Framework: October 2018
BAF risk 007a/18 Inadequate fire safety management arrangements and plans impact on patient and staff safety and continuity of clinical Current risk service delivery. rating:
Strategic theme ST3: Strengthening the organisation (ST 3.3) Lead Executive Chief Finance Officer Latest review date October 2018 Board monitoring committee Board of Directors 20
Risk rating Impact Likelihood Total Change Related BAF and Corporate Risk Register entries since last ID Score Summary risk description month Initial (Dec 17) 5 4 20 CR 09 12 Health and Safety engagement Current (Oct 18) 5 4 20 BAF 002/18 20 Capacity to manage patient flow Target (Mar 19) 5 4 20 BAF 007/18 20 Capital funding and estates backlog
Key controls Assurances on controls What are we already doing to manage the risk? How do we gain assurance that the controls are working? 1. Fire policy, protocols and risk assessments in place for all areas. 1. Monthly updates to the Management Executive to provide executive oversight. 2. Fire Safety Team and Fire Response Team in place. 2. Monthly updates to the Board of Directors to provide updates and assurance 3. Fire aspiration system for Level 1 integrated to the Trust's fire alarm on plans. system has been implemented. 3. Work of Physical Capacity Steering Group to develop capacity plans for 4. Plans for upgrade of fire alarm system developed and works commenced 2018/19 and 2019/20 – see risk 002/17. (99% of detectors upgraded to date). 4. Capital Advisory Board reviews capital priorities, reporting to Management 5. Evacuation strategy and plan and equipment in place, including two fire Executive. evacuation lifts in A Block. 5. Biannual assurance reports to the Board’s Performance Committee on estate 6. New fire extinguisher contract in place. and facilities services – first scheduled for December 2018. 7. Fire safety awareness training in place – 95.2% compliance rate. 6. Review of Trust plans by CFRS. Regular meetings continue to take place and 8. 2018/19 capacity plan includes upgrade to C3 and PICU including fire future meetings are scheduled. safety measures. Alternative means of escape for PICU is under design. 9. Improvement Plan in development in liaison with Cambridgeshire Fire and Rescue Service (CFRS) based on a two-stage approach and focused around compartmentation, evacuation and the fire alarm system. Includes immediate ‘find-and-fix’ element of fire stopping for designated ‘hazard rooms’.
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Cambridge University Hospitals NHS Foundation Trust Board Assurance Framework: October 2018
Gaps in control Gaps in assurance Actions to address gaps in controls and assurances Due date C1. Stage 1 Fire Improvement Plan finalised and agreed A1. Stage 2 work C1. And A1. Ongoing discussions with CFRS – updates provided with CFRS. programme not to Board on a monthly basis. Board agreement in December Ongoing C2. Decant capacity not yet fully identified to allow fully developed. 2017 to proceed with capital expenditure as required to work on fire compartmentation. deliver agreed Improvement Plan. C2. Management Executive working on a phase 2 capacity plan December 2018 for 2019/20 and 2020/21. STP capital bid submitted in July 2018 for additional short-term capacity – Board decision in December 2018 on next steps following outcome of capital bids. C2. Accelerated works scheme being developed as an December 2018 alternative to whole ward decant and ward decant for fire safety works only.
Risk score Mar 18 Apr 18 May 18 Jun 18 Jul 18 Aug 18 Sep 18 Oct 18 Nov 18 Dec 18 Jan 19 Feb 19 Mar 19 20 20 20 20 20 - 20 20
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Cambridge University Hospitals NHS Foundation Trust Board Assurance Framework: October 2018
BAF risk 008/18 As a result of capital and capacity constraints, decisions on estates and infrastructure investment are delayed and/or Current risk sub-optimal for the long term despite having an estates strategy and masterplan aligned with the Trust’s organisational rating: and clinical strategy.
Strategic theme ST3: Strengthening the organisation (ST 3.3) Lead Executive Chief Finance Officer 12 Latest review date October 2018 Board monitoring committee Board of Directors
Risk rating Impact Likelihood Total Change Related BAF and Corporate Risk Register entries since last ID Score Summary risk description month Initial (Sep 17) 3 4 12 BAF 012/18 12 Working with Campus partners and stakeholders Current (Oct 18) 3 4 12 Target (Mar 19) 3 2 6
Key controls Assurances on controls What are we already doing to manage the risk? How do we gain assurance that the controls are working? 1. 1-3 year estates strategy approved by the Board in September 2017. 1. All major business cases reviewed by Investment Committee chaired by the 2. Trust Strategy refresh undertaken during 2017/18 Q4 and 2018/19 Q1. Chief Finance Officer; and business cases >£4m reviewed by the Board. 3. Capacity plan for 2018/19 developed. 2. Board review of Cancer Research Hospital OBC in December 2017 and 4. Joint working with Campus partners on Cancer Research Hospital; and on agreement on next steps. OBC approved by Board in July 2018. Children’s Hospital SOC. 3. Board approval of Children’s Hospital SOC in November 2017. 5. Phase 1 of Estates Masterplan Refresh completed in March 2018. 4. CUH Estates Masterplan Refresh discussed by Board in March and April 2018. 6. STP capital bid in July 2018 for interim replacement capacity. 5. Emerging risks managed through the Risk Oversight Committee through 7. Fire safety works are undertaken to existing buildings. candidate risks and corporate risk register and Board Assurance Framework. 6. Divisional oversight of capital programme at Capital Advisory Board.
Gaps in control Gaps in assurance Actions to address gaps in controls and assurances Due date C1. STP capital bid submitted in July C1. Board to review position following outcome of capital bids December 2018 2018. process. C2. Wider Campus masterplanning C2. Wider campus masterplanning to be undertaken in tbc exercise to follow. 2018/19.
Risk score Mar 18 Apr 18 May 18 Jun 18 Jul 18 Aug 18 Sep 18 Oct 18 Nov 18 Dec 18 Jan 19 Feb 19 Mar 19 12 12 12 12 12 - 12 12
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Cambridge University Hospitals NHS Foundation Trust Board Assurance Framework: October 2018
BAF risk 009/18 As a result of slippage against its activity and CIP plans, the Trust does not achieve its financial plan for 2018/19. Current risk rating:
Strategic theme ST3: Strengthening the organisation Lead Executive Chief Finance Officer Latest review date October 2018 Board monitoring committee Performance 12
Risk rating Impact Likelihood Total Change Related BAF and Corporate Risk Register entries since last ID Score Summary risk description month Initial (Sep 17) 4 4 16 BAF 002/18 20 Emergency and elective flow Current (Oct 18) 4 3 12 BAF 004/18 16 Recruitment and retention Target (Mar 19) 4 3 12 BAF 010/18 16 Achieving financial sustainability
Key controls Assurances on controls What are we already doing to manage the risk? How do we gain assurance that the controls are working? 1. Financial control framework as set out in Standing Financial Instructions. 1. Monthly oversight of performance against financial plan by Improvement 2. Budget holder training. Steering Group (ISG) chaired by Chief Executive, informed by established suite 3. Trust financial plan for 2018/19 acknowledged by NHSI and of PMO reports. acknowledgement of cash cover (control total not agreed). 2. Monthly review of financial performance by NED-chaired Performance 4. Guaranteed Income Contract for 2018/19. Committee and Board of Directors. 5. 2018/19 CIP programme in place with clear divisional/workstream targets 3. NHSI Performance Review Meetings (bi-monthly). – refresh exercise at Improvement Steering Group in December 2018. 6. Programme Management Office resourced and tracking delivery. 7. Monthly Executive Performance Review Meetings with divisions.
Gaps in control Gaps in assurance Actions to address gaps in controls and assurances Due date C1. Transition costs of Commodity IT C1. Ongoing discussions with provider – Board updated Ongoing contract still to be finalised. regularly.
Risk score Mar 18 Apr 18 May 18 Jun 18 Jul 18 Aug 18 Sep 18 Oct 18 Nov 18 Dec 18 Jan 19 Feb 19 Mar 19 16 16 16 16 12 12 12 12
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Cambridge University Hospitals NHS Foundation Trust Board Assurance Framework: October 2018
BAF risk 010/18 As a result of not achieving system-wide service redesign and securing support for the structural element of the Current risk financial deficit, the Trust does not achieve a position of financial sustainability by 2020 which impacts on its ability to rating: improve services for patients.
Strategic theme ST3: Strengthening the organisation Lead Executive Chief Finance Officer 16 Latest review date October 2018 Board monitoring committee Performance
Risk rating Impact Likelihood Total Change Related BAF and Corporate Risk Register entries since last ID Score Summary risk description month Initial (Sep 17) 4 3 12 BAF 009/18 12 Achievement of 2018/19 financial plan Current (Oct 18) 4 4 16 Target (Mar 19) 4 4 16
Key controls Assurances on controls What are we already doing to manage the risk? How do we gain assurance that the controls are working? 1. Financial control framework as set out in Standing Financial Instructions. 1. Monthly oversight of performance against financial plan by Finance Steering 2. 2018/19 CIP programme in place with clear divisional/workstream targets. Group chaired by Chief Executive, informed by suite of PMO reports. 3. Programme Management Office resourced and tracking delivery. 2. Monthly review of financial performance by NED-chaired Performance 4. Review of financial performance on a monthly basis via Executive Committee and Board of Directors. Performance Review Meetings with divisions. 3. NHSI Performance Review Meetings (bi-monthly). 5. Ongoing discussions with NHSI and Department of Health on support for 4. Board review of progress against longer-term financial plan. the structural element of the deficit (debt restructuring and eHospital). 5. Audit Committee discussions of ‘going concern’.
Gaps in control Gaps in assurance Actions to address gaps in controls and assurances Due date C1. Long-term financial model (LTFM) requires refresh. C1. Refresh LTFM and align with system plan and capital bid January 2019 C2. Uncertainty on prospects for structural deficit outcome. Future budget discussion at Performance Committee. Nov 2018 support. C2. Ongoing discussions with NHSI and DH as part of STP C3. Financial implications of STP work programme and financial planning. Ongoing priorities. Uncertainty around system capital C3. Development of STP system financial plan underpinned by December allocation. analysis of drivers of the deficit, system capacity plan and 2018 system capital plan.
Risk score Mar 18 Apr 18 May 18 Jun 18 Jul 18 Aug 18 Sep 18 Oct 18 Nov 18 Dec 18 Jan 19 Feb 19 Mar 19 16 16 16 16 16 16 16 16
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Cambridge University Hospitals NHS Foundation Trust Board Assurance Framework: October 2018
BAF risk BAF 011a/18 There is insufficient protection in the Trust’s IT network and technology platform given the reliance on electronic Current risk patient information to cope with a cyber attack which impacts on the delivery of safe and effective services for rating: patients.
Strategic theme ST3: Strengthening the organisation (ST3.3) Lead Executive Director of Improvement and 15 Transformation Latest review date October 2018 Board monitoring committee Audit
Risk rating Impact Likelihood Total Change Related BAF and Corporate Risk Register entries since last ID Score Summary risk description month Initial (Aug 18) 5 3 15 BAF 003/18 12 Emergency planning and resilience Current (Oct 18) 5 3 15 n/a Target (Mar 19) 5 2 10
Key controls Assurances on controls What are we already doing to manage the risk? How do we gain assurance that the controls are working? 1. Information security policy and guidelines. 1. Information Security and Governance Programme Board (ISGPB) in place 2. Network security and antivirus/malware/data loss protection in place with chaired by Director of Digital. Internal Cyber Security group reports to ISGPB. regular application of upgrades/patches. Purpose is to define and manage the Cyber Security plan - review issues and 3. Retendering of Commodity IT services with enhanced specifications. notifications and provide a framework of assurance that the Trust has the 4. Weekly CareCert Security notification received and issued to Technical appropriate level of security in place. Support suppliers. eHospital support teams forwarded the weekly 2. Monthly performance reports from DXC and Novosco. CareCert Security notifications for information and where appropriate 3. Biannual assurance reports to the Board's Performance Committee. action accordingly. 4. Action plan to address findings of Cyber Security audit reports from Dionach and Internal Audit monitored through Audit Committee. 5. IT Services Transition (ITST) Programme Board manages the activities required (including cyber security) for successful transition of technology infrastructure services. Bi-monthly reporting to the Board of Directors on Commodity IT retender. 6. Internal process in place to monitor responses to the notifications – KPIs relating to response rate within 4 days and actions outstanding monitored at the Cyber Security group and ISGPB. Non-compliance is escalated accordingly.
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Cambridge University Hospitals NHS Foundation Trust Board Assurance Framework: October 2018
Gaps in control Gaps in assurance Actions to address gaps in controls and assurances Due date C1. Known gaps which are dependent A1. Cyber security reporting to C1. Procurement process continues – specifications will cover March 2019 upon revisions to or re-tendering of the Board. 90% cyber security robustness. Commodity IT. A2. Improved staff awareness. C2. Action plan in place. Continue to work with DXC to October 2018 C2. Dionach audit failed and A3. Better national understanding complete respective actions. To be monitored through Digital recommendations - actions resulting in required of IT security issues with Board and reported to Audit Committee. plan. Some aspects of programme respect to medical devices. C3. Out to recruit for cyber security technical specialist – November 2018 dependant on DXC input. second round of recruitment. Applied for additional funding C3. Technical skill set within team not available centrally and NHS Digital to help with Dark Trace and robust enough to fully cover all aspects segmentation. of cyber security. C4. Workshop with Internal Audit planned for October 2018. October 2018 C4. Further recommendations from A1. Further Cyber security paper to the Audit Committee in October 2018 internal audit. October. A2. eLearning package designed and awaiting set up. September 2018 A3. Subject to national discussions. Ongoing
Risk score Mar 18 Apr 18 May 18 Jun 18 Jul 18 Aug 18 Sep 18 Oct 18 Nov 18 Dec 18 Jan 19 Feb 19 Mar 19 Risk respecified in August 2018 15 15 15
16
Cambridge University Hospitals NHS Foundation Trust Board Assurance Framework: October 2018
BAF risk 011b/18 There is insufficient resilience in the Trust’s IT network and technology platform given the reliance on electronic patient Current risk information to cope with IT infrastructure failures which impacts on the delivery of safe and effective services for rating: patients.
Strategic theme ST3: Strengthening the organisation (ST3.3) Lead Executive Director of Improvement and 16 Transformation Latest review date October 2018 Board monitoring committee Quality
Risk rating Impact Likelihood Total Change Related BAF and Corporate Risk Register entries since last ID Score Summary risk description month Initial (Aug 18) 4 4 16 BAF 003/18 12 Emergency planning and resilience Current (Oct 18) 4 4 16 n/a Target (Mar 19) 4 4 16
Key controls Assurances on controls What are we already doing to manage the risk? How do we gain assurance that the controls are working? 1. Network resilience in place with regular application of upgrades. 1. Monthly performance reports from DXC and Novosco. Biannual assurance 2. Incident response plan and detailed business continuity plans in place. reports to the Board's Performance Committee. 3. Retendering of Commodity IT services with enhanced specifications. 2. Business continuity response to March 2018 IT outages. Contract management approach involving external legal advisers. 3. IT Services Transition (ITST) monthly programme board set up March 2018, 4. Identification of legacy server Operating Systems and reviewing chaired by Director of Digital. Manages the activities required for opportunity to upgrade to current and or supported level. successful transition of technology infrastructure services from the 5. Formal review of all requests for new desktop or server applications to current incumbent supplier to the new service provider. Bi-monthly ensure that they are operationally necessary and that they conform to reporting to the Board of Directors on Commodity IT retender. current support standards. 1, 2, 4 & 5. KPMG IT audit planned.
Gaps in control Gaps in assurance Actions to address gaps in controls and assurances Due date C1. Known gaps which are dependent C1. Robust contract management approach adopted which July 2019 upon revisions to or re-tendering of involves Trust’s external legal advisers. Procurement process Commodity IT relating to network and continues. IT Services Transition (ITST) monthly programme data centre connectivity. board in place. Actions relating to Network, Data Centre C2. Technical resource within team not Connectivity, Servers and Storage and Desktop robust enough to cover infrastructure skill C2. Transition Programme Manager appointed January 2018. October 2018 set and commercial capability needed. New interim Head of IT recruited in April 2018 so that previous
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Cambridge University Hospitals NHS Foundation Trust Board Assurance Framework: October 2018
C3. A1. Risk of service impact to clinical incumbent’s expertise used to lead and focus on the IT and corporate staff when core network transitional programme. Review of commercial capability switches are cut over from the current DXC skillset within eHospital – Internal Audit workshop in October provided operational service onto the 2018. newly installed Novosco switches. C3. Detailed planning, testing and management of any change Ongoing will be in place.
Risk score Mar 18 Apr 18 May 18 Jun 18 Jul 18 Aug 18 Sep 18 Oct 18 Nov 18 Dec 18 Jan 19 Feb 19 Mar 19 Risk respecified in August 2018 16 16 16
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Cambridge University Hospitals NHS Foundation Trust Board Assurance Framework: October 2018
BAF risk 012/18 The Trust does not maximise the opportunities of working with Campus partners and other stakeholders to harness the Current risk benefits of the biomedical campus and life sciences for its patients and the wider NHS. rating:
Strategic theme ST4: Contributing nationally and internationally Lead Executive Director of Strategy and Major (ST 4.1, 4.2) Projects 12 Latest review date October 2018 Board monitoring committee Board of Directors
Risk rating Impact Likelihood Total Change Related BAF and Corporate Risk Register entries since last ID Score Summary risk description month Initial (Sep 17) 4 3 12 BAF 001/18 16 Redesign models of care and patient pathways Current (Oct 18) 4 3 12 BAF 004/18 16 Recruitment and retention challenges Target (Mar 19) 4 3 12 BAF 008/18 12 Estates strategy and masterplan
Key controls Assurances on controls What are we already doing to manage the risk? How do we gain assurance that the controls are working? 1. Input to national Life Sciences Industrial Strategy and identification of 1. Chief Executive attendance at CUHP Board meetings. clear Cambridge priorities – responding to opportunities as they arise. 2. Update provided to the Board on CUHP and Life Sciences in May 2018. 2. Chief Executive on Life Sciences Industrial Strategy Implementation Board 3. Quarterly strategy updates to the Board. and member of Research and Innovation working group as part of NHS 10- 4. Estates Masterplan Refresh Phase 1 presented to Board in April 2018. year plan development. 5. Cancer Research Hospital OBC approved by Board in July 2018. 3. Membership of Cambridge University Health Partners (CUHP). 6. Digital Strategy discussion at Board in June 2018. 4. Appointment of Director of Major Projects from January 2018. 7. Review of progress through Strategy Steering Group. 5. Joint working with Campus partners on Cancer Research Hospital. 8. Work of Commercial Services Group. 6. Membership of Global Digital Exemplar programme.
Gaps in control Gaps in assurance Actions to address gaps in controls and assurances Due date C1. Further develop strategic decision making A1. Continued C1. and A1. Work with CUHP on development of campus Ongoing and partnering arrangements at Campus level to strengthening of Campus management and governance arrangements. benefit the hospitals and patients. governance and link to C2. Inclusion in STP capital bids. December 2018 C2. Cancer Research Hospital funding. individual organisations. C3. Commercial strategy update to Board of Directors. tbc C3. Development of commercial strategy.
Risk score Mar 18 Apr 18 May 18 Jun 18 Jul 18 Aug 18 Sep 18 Oct 18 Nov 18 Dec 18 Jan 19 Feb 19 Mar 19 12 12 12 12 - 12 12 12
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Cambridge University Hospitals NHS Foundation Trust Board Assurance Framework: October 2018
Annex A: Trust risk scoring matrix and grading
Likelihood 5 1 2 3 4 Risk Almost Grading Rare Unlikely Possible Likely Assessment Impact certain Catastrophic 5 10 15 20 25 5 15 – 25 Extreme Major 4 8 12 16 20 4 Moderate 3 6 9 12 15 8 – 12 High 3 Minor 2 4 6 8 10 4 – 6 Medium 2 Negligible 1 2 3 4 5 1 – 3 Low 1
Cambridge University Hospitals NHS Foundation Trust
Report to the Board of Directors: 14 November 2018
Agenda item 15.1 Title Infection Control Annual Report 2017/18 Sponsoring executive director Ashley Shaw, Medical Director Author(s) As above Purpose To receive the Infection Control Annual Report. Previously considered by Quality Committee, 7 November 2018
Executive Summary The Trust’s Infection Control Annual Report for 2017/18 is attached. It was received and endorsed by the Quality Committee at its meeting on 7 November 2018.
Improving patient journeys; Working with our Related Trust objectives communities. The paper provides assurance on Risk and Assurance arrangements in place for infection prevention and control. Related Assurance Framework Entries n/a Legal / Regulatory / Equality, Diversity n/a & Dignity implications? How does this report affect n/a Sustainability? Does this report reference the Trust's values of “Together: safe, kind and Yes excellent
Actions required by the Board of Directors The Board is asked to receive the Infection Control Annual Report 2017/18.
Infection Control Annual Report 2017/2018
Addenbrooke’s Hospital | Rosie Hospital
Contents
1 Executive Summary
2 Introduction
3 How we prevent and control infection
Management structure and oversight Policies and Procedures Training Environment and cleaning
4 Methodologies for Assurance
5 Key Infections
MRSA bacteraemia Clostridium difficile Infection E. coli bacteraemia Carbapenemase Producing Enterobacteriaceae (CPE) Norovirus Influenza
6 Water safety
7 Surgical Site Infections (SSI)
8 Objectives
9 Appendices
1 Hygiene code 2 Methodologies used for assurance
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Infection control annual report 2017 – 18
1 Executive summary
1.1 This annual report collates and summarises information related to healthcare associated infection for the period from April 2017 until the end of March 2018.
1.2 It also describes the management structure and oversight of the approach we take to prevent and control infection, the policies and procedures we use and the methodologies employed for assurance.
1.3 There were no cases of hospital avoidable MRSA bacteraemias attributed to CUH in 2017/18.
1.4 The number of patients who acquired MRSA in 2017/18 is slight lower than in 2016/17. We continue to screen more patients due to the routine practice of rescreening all in-patients staying longer than 40 days
1.5 A key priority for the Trust in 2017/18 was to continue to control the number of cases of Clostridium difficile infection (CDI). Every case of healthcare associated C. difficile is reviewed. Although the total number for 2017/18 was higher than 2016/17, the percentage of avoidable cases has decreased. Due to the lack of decant ward facility, the deep cleaning programme to clean wards following cases of C. difficile has not been possible. Single rooms can be deep cleaned but only amber cleans can be performed if the patient was previously in a bay. Previous experience has shown that thorough cleaning is a key control measure for C. difficile and that the number of cases increases when wards cannot be deep cleaned.
1.6 Antibiotic resistance has been an increasingly important issue in recent years. The Trust has implemented national guidance for the identification and management of the most resistant microorganisms. We had two outbreaks with carbapenemase producing Enterobacteriaceae (CPE) involving patients on one our intensive care units, a medical ward and a surgical ward. These were both dealt with promptly and aggressively. Further cases were identified in the trust but no further on-going transmission was noted.
1.7 Work by the Estates and Facilities department continues to ensure that the risk of infection resulting from exposure to water remains as low as possible. This includes the risk of infection from legionella. No confirmed infections were seen in 2017/18, but the age of the hospital water distribution system has meant that a significant amount of maintenance work is required on an on- going basis and additional major work is required to update or replace the existing infrastructure. A strategy for dealing with this has been developed.
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Implementation will be challenging, but needs to be done as soon as possible.
1.8 The number of patients admitted with influenza in 2017/18, was almost double the numbers in 2016/17. However, due to availability of N2 (isolation ward), less bays/ward were closed.
1.9 I would like to thank everyone in the Trust for their persistent efforts to avoid all preventable infections in our hospitals. This is a key priority for us and we will continue to work in order to demonstrate real improvement to the care that we provide.
Dr A Shaw
Medical Director and Director of Infection Prevention & Control
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2 Introduction
2.1 This annual report aims to summarise and inform the Board, staff and public of the work the Trust has completed to ensure we discharge our statutory duty in meeting the standards for the prevention and control of infection described in the Care Quality Commission (CQC) Code of Practice. More importantly it describes the work of the infection control team and wider staff, both clinical and operational, to reduce the harm associated with infection.
2.2 Cambridge University Hospitals NHS Foundation Trust (CUH) is a 1,000 bedded hospital with over 10,000 staff caring for elective and emergency admissions from the local community and regionally for many specialities.
2.3 The Trust is registered with the CQC. The ten criteria required in the CQCs revised Code of Practice is detailed in Appendix 1; the Trust’s Strategy for the management of risks associated with Infection Prevention and Control sets out how the Trust achieves compliance with these requirements. The CQC has a programme of unannounced visits to Trusts to assure compliance, but no infection prevention and control visit was made to the Trust in 2017/18.
3 How we prevent and control infection
3.1 Management Structure and oversight
3.1.1 The Chief Executive has overall corporate responsibility for the control of infection within Cambridge University Hospitals NHS Foundation Trust (CUH). The Medical Director (MD) is the Trust designated Director of Infection Prevention & Control (DIPC) and is supported in this role by one of the Deputy Medical Directors who acts as Deputy DIPC. The infection control team is comprised of a number of infection control nurses (6.25 WTE), a full time clinical educator, a full time data information analyst, surgical site surveillance nurses (2.1 WTE), a full time healthcare assistant and secretarial support (0.4 WTE). They are supported by a consultant microbiologist. The team is further supported by other consultants in microbiology and virology, hotel services and an antimicrobial pharmacist.
3.1.2 This multi-disciplinary team have oversight of all matters related to the prevention of infection and its control. The team meet weekly to discuss progress against objectives, current concerns and performance in any area related to infection and meet monthly with the MD.
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3.1.3 Local review of matters related to infection control sit with the specialty, directorate and divisional committees for the prevention and control of infection. These groups report to the Trust’s Infection Prevention & Control Committee (IPCC). Other committees that report to the IPCC include the decontamination committee, the antimicrobial stewardship group and the water safety committee, all of which have key roles in the prevention and control of infection. The IPCC is chaired by a Consultant Microbiologist and has representation from Public Health England (PHE), Central Sterile Services Department, Occupational Health, Estates and members of the senior divisional teams. This committee reports to the Trust’s Quality Committee, via the Clinical Governance Monitoring Committee.
3.2 Policies and Procedures
3.2.1 We have a number of up to date policies and procedures that describes in detail how we as an organisation aim to prevent and control infection. These are available on the intranet.
3.3 Training
3.3.1 All trust staff joining the trust attend corporate induction; infection control is part of this. They are also required to undertake mandatory training every 2 years.
3.4 Environment and cleaning
3.4.1 Ward nurses are responsible for cleaning medical equipment and the immediate bed-space. Environmental cleaning is provided by Medirest. A system is currently in place whereby different levels of cleaning are provided using a RAG rating scheme, depending on the infection status of the patient. As an example, non-infected patients receive a ‘green clean’ which involves the bed space being cleaned with a chlorine-based product. A patient infected with C. difficile will have their bed space cleaned with a chlorine- based product and then cleaned using hydrogen peroxide vapour (HPV), known as a ‘red clean’.
3.4.2 In addition to routine cleaning, the infection control team can request additional cleaning in the event of an outbreak or period of increased incidence of an infection. This ‘reactive cleaning’ can take the form of:
Enhanced clean: When additional Medirest staff are allocated to an area to clean communal areas such as patient bays, toilets, dirty utility rooms and touch points. Rolling clean: When an empty bay is used to decant patients within that given ward so that each bay is cleaned on rotation. Depending on the reason for the clean and time available the bays may undergo an HPV or Ultraviolet light clean in addition to cleaning with a chlorine based product.
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Deep clean: When a bay or side room is empty for sufficient time to allow for a full red clean. There was, until December 2015, the availability of a spare ‘decant’ ward where a whole ward would be proactively moved to a decant facility for that the home ward could undergo a deep clean. This facility was not available for the period 2016/17 or 2017/18 due to capacity issues and as a result the formal deep clean programme was suspended. This is seen as a significant risk, particularly for the control of C. difficile infection, and the intention is to reinstate the programme as soon as possible.
3.5 Methodologies for Assurance
3.5.1 A number of methods are in use to provide reassurance and assurance, both internally and externally, and to demonstrate our infection control programme is compliant and fit for purpose. These are described in detail in Appendix 2 but include audit of documentation and observation of practice, case note review and external scrutiny.
4 Key Infections
4.1 Meticillin Resistant Staphylococcus aureus (MRSA)
4.1.1 Bacteraemias
There were no cases of hospital avoidable MRSA bacteraemias attributed to CUH in 2017/18 (figure 1).
MRSA Bacteraemias by NHS Year
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7
6
6 6 5
4 5 4 3
MRSA Bacteraemieas MRSA 2 2 1 1 0 0 0 10/11 11/12 12/13 13/14 14/15 15/16 16/17 17/18 NHS Year
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It is of interest to note the figures and trends reported at CUH follow those reported nationally by Public Health England at:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/634675/Annual_epidemi ological_commentary_2017.pdf
Compared to our peers in the Shelford Group, the Trust had the lowest MRSA bacteraemia rate (Table 1 and Figure 2).
Table 1 CUHFT Position Amongst the Shelford Group April 2017 - March 2018 for MRSA Bacteraemias.
Rank Name of NHS Trust Bed Days# Number Rate
1 Cambridge University Hospitals 323736 0 0.00
1 University Hospitals Birmingham 376362 0 0.00
3 Oxford University Hospitals 408361 1 0.02
4 University College London Hospitals 266584 1 0.04
5 Sheffield Teaching Hospitals 536793 3 0.06
6 The Newcastle Upon Tyne Hospitals 481637 4 0.08
7 Imperial College Healthcare 357126 3 0.08
8 Manchester University 671237 7 0.10
9 King's College Hospital 457516 6 0.13
10 Guy's & St. Thomas' 324601 5 0.15
Figure 2
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Funnel chart showing CUHFT's (in red) position amongst Shelford group for MRSA bacteraemia rates (blood stream infections per 10,000 occupied bed days) April 2017 - March 2018 0.25
0.2
0.15
0.1
0.05
0 250000 300000 350000 400000 450000 500000 550000 600000 650000 700000 -0.05
-0.1 Rate Mean 3sd 2sd -0.15
4.1.2 Acquisitions
The term acquisition refers to someone who has been found to be MRSA- positive for the first time and includes isolates from samples taken for clinical purposes (e.g. wounds, urine, sputum etc.) and also routine swabs taken of the skin during MRSA screening of patients (representing colonisation i.e. present on the skin). Figure 3 shows the number of new acquisitions of MRSA. There was a rise in numbers in 2016/17 to 321 compared to 245 in 2015/16; this remained relatively stable in 2017/18. This partly reflects changes in policy that requires enhanced screening in higher risk areas and long stay patients and active screening in outbreak situations. The MRSA policy was changed in August 2016 to increase screening in higher risk patients, following an outbreak in June 2016. All patients admitted for prolonged periods (defined as ≥40 days) are now routinely screened. In addition, the whole ward is also screened for MRSA if a patient acquires MRSA during their stay; previously we screened the bay they had resided in.
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Figure 3: MRSA 1st Isolates by Year
1200 1089
1000 889 804 800
595 600 442 406 400 320 321 311 247 230 227 245 200
0
2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18
4.1.3 Outbreaks
In July 2017 a new patient was identified with MRSA shortly after admission to the rehabilitation ward. Four further cases were found on screening the whole ward; two bays were therefore closed to admissions. Further screening identified two more cases and the ward was closed to new admissions. The ward remained closed for ten days and re-opened after three sets of negative screens from the patients indicated that on–going transmission had ceased and a rolling deep clean had been undertaken.
In August 2017 a new patient was identified with MRSA on one of the Elderly care wards. The whole ward was screened and three more cases were identified in the same bay as the index case including a patient who had previously been MRSA positive. The bay was closed to admissions and then the ward was closed after new cases were identified in different bays. A total of 8 patients were found to have MRSA. The ward was closed to new admissions for 8 days. It was reopened after three sets of negative screens from the patients indicated that on-going transmission had ceased and a rolling deep clean had been undertaken.
In March 2018 a general medical ward was closed to new admissions following an increased prevalence of new MRSA positive patients and an inability to isolate all of the previous and current MRSA positive patients. At the same time there was also an increased prevalence of MRSA positive patients on the adjacent Elderly care ward. There did not appear to be a common link between the wards except a small number of potentially shared pieces of equipment. Both wards increased the frequency of patient screening and enhanced cleaning was put in place. Although both wards identified similar numbers of new cases in February and March the patients on
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the medical ward were felt to be particularly vulnerable so this ward was closed for 13 days to ensure that on-going transmission had ceased and to allow for a rolling deep clean.
Staff screening was also undertaken on all four wards and any staff found to be positive were treated with topical decolonisation therapy and followed up by Occupational Health.
4.2 Clostridium difficile
4.2.1 There were 67 cases of hospital-onset C. difficile in 2017/18 (figure 4) which represents a slight rise compared to recent years. This infection can be life- threatening and in four patients the infection was recorded in part one of their death certificates (figure 5). This is the highest it’s been for several years and reflects the rise in cases. No patients required a colectomy. As with MRSA the figures and trends reported at CUH for CDI also follow those reported nationally by Public Health England.
Figure 4 Clostridium difficile by Year
450 399 400
350
294 300
250
200
150 Numberofcases 126
92 100 73 67 48 50 54 53 47 50
0 2007/8 2008/9 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18
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Figure 5: CDI on part 1 & part 2 death certificates 54
48
42
36
30
24
18
12
6
0 FY FY FY FY FY FY FY FY FY FY FY FY 06/07 07/08 08/09 09/10 10/11 11/12 12/13 13/14 14/15 15/16 16/17 17/18 Part 2 16 27 26 14 4 2 6 7 9 5 2 3 Part 1 10 23 20 3 2 0 1 2 3 3 1 4
Within the Shelford Group, CUH was 9th for the year 2017/18 for C. difficile (table 2 and figure 6).
Table 2 - CUHFT Position amongst the Shelford Group April 2017 - March 2018 for CDI
Rank Name of NHS Trust Bed Days# Number Rate
1 Guy's & St. Thomas' 324601 26 0.08
2 Sheffield Teaching Hospitals 536793 83 0.15
3 Oxford University Hospitals 408361 71 0.17
4 Imperial College Healthcare 357126 63 0.18
5 The Newcastle Upon Tyne Hospitals 481637 88 0.18
6 King's College Hospital 457516 88 0.19
7 University Hospitals Birmingham 376362 77 0.20
8 Manchester University 671237 138 0.21
9 Cambridge University Hospitals 323736 67 0.21
10 University College London Hospitals 266584 71 0.27
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Figure 6
Funnel chart showing CUHFT's (in red) position amongst Shelford group in England for C. difficile rates (C difficile infections per 1000 occupied bed days) April 2017 - March 2018 0.3
0.25
0.2
0.15
0.1 Rate Mean
3sd 2sd
0.05 250000 300000 350000 400000 450000 500000 550000 600000 650000 700000
4.2.2 Of these 67 cases, case note review and multidisciplinary discussion demonstrated no lapse in care in 50. Delays in isolating patients, an inability to isolate due to lack of side rooms and delays in sending a sample constituted the majority of the identified lapses in care for the remaining 17 cases. These findings are shown in table 3 which also demonstrates the progress in improving process and procedures over the last three years.
Table 3: Reasons given for lapses in care for patients with C. difficile infection
2014/15 2015/16 2016/17 2017/18 Total Delay in sample collection 12 10 4 3 29 Delay in sample collection and isolation 11 7 5 1 24 Delay in isolation 6 8 4 2 20 Issues with antibiotic stewardship 1 0 2 3 6 Delay in isolation and poor documentation 0 0 0 5 5 Poor hand hygiene 1 1 0 0 2 Poor documentation, no bowel history 0 0 0 1 1 No clinician attended the meeting to discuss the antibiotic usage and failure to identify that this 0 0 1 0 1 patient was at risk of C. difficile earlier in this admission
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Delay in sample collection and ward cleaning 1 0 0 0 1 Delay in sample collection and issues with 1 0 0 0 1 antibiotic stewardship Possible delay in sample collection and poor 0 0 0 1 1 hand hygiene Possible cross transmission 0 0 0 1 1 Wrong sample collection 1 0 0 0 1 Wrong sample collection and antibiotic 1 0 0 0 1 stewardship Inappropriate CDT management from previous 0 1 0 0 1 admission Total 35 27 16 17 95
4.3 E. coli bacteraemia
4.3.1 All hospital onset E. coli bacteraemias are reviewed by the infection control team in order to assess likely source and whether or not they were preventable. Cases are described as not preventable, possibly preventable, probably preventable or definitely preventable.
There were 95 hospital onset E. coli bacteraemias in 2017/18. The source was considered to the urinary tract in 42 (44%), biliary tract (13; 14%), gastrointestinal tract (9; 9%), skin soft tissue infection (3; 3%), pneumonia (3; 3%), central venous catheter (1; 1%) and unknown (42; 44%).
Two (2%) were thought to be definitely preventable (urinary catheter-related), two were probably preventable (urinary catheter-related) and 15 (16%) were possibly preventable (dehydration 7; urinary catheter 6; ERCP prophylaxis 1; CVC care 1).
4.4 Carbapenemase Producing Enterobacteriaceae (CPE)
4.4.1 Carbapenemase producing Enterobacteriaceae (CPE) are Gram negative bacteria that are resistant to most antibiotics. They can cause colonisation (with no evidence of infection) or infections. They have emerged as a problem in the UK (particularly in London and Manchester/north west England) in the last 5 years. There was one case in 2015/16, 17 in 2016/17 and 24 in 2017/18. Whilst most of the cases in 2016/17 were related to outbreaks, most cases in 2017/18 were detected on admission and appropriately dealt with. Only three (13%) were detected >48 hours after admission, suggesting hospital onset. There has been a corresponding rise in the number of CPE screens that the laboratory processes due to increased awareness and evolving screening criteria. Approximately 600 screens are performed per month. Three patients were admitted from hospitals abroad and none were from London or the north west of England. Most patients in whom CPE was detected had been admitted to Addenbrookes or a local hospital in the preceding year, rather than from a recognised high risk area.
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4.4.2 A point prevalence survey was performed across all adult inpatient areas in July 2017 in response to the outbreaks in 2016. 595 samples were taken from patients who provided informed consent. No cases were detected.
4.5 Norovirus
4.5.1 Norovirus infection is a short-lived vomiting and diarrhoeal illness, which is readily transmitted from one person to another. The virus can be caught from the environment or shared equipment that has become contaminated. In hospitals, large numbers of patients, staff and visitors may be affected, which can disturb the normal working of the hospital and cause distress to those affected. It is difficult to prevent infection coming into the hospital when there are high numbers of infected people in the community who need admission and when patients incubating the virus may be transferred from referring hospitals.
4.5.2 The Trust management of norovirus is based on the national Guidelines for the management of norovirus outbreaks in acute and community health and social care settings (2012). An escalation plan devised in 2012 is updated annually and continues to improve communication to staff and provide a clear stepped management plan to response to increasing numbers of areas affected and the impact on the Trust’s activity at that given time.
4.5.3 Four wards and 44 bays were closed to admissions in 2017/18. The overall number of cases was higher than last year and although the numbers of bays closed was high this in practice demonstrates that the wards were managing these patients well and preventing further transmission which would have resulted in more ward closures . The numbers of patients affected fluctuates year by year, as shown below so it is difficult to estimate the impact on the Trust.
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Figure 7: Ward/Bay Closures due to Norovirus 120
100
80
60
40
20
0 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 Bay closures 23 90 95 35 31 13 30 44 Ward closures 5 13 15 5 7 3 9 4
4.6 Influenza
4.6.1 The numbers of influenza cases have historically been small and manageable for the Trust resulting in small number of bay closures and occasional ward closures. However, during the 2016/17 season, unprecedented numbers of patients were admitted with influenza. A total of 72 bays and 5 wards were closed. During 2017/18, the number of positive patients doubled but the numbers of bay and ward closures was significantly less, with 4 only ward closures and 49 bay closures.
4.6.2 Influenza was managed more effectively due to our ability to isolate more patients on admission. The isolation ward (N2) was made available to create capacity so that patients admitted with respiratory symptoms could be admitted directly to a side room until their virology results were available. A step down facility was also created on one of the elderly care wards so that confirmed cases on appropriate antiviral treatment could be moved from the isolation ward to a cohort bay. The absolute requirement to establish a single room isolation ward before the onset of influenza season was a key learning point last year and allowed better patient flow this year.
4.6.3 A further action identified was related to staff vaccination. The Trust continued to provide rapid access flu vaccination clinics late in the season to encourage staff members to be vaccinated. The Occupational Health team employed a dedicated flu vaccination team to lead on the vaccination campaign and held very successful ‘pop-up’ clinics in the concourse to provide staff arriving for all shifts with the opportunity to be vaccinated. The Trust had already performed well during the 2016/17 season and performed even better in 2017/18 with 86.3% of staff vaccinated.
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5 Water safety
5.1 Criterion 2 of the Hygiene Code states that a hospital should be able to provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections. Legionella spp. and Pseudomonas aeruginosa are two bacteria that are capable of living in hospital water systems and are then able to cause clinical infections in patients. The water quality team meet regularly to discuss matters related principally to Legionella spp. and Pseudomonas aeruginosa. Microbiological control of Legionella is achieved by:
Temperature: the Trust employs temperature control as the primary method of Legionella control within the domestic water systems (as far as is reasonably practicable). This is achieved by maintaining temperatures of: Cold water at temperatures of < 20°C Stored hot water at >60°C (where exceeding 15 litres storage) Avoidance of Stagnation: experience has shown that avoiding stagnation is highly important in keeping bacterial counts within acceptable limits. This is achieved by the following: Removing any ‘blind ends’ on distribution pipework so far as is practicable Ensure all ‘Dead-Legs’ (e.g. low use taps) are either flushed or removed including any associated pipework Minimising Stored Water Designing and installing new or modified systems so that the risk of stagnation is minimised Maintain Cleanliness Pipework, distribution, storage, plant and outlets shall be maintained in a clean condition at all times as far as is reasonably practicable to avoid providing nutrients to bacteria.
5.2 Legionella continues to be a problem in outlets across the Trust, suggesting the above methods are failing. This is caused by the water heaters being 40 years old, piping being made of galvanised steel, which in parts is heavily corroded, and areas with poor circulation remain. Some of the piping in C & D block has been replaced but the piping in other wards still require urgent replacement. Therefore, silver-copper ionisation has recently been reintroduced due to its antibacterial properties, in order to reduce the growth of these organisms. This is achieved by injecting the copper and silver ions into various parts of the system and maintaining levels of silver and copper ions to the supplier’s specifications. In addition to this, flushing is also performed across the trust. Despite the risks associated with an aging water system no patient contracted a hospital onset legionella infection in 2017/18.
5.3 Testing for Pseudomonas aeruginosa in augmented care areas (i.e. dialysis units and intensive care units) is also performed. Positive results were recorded from the John Farman intensive care unit (JVF). The problem was thought to
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be due to the taps so these have been replaced over the last year. This has led reductions in patients with infections due to P. aeruginosa and also to reductions in a related organism called Elizabethkingia meningoseptica.
5.4 A hospital-wide engineering and estates strategy to reduce the risk of infection from Legionella spp. and Pseudomonas aeruginosa was identified as necessary in 2016/17. This has been now been published and presented to the Board of Directors. In 2017/18 this was implemented.
6 Surgical site infection (SSI)
6.1 Surgical procedures can be complicated by infection. This is usually a minor infection of the surgical wound, although more serious infections do occasionally occur. The risk of infection varies with the particular type and site of surgery. Surgery associated with the gastrointestinal tract, for example, has a much higher infection rate than ‘clean’ surgery, such as the elective insertion of a prosthetic hip joint. 6.2 On-going surveillance of surgical site infection is used within the Trust as one measure of the quality of surgery, to identify areas where further investigation or improvement might be required. Currently the Department of Health requires all trusts to provide data from elective orthopaedic implant surgery (either hip or knee), repair of neck of femur or reduction of long bone fracture for one 3-month time period. We therefore contribute to the mandatory reporting of orthopaedic implant surgery surveillance. 6.3 Surgical Site Surveillance (SSS) is performed for individual types of surgery in blocks of three months at a time. During 2017/18, (period ending March 2018) surveillance was performed for total knee replacement surgery, large and small bowel surgery and cranial surgery. 6.4 For many years, surgical site infection rates in the Trust for orthopaedic knee replacement surgery have been equivalent to or below the national mean rate for all participating NHS Trusts (<1%). The number of infections seen following this type of surgery is very low. The latest data for total knee replacement surgery for six months was 1,2% compared to 0.8 % nationally for the same six month period Rates for small bowel surgery were 7.4% (national average 6.8%), large bowel surgery was 11.1% (national average 9.1%) and cranial surgery was 3.0% (national average 2.0%). These latter categories were optional and not mandated by Department of Health. Meetings occurred with infection control and the surgeons when rates were higher than the national average in order to identify any actions necessary to reduce the incidence of SSI. No remediable actions were identified.
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7 Objectives for 2017/18
Objective Completion date
Optimise antimicrobial prescribing using ‘Start March 2019 On-going smart, then focus’ criteria MRSA bacteraemia – no avoidable cases of trust March 2018 Achieved acquired MRSA bacteraemia C. difficile – no avoidable cases of trust acquired March 2018 Failed C. difficile E. coli bacteraemia– reduce hospital onset E. March 2019 On-going coli bacteraemia by 20% MSSA bacteraemia– reduce hospital onset of March 2019 Failed MSSA bacteraemia to 0 In conjunction with operations staff identify a March 2018 Failed method to re-commence the deep clean programme Record the number of bed days lost to infection March 2018 Achieved for influenza and norovirus Re-launch the hand hygiene programme and September 2017 Achieved introduce new hand hygiene products Update the isolation signage March 2018 Failed In conjunction with operations staff identify a September 2017 N2 – achieved permanent isolation ward (100% single rooms) Perform a CPE point prevalence survey September 2017 Achieved Water safety – to agree and implement a March 2018 On-going hospital-wide engineering and estates strategy to reduce the risk of infection from Legionella spp. no avoidable case of trust acquired Legionella infection Review the resources for the infection control September 2017 Achieved team and occupational health teams Update the Strategy for infection prevention and March 2018 On-going control
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7 Objectives for 2018/19
Objective Completion date
Optimise antimicrobial prescribing using ‘Start March 2019 smart, then focus’ criteria MRSA bacteraemia – no avoidable cases of trust March 2019 onset MRSA bacteraemia C. difficile – maintain or improve on 25% of total March 2019 cases as avoidable trust onset C. difficile E. coli bacteraemia– reduce trust onset E. coli March 2019 bacteraemia by 20% Klebsiella pneumoniae bacteraemia – reduce March 2019 trust onset bacteraemia by 20% Pseudomonas aeruginosa bacteraemia – March 2019 reduce trust onset bacteraemia by 20% In conjunction with operations staff identify a March 2019 method to re-commence the deep clean programme Record the number of bed days lost to norovirus March 2019 and influenza Re-launch the hand hygiene programme and September 2018 introduce new hand hygiene products Update the isolation signage March 2019 Water safety – to agree and implement a March 2019 hospital-wide engineering and estates strategy to reduce the risk of infection from Legionella spp. No avoidable case of trust acquired Legionella infection Review the resources for the infection control September 2018 team and occupational health teams Update the Strategy for infection prevention and March 2019 control
Medical Director’s Office Cambridge University Hospitals NHS Foundation Trust Cambridge Biomedical Campus Hills Road Cambridge CB2 0QQ Telephone: 01223 217996
Published: October 2018
Web: www.cuh.org.uk
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Appendix 1 CQC Code of Practice for the Prevention and Control of Infection
Criterion 1
Have systems to manage and monitor the prevention and control of infection. These systems use risk assessments and consider how susceptible service users are and any risks that their environment and other users may pose to them.
Criterion 2
Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections.
Criterion 3
Ensure appropriate antimicrobial use to optimise patient outcomes and to reduce the risk of adverse events and antimicrobial resistance.
Criterion 4
Provide suitable accurate information on infections to service users and their visitors and any person concerned with providing further support or nursing/ medical care in a timely fashion.
Criterion 5
Ensure that people who have or develop an infection are identified promptly and receive the appropriate treatment and care to reduce the risk of passing on the infection to other people.
Criterion 6
Ensure that all staff and those employed to provide care in all settings are fully involved in the process of preventing and controlling infection.
Criterion 7
Provide or secure adequate isolation facilities.
Criterion 8
Secure adequate access to laboratory support as appropriate.
Criterion 9
Have and adhere to policies, designed for the individual’s care and provider organisations, which will help to prevent and control infections.
Criterion 10
Ensure, so far as is reasonably practicable, that care workers are free of and are protected from exposure to infections that can be caught at work and that all staff
22 are suitably educated in the prevention and control of infection associated with the provision of health and social care.
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Appendix 2 Methodologies used for Assurance
Method Practice Frequency Outcomes Reported to Internal Audit Hand hygiene Fortnightly Any serious lapses All Senior staff via reported to Senior CHEQS and discussed staff at divisional monthly meetings meeting Audit Cleaning Scores Weekly for high risk Reasons behind areas Senior Nursing staff via areas. falling below email. Also, discussed at Fortnightly for standards monthly cleaning medium risk areas investigated by Root meetings Monthly for low risk Cause Analysis and areas problems rectified Report generated Intravascular catheter sites Monthly Senior Nurses via CHEQS from Epic to monitor compliance with VIP score documentation
Root Cause Analysis – CDI or MRSA Monthly (where Learning shared across scrutiny meetings with they occur) the organisation IPCT, clinical team and the CCG Audit of practice Care bundles for urinary Monthly Any lapses identified CCG via the quality documented on Epic. catheter care, MRSA fed back to wards dashboard. Reported in decolonisation, C. difficile involved. Infection Control management and ventilator Performance Report. associated pneumonia Specific issues discussed at monthly divisional meetings Audit/ Service Evaluation of any processes Yearly for clinics Audit or service Report to Senior staff in Evaluation undertaken, observations of and departments evaluation reports area visited. Specific practice and condition of such as theatres, and action plan issues discussed at furniture and fittings quarterly for critical generated. monthly divisional care areas. meetings
Method Practice Frequency Outcomes Reported to
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Internal Audit Practical aspects of Varies from Any lapses identified Ward Managers , Infection Control such as monthly to six fed back to Wards Divisional monthly isolation nursing monthly involved. Audit meetings and Infection management and frequency increased if Prevention and Control equipment cleaning indicated Committee Mini PLACE visits Service evaluation including Monthly Report generated by Areas visited and food quality team. presented at monthly cleaning meeting. Benchmarking Audit data Numbers of HCAI Monthly Report produced and Infection Control outcomes of RCA Performance Report Meetings detailed. and Board of Directors report. External Mandatory reporting National surveillance data Quarterly Reconciliation of PHE and DH of HCAI - triangulation held by PHE compared with mandatory reporting with national Trust reports data to ensure surveillance data accuracy Monthly review of PHE surveillance data for Monthly Trends monitored and PHE and Trust ICT MRSA, C diff, E. coli each Trust in East of England any high numbers and MSSA by PHE reviewed reviewed with Trust ICT to ensure actions taken Feedback of any CPE Weekly feedback of Weekly Trust ICT were aware Trust ICT confirmed by national reference lab data relating of all confirmed CPE. reference lab to the Trust to ensure action taken
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