TRUST BOARD AGENDA for a meeting of the Board of Directors of Heart of England NHS Foundation Trust to be held at The Partnership Learning Centre, Good Hope Hospital, Sutton Coldfield, on 6 September 2011 at 10.00am
PART 1
1. APOLOGIES
2. DECLARATIONS OF INTEREST (Enclosure)
3. MINUTES: 5 July 2011 (Enclosure )
4. MATTERS ARISING AND ACTION POINTS (Enclosure)
5. CHAIRMAN’S REPORT 5.1 UPDATE (Enclosure) 5.2 BOARD GOVERNANCE REVIEW (Enclosure)
6. CHIEF EXECUTIVE ’S REPORT (Enclosure)
REPORT S FROM BOARD COMMITTEES 7. AUDIT COMMITTEE REPORT (RS) (Oral ) 8. AUDIT COMMITTEE MINUTES (Enclosure) 9. DONATED FUNDS COMMITTEE REPORT (PH) (Oral ) 10 . DONATED FUNDS COMMITTEE MINUTES (Enclosure) 11. GOVERNANC E AND RISK COMMITT EE REPORT (AE / SW) (Oral ) 12. GOVERNANCE AND RISK COMMITTEE MINUTES - DRAFT (Enclosure) 13. STANDING COMMITTEE (MONITOR RETURN) MINUTES (Enclosure) 14. EXECUTIVE MANAGEMENT BOARD MEETING MINUTES (Enclosure)
QUALITY AND PERFORMANCE MONITORING 15. INFECTION CONTROL Q1 REPORT (AA ) (Enclosure) 16. A&E WINTER PLANNING UPDATE ( AA ) (Oral ) 17 . FINANCE & PERFORMANCE REPORT (AS) (Enclosure) 18 . IPROC REQUISITION APPROVALS (AS) (Enclosure) 19 . HR COMMITTEE NOTES (H G) (Enclosure) 20 . STAFF SURVEY RESUL TS (HG) (Enclosure) 21 . BUSINESS PLAN Q1 UPDATE (SH) (Enclosure) 22. TRAUMA UNIT (AA) (Enclosure) 23 . BUSINESS CASE – PATHOLOGY EXTENSION AT HEARTLANDS (JS) (Enclosure) 24 . EQUALITY DELIVERY SYSTEM (MS) (Enclosure) 25 . PRE -REGISTRATION NURSE TRAINING (MS) (Enclosure) 26 . COMMUNITY SERVICES INTEGRATION UPDATE (CM) (Enclosure) 27 . LAY PERSON INVOLVEMENT IN CONSULTANT INTERVIEW PANELS (PH / MN) (Oral )
TRUST NEWS AND EXTERNAL ENVIRONMENT 28 . NEWS UPDATE (LD) (Enclosure) 29 . PATIENT EXPERIENCE UP DATE (LD) (Enclosure) 30 . VOLUNTEERING REPORT (LD) (Enclosure)
COUNCIL OF GOVERNORS AND MEMBERSHIP 31 . UPDATE (PH / LD) (Oral) 32 . GOVERNORS’ GOVERNANCE REVIEW (PH) (Enclosure)
MATTERS FOR INFORMAT ION 37 . NONE THIS MONTH
ANY OTHER BUSIN ESS
DATE OF NEXT MEETING 8 November 2011
EXCLUSION OF THE PRE SS AND PUBLIC The Board will be asked to resolve “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”.
PART 2
1. PATHOLOGY MANAGED SERVICE PROJECT (Enclosure)
2. TO RECEIVE MINUTES OF 2.1 APPOINTMENTS COMMITTEE MEETING 1/6/2011 (Enclosure) 2.2 NOMINATIONS COMMITTEE MEETING 1/6/2011 (Enclosure) 2.3 REMUNERATION COMMITTEE MEETING 1/6/2011 (Enclosure)
PRESS AND PUBLIC ARE WELCOME TO ATTEND THIS MEETING AS AN OBSERVER. YOU WILL , HOWEVER, BE ASKED TO LEAVE BEFORE THE BOARD CONSIDERS ANY ITEMS IN THE PART 2 AGENDA.
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REGISTER OF DIRECTORS and REGISTER OF DIRECTORS’ INTERESTS
VOTING TRUST BOARD MEMBERS DATE OF DATE OF DATE OF TERMINATI NAME INTEREST (if any) NOTIFICATIO APPOINTMENT ON OF N INTEREST Dr Aresh Anwar 01.03.11 1. South Asian Health Foundation : 01.03.11 Member of Di abetes Working Group
Mr David Bucknall 08.01.08 1. Chairman of Rider Levett Bucknall 08.10.08 UK Limited 2. Rider Levett Bucknall are major 08.10.08 shareholders in More-Park Group, Bristol who have been appointed to carry out car parking services for HEFT. 3. Chairman of the Birmingham 08.10.08 Community Foundation
Ms Mandy Coalter 24.07.06 1) Prior to Ms Coalter’s appointment 23.01.07 HEFT contracted ‘Q Learning’ to provide an Organisational Development programme. This contract is under review and si nce the Q Learning contact is a personal friend of Ms Coalter’s, she has delegated all decisions about the future of the contract to Theresa Nelson (Head of OD). 2) Ms Coalter’s husband, Lee 12.07.10 Moreton, is a professional tennis coach and he will potentially be working with the Trust on the staff sports programme. Ian Cunliffe is the executive lead for the contract negotiations.
Ms Anna East 01.07.05 1) Director of Dudley Building Society 01.01.08 01.05.10 2) Non Executive Di rector Midland 25.10.10 Heart Housing Association 01.09.10 3) Regional Panel CEAA 25.10.10
Mr Simon 01.03.07 Board Director for a 1 year t erm of office 09.10.09 Hackwell at MidTECH - one of a network of nine regional NHS innovation hubs, established by the Department of Health to identify, protect and commercialise innovative ideas from within the NHS. Ms Najma Hafeez 01.04.07 Chair of Postwatch 01.01.07 30.10.08
Mr Richard Harris 01.05.08 1) Brambles Limited Shareholder and 01.05.08 Chair of UK Pension Fund 2) Trustee of Action for Children 01.05.08 Superannuation Fund. 3) Birmingham Community 01.05.08 Foundation Trustee 4) RSA Academy - Governor 01.05.08 5) Flora Forster Students’ Fund 01.05.08 Trustee 04.08.09 6) Director and Shareholder, Gorilla Box Limited. 04.08.09 7) President, Solihull School Parents Association 04.08.09 8) Richard Harris’ w ife is a volunteer WRVS worker at Solihull Hospital (half a day per week) 19.07.10 9) Non executive director of 14.09.10 Simplyhealth Group Limited 4.11.10 10) Member of the Audit & Risk Committee of the RSA (Royal Society for the encouragement of Arts, Manufactures and Commerce). Mr Paul Hensel 01.08.05 1) Paul Hensel’s wife has been 30.01.07 appointed as a non executive director of the Royal Orthopedic Hospital. No c onflict is foreseen but it is registered for the sake of good order. 22.02.07 01.08.07 2) Non Executive Director of Kplus Software Limited (small company involved in development and delivery of Mobile Data Solutions)
Rt Hon Lord Philip 01.10.10 1) Member and Deputy Leader of the 11.10.10 Hunt PC OBE Opposition, House of Lords 2) Self-Employed Consultant on NHS and wider health issues , t/a Phillip 11.10.10 Hunt Consultancy 11.10.10 3) Trainer and Policy Analyst, Cumberlege Connections Ltd. (NHS leadership/awareness programmes) 4) Philip Hunt Consultancy consultant and trainer, 5) President, British Fluoridation Society 6) Trustee, Terrence Higgins Trust 26.04.11 17.08.11 7) President, Royal Society of Public Health 8) President, Health Care Supply June 2011 Association 9) Chair, University Policy Commission on Nuclear Energy June 2011
Dr Mark Newbold 01.08.10 Nothing to declare
Mr Richard 01.07.06 Non Executive Director of Horton 16 June 2006 Samuda Estates Limited (On Appointment)
04.01.11 Director of Warwick Racecourse 04.01.11 Mr Adrian Stokes 01.07.08 (as 1) Director of HECL 1) On app’t voting board 2) Pfizer Virtual Customer programme 2) 20/6/2011 member) Mandie 01.12.08 Nothing to declare Sunderland Dr Sarah Woolley 07.05.07 Energy & Home Condition Surveys Ltd 16.03.07 July 08 – Company Secretary
REGISTER OF INTERESTS
NON VOTING TRUST BOARD MEMBERS
NAME DATE OF INTEREST (if any) DATE OF DATE OF APPOINTMENT NOTIFICATION TERMINATION OF INTEREST Ms Lisa Dunn 23.10.08 1) Non Executive Director of 22.12.08 Multistory Mr Andy Nothing to declare 18.12.08 Laverick
Mr John Sellars 08.01.07 Nothing to declare 16.04.08
Mrs Claire 01.05.11 Nothing to declare Molloy
TRUST BOARD
Minutes of a meeting held at MIDRU, Heartlands Hospital on 5 July 2011
PRESENT: Lord P Hunt (Chairman) Dr A Anwar Mr D Bucknall Mrs A East Mr S Hackwell Ms N Hafeez Mr R Harris Mr P Hensel Dr M Newbold Mr R Samuda Mr A Stokes
IN ATTENDANCE: Ms R Blackburn Ms S Foster Ms H Gunter Dr A Keogh Mr A Laverick Ms S Moore Mr M Pye Mr J Sellars
Mrs A Hudson (Minutes)
11. 92 APOLOGIES and WELCOME
Apologies were received from Ms M Coalter, Ms L Dunn, Ms C Molloy, Ms M Sunderland and Dr S Woolley.
The Chairman w elcome d Ms Hazel Gunter, who is covering Ms Coalter’s maternity leave and Ms Sue Moore, Managing Director Designate for Good Hope Hospital.
The Chairman introduced Kerry Jones, Faculty Dean, HEFT Faculty of Educ ation who has been leading the HEFT Apprenticeship Activity and Workplace Diversity Programme. Ms Jones firstly introduced her colleagues Mr C Newbold, Ms T Harris, Ms S Welch, Ms C Hawkins, Ms W Ilsley, Ms L Williams and then gave an overview of the proje ct. The Board then watched a short presentation and video clip showcasing the programme. HEFT has delivered nearly 500 new apprenticeship starts since 2009 and in 2011/12 another 210 are planned. This means that HEFT will have better ed the combined perform ance of four of the ten Strategic Health Authorities over the last twelve months.
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The Trust recently won HR Magazine ’s award ‘Best Workplace Diversity Strategy ’, competing against many of UK leading companies. The Chairman congratulated Ms Jones and the team both for winning the Award and on the huge amount of work they have put into the project and the presentation; the project has made an enormous difference to not only the apprentices but to patient’s lives too.
Mr Conrad Ne wbold, National Apprenticeship Scheme, presented certificates to Lord Hunt, Dr Newbold and Ms Kerry Jones in recognition of the board level commitment to the apprenticeship scheme.
11. 93 DECLARATION OF INTEREST
Lord Hunt: Chair of Birmingham University Policy Commission o n Nuclear Energy previously declared but still to be included on the Register.
11. 94 MINUTES OF LAST MEETING
26 May 2011 The minutes were approved by the Board and signed by the Chairman.
1 June 2011 The minutes were approved by the Board and s igned by the Chairman.
7 June 2011 The minutes were approved by the Board and signed by the Chairman.
It was noted that actions agreed by the Board would be appropriately highlighted.
11. 95 MATTERS ARISING
The Schedule of Matters Arising was discussed and the following actions noted:
HEFT University: Ms Sunderland is continuing to pursue the scheme with a pilot of 30 students commencing in the Autumn. Mr Bucknall commented that the pilot should be very positive for the Trust. Dr Newbold noted that a lthough there is much support with in the NHS there has been some resistance to the scheme from the current University provider. The Board was supportive of the HEFT University concept but mindful of the challenges. The Board requested that Ms Su nderland present an update to the September meeting.
Annual Business Plan: Mr Hackwell a dvised that the wording in the P lan had been finalised and an update will be presented to the September Board meeting.
Community Services Integration Update: Ms Molloy to present an update to the September Board meeting.
Doctor Revalidation: Dr Anwar to present an update report to the November meeting.
No Matters Arising originating from the approved minutes were noted.
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11. 96 CHAIRMANS REPORT
The Chairman presented a summary of his written report and drew the Board ’s attention to several items Lord Hunt had met with Jenni Ord, Chair of the Birmingham and Solihull Cluster Group and had discussed the challenging financial position of the individual PCTs within the Cluster and whether transfer of funds between PCTs was possible at the present time whilst the PCTs and Cluster were still evolving. There was currently no clear position on this. Mr Stokes agreed to put together a paper setting out four or five bullet points for use in meetings and will circulate to Board members. Mr Harris raised the point that due to the high cash reserves the Trust holds, albeit they are ear-marked for estates development, might the Trust fa ce a bad debt risk from BEN PCT due to its financial position? Mr Stokes advised that as there was a contract in place he would expect payment to be forthcoming. The Trust is continuing to work with the PCTs and Clusters to give as much help as practicable. As part of his own induction programme, the Chairman has been invited to meet at the end of July with David Bennett, the newly appointed Chair of Monitor. The agenda for the meeting includes a discussion on A&E 4 Hour waits. The Chairman had attended a recent Birmingham Budget Group meeting chaired by Councillor Randall Brew. The meeting is an estate rationalisation group, concerned with property and land that the Council holds. In a separate meeting between Councillor Brew and the Chairman the subject of outstanding fines and the Belchers Lane site had been discussed; Councillor Brew had advised that he has instructed his officers to resolve any outstanding issues regarding outstanding fines . A meeting had been held on the 17 June 2011 to discuss the development of Belchers Lane and Mr Bucknall had attended on behalf of the Trust. Mr Bucknall advised that the meeting had been very positive with three cabinet members being in attendance, together with Mr Liam Byrne MP. 11.97 CHIEF EXECUTIVE’S RE PORT
Dr Newbold presented a summary of his written report. The Trust has appointed a new Group 5 Director. Clive Ryder is a senior clinician currently working at the Children’s Hospital and is very respected in his field. His appointment will also bring tangibl e links between the Children’s Hospital and HEFT. The Children’s Hospital is known to be reviewing its estate and the future structure for the Women’s Hospital is known to be also under review. There would be considerable clinical benefits fr om closer linkage of our paediatric services to those of the Children’s Hospital. It was agreed that the Chairman and Chief Executive would meet with the Chief Executive of the Children’s Hospital. Dr Newbold has met with Hall Green GP practice as well as other GP practices to discuss how the Trust can build better working links.
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11 .98 QUALITY AND PERFORMANCE MONITORING
11.98.1 GOVERNANCE & RISK COMMITTEE REPORT INC AUDIT UPDATE AND SITREP
Dr Keogh presented a summary of the written report and t abled the executive summary of S afety SITREP report. The Trust had 14 SUIs during 2010/11. Since April this year there had been a further 5 new SUIs all of which are currently being investigated. There are no major Coroner cases to be hear d in the near future; however , the Trust is expecting three Rule 43 rulings : two involving medication error and one for the Harrop inquest held in May. Dr Newbold qu eried the trend in SUIs and Dr Keogh reported that there had been a slight increase but thi s is down to a change in type of SUI being reported; this had been predicted when the Safety Strategy was launched . A piece of work is underway to look back at previous SUI s and how the organisation is using lessons learned to ensure that these do not recur.
The Aggregation of D ata report is a new report and sets out the top five category themes for incidents, complaints, claims and SUIs under investigation by the Trust. A discussion was held on how lessons learned are communicated throughout to the organisation and it was agreed that this is an area in which the Trust could improve.
The Board discussed at length the Risk Register, particularly around the number of items which were red rated and it was queried if the rating was truly representat ive of the circumstances. Mrs East suggested that the Board needed to give detailed consideration to how the Trust sets the bar for SUIs and benchmark itself against other Trusts. Mr Harris said it was very important that any changes to categorisation does not ca use safety to slip and urged the Board to ensure it kept well briefed on trends and understand why SUIs happen.
Mr Stokes asked why the incident category report did not reflect the circumstances of Group 1 especially in view of acute services at Good Hope Hospital. Dr Keogh agreed to look at the documentation and bring it back to a future meeting. Mr Bucknall asked about the red rat ing for estates and if there were any plans in place to resolve the actions. It was agreed that the ratings needed to be reviewed and an updated register is to be bought back to a future meeting.
It was agreed that there might be benefit in inviting the Coroner for a return visit later in the year.
AUDIT UPDATE
Ms Sunanda Gargeswari attended to give an update on Clinical Audit. An electronic system is now in place having been launched in September and this has resulted in an i ncreased number of audits being undertaken. Act ion plans are now incorporated into the system and are being regularly updated, with 30% of action pla ns already having resources allocated. Forward action plans will consider NICE standards. Guidelines are now accessible on the front page of the Intranet. A discussion took place on how the Trust ensures that Clinical Audit continues to move forward. Consultants should be undertaking these as part of their job plans and this links in with the Doctor Revalidation, a consultation P a g e | 5
document will be circulated to all clinicians. M rs East requested an update on performance progress to be brought to a future Go vernance & Risk Committee. The Board asked to receive reassurance that the guidelines are updated and the clinical audit recommendations are referred to the appropriate Executive Direc tors for monitoring and mirror the way financial audit recommendations are dealt with .
The Chairman thanked Ms Gargeswari and she left the meeting at this point.
11.98.2 GOVERNANCE & RISK COMMITTEE MINUTES
Mrs East presented the minutes of the meeting held on 13 June 2011 and particpa ularly drew the Board ’s attention to two items: The presentation by Eleanor Ward on the patient safety improvements to Ward 12 at GHH that had taken place as a result of concerns identified through patient complaints and the nursing metric scorecard. The work undertaken on Ward 12 has been very inspirational and was a great example of strong leadership and the benefit of putting in place clear expe ctations of the nursing staff. Complaints performance sits at 61% year to date which is worse than Board’s target, this is primarily due to difficulties with low manpower cover for dealing with complaints. Dr Newbold advised that Complaints are undergoing a review at the present time following the move to the C ommunications Directorate.
11.98.3 ASSURANCE FRAMEWORK AND STRATEGIC RISK REGISTER
Ms Black burn presented the Assurance F ramework and copy of the Trust Strategic Risk Register. The register is reviewed on an o ngoing basis and reviewed quarterly by the Board. As discussed earlier in the meeting, there was an in depth debate undertaken to ensure that risks that are red rated are reviewed to ensure that the risks are correctly rated and action plans are in place to mitigate the risks. Dr Newbold expressed concern that having too many red risks will increa se the tolerance of them. He believed that red risks ought to refer only to risks where significant and immediate action was an imperative and not embrace more generic risks such as the impending NHS reforms which had been recognised and mitigated. Mrs East added that the Trust needs to ensure that the Risk Register is a dynamic document and risks that are potential problems to the Trust are assessed and actions to mitigate the risks put in place. Ms Blackburn agreed to feedback comments and an updated document and report will be bought back to the September meeting.
11.98.4 FINANCE AND PERFORMANCE REPORT
Mr Stokes presented the finance report and key performance indicators for month 2. May had been another difficult month with a small surplus of £0.1m, £1.9m deficit year to date. There had been higher income in May providing an improved position with over -performance of £2.1m year to date. £0.8m inco me has been withheld due to new -to-follow-up fines. The operational budget was overspent by £2.0m in May and £3.7m year to date. CIP actual delivery in May was £1.3m, £2.4m year to date and an overall shortfall of £1.0m against plans and £1.9m against budget with significant improvements in CIP delivery and implementation rectification required. CIP delivery in Group 1 is a major issue and this has been escalated with meetings taking place to review the revised plan. Medical staffing P a g e | 6
costs remain stubbornly high caused, in part, by the continuing use of locums, the current rate of which is not financially sustainable . Months 1 and 2 had been financially very demanding and reinforce the need to ensure Cost Improvement Plans are vigorously pursued. The re ntal charge rise over Good Hope carpark land has been settled by arbitration resulting in a provision write back of £0.4m. A review of quarter 1 performance will be presented to the September meeting.
A&E performance has improved and the Trust achieved the 95% target at the end of quarter 1 , and continues to work towards achieving the Quarter 2 target. Mr Stokes advised that Monitor has agreed that the walk-in activity on the Solihull Hospital s ite can be included. Dr Anwar added that the improvements se en were multifaceted with various strands of work still ongoing. He also emphasised that staff have worked really hard to improve the position; the Board recognised the immense amount of work that had been undertaken. A huge change has been seen at Good Ho pe Hospital and it was now performing at a higher standard. Mr Hensel noted the positive changes but challenged why issues with length of stay have not improved. Dr Anwar responded that the data presented included long stays (ie those greater than 100 days) but reassured the meeting that both 7 to 14 day and 7 to 21 day stays have improved with the result that capacity has been created. It was also pointed out that the data provided is for May and that the June data will show an improved position. Dr Anwa r confirmed that work on winter planning was underway and this includes working with the Clusters and GPs on external pathways to keep patients out of hospital where possible and an update on winter planning will be presented to the September Board meeting.
Mr Harris and Mr Hensel expressed concerns around the financial constraints on commissioners together with the financial implications of over performance and the consequential difficulties in recovering these funds. Mr Stokes advised that activity is broadly flat and in line with last year. The possibility of cross subsidy within the Cluster had not been ruled out. Mr Harris also suggested that the Trust needed to consider doing something fundamentally different to improve funding, to which Mr Stokes responded that more radical solutions will start to be seen next year.
The financial outturn at the end of Q1 will be more indicative of the normal t rend of financ ial performance for the full year. Mr Stokes will advise the Board more fully when Q1 fig ures are available.
11.98.5 FINANCE COMMITTEE MINUTES
Mr Stokes presented the minutes from the Finance Committee meeting held on 31 May 2011 and 27 June 2011 which were taken as read and no comments were received.
11.98.6 IPROC REQUISITION APPROVALS
There were two iproc requisitions presented for approval.
Iproc no. 633900 for contract extension for the provision of linen by Sunlight Textile Services for the period May 2011 to March 2012. Iproc no. 632871 SLA for posts associated with medical education at the University of Birmingham for the period 1 April 2011 to 31 March 2012.
The Board approved both requisitions. P a g e | 7
11.98.7 QUARTERLY HR & OD UPDATE
Ms Gunter presented an overview of her written quarterly report . The staff survey has been undertaken during June with the results being analysed and presented to the September meeting. Initial results show a 20% return which is considered low. The survey was only available on line and this may be a contributing factor. The possibility of monthly staff feedback is being considered but it was recognised that this may well cause survey fatigue. Work is underway between the OD team and Faculty of Education to develop a VITAL style assessment for manager s. Developing managers early is fundamental to the success of a performance culture and improving how we manage our staff appropriately. A progress report will be presented to the November board meeting. The Clinical leadership is now complete and this has been shared with clinical directors at a recent away day. A significant amount of work is required to implement the outcomes and the OD team are working with the Medical Director in taking this forward. Mr Bucknall stressed how important communication, perception and understanding was and the need for the Trust to have som e strategic communication with partner universities to ensure that the right messages are being disseminated.
The st aff summer festival was held on 3 July 2011 with over 2,000 people attending the event.
Pensions C hoice is underway and whilst there has been some unrest with unions that may result in industrial action later in year the Trust is putting contingency plans in plac e. Mr Harris asked if the Trust has been affected by last week ’s strike, Ms Gunter advised that social care workers had taken ac tion but it didn’t have too much of an impact on the Trust.
Sickness absence needs to be improved and a concerted effort will be made to reduce absence by 50% over next 3 years. Wellbeing is high on the agenda and the T rust has made improvements over the last year s with sickness reducing from 7% to 4%. The questions was raised as to what the percentages mean in number terms, Ms Gunter will find out and report back to the Board. Occupational Health may need to become more interventional in order to drive down absence rates.
11.98.8 HR COMMITTEE NOTES
Ms Gunter presented the notes from the HR Committee held on the 1 June which were taken as read and no comments were received.
11.98.9 AUDIT COMMITTEE REPORT
Mr Samuda gave a verbal update on the meetings held on 3 May 2011 and 1 June 2011. The 3 May 2011 meeting had discussed the assurance framework and the rating of the risks as discussed above. The meeting had also received a rep ort on misdirected mail and actions in place to follow up. The meeting held on the 1 June 2011 was dedicated to consideration of the draft report and accounts 2010/11. Mr Samuda reported that PWC had been extremely compl imentary on the Trust ’s handling o f the report and accounts and Monitor Annual Plan processes.
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11.98.10 AUDIT COMMITTEE MINUTES
3 May 2011 The minutes of the meeting held on the 3 May were received , taken as read and no comments were received.
1 June 2011 The minutes of the meeting held on the 1 June were received, taken as read and no comments were received.
11.98.11 INQUEST UPDATE
Dr Keogh circulated a draft paper providing the Board with an update on the recent Horrop inquest following the receipt of the Coroners draft findings. The Coroner has indicated that he will be writing to the Trust ’s Governors under Rule 43, setting out his findings. Mrs East raised the point that the Coroner needed to understand the separate roles of the Board and Governors and recognise that it was the Board ’s remit to answer his letter and not that of the Governors. The Board discussed the subject in detail and at length and agreed the following actions:
The Board felt that it was not appropriate for the Governors to respond to the Coroner given that the Board is the responsible body and not the Governors. It was agreed that Dr Newbold will respond to the Coroner on behalf of the Trust when the formal Rule 43 notice is received. The Chairman will update the Governors fully at the September meet ing of the Council of Governors on the Coroners findings and the Trust actions going forward.
The draft paper was returned to Dr Keogh for updating when circumstances re quire.
11. 99 TRUST NEW AND EXTERNAL ENVIRONMENT
No items submitted this month.
11. 100 GOVERNING BODY AND MEMBERSHIP
An away day for Governors is to be held on 15 July and the Chairman will report back to the next meeting.
11. 101 MATTERS FOR INFORMATION
11.10 1.1 OTHER ITEMS
Agenda Items 20.1 and 20.2 were appendices to items discussed earlier in the meeting and were duly noted.
11.101.2 EXECUTIVE MANAGEMENT BOARD MINUTES
The minutes from the meeting held on 17 May 2011 were received and taken as read with no comments being received. . P a g e | 9
11. 102 ANY O THER BUSINESS
11.102.1 AWAY DAY ACTION LIST
The Chairman presented th e action list from the recent Board Away Day.
It was agreed that the Chairs of the Board Committees would be as follows:
Finance and P erformance Mr Richard Harris Community Engagement Ms Najma Hafeez HR Lord Philip Hunt Governance & Risk Mrs Anna East IM&T Mr Paul Hensel Audit Mr Richard Samuda Estates Programme Lead Mr David Bucknall
It was agreed to hold more regular Board Away Days.
The Chair man, together with the respective Committee Chairs, will look at respective Committee membership, discuss with non executive directors and report back to the September meeting
11.102.2 STRATEGY UP DATE
Mr Hackwell presented an update on Strategy. The Trust needs to plan for ho w it will meet its vision and goals for the next three years. The approach to developing the strategy is based on services being Specialty led - created and owned by the clinical directorate, Transparent and focussed – based around a clear and structured approach, grounded and explicitly addressing today’s financial context , Working relationships – involving dialogue with commissioners, corporate functions, GMDs and the Board, Capability – must involve an increase in the capability and capacity around planning and execution, Integrated – must result in an integrated strategy giving clear future direction for our three hospital sites. The preparation work will commence in August with workshops in September and option/plans drawn up in October. The options will then be presented for review by the Board. The Board discussed the above at length including the need for additional capacity t o run the workshops which will be where p ossible be sourced internally. The political agenda will be considering when drawing up options. The Board will undertake a further review on 2 1 October 2011.
11.102.3 PUBLIC BOARD MEETINGS Mr Harris asked about Board conduct and challenge now that future Board meetings would be held in public. The Chairman advised that the meetings would be business as normal.
11.102.4 BREAST UPDATE Dr Anwar advised that the Surgeon concerned has been excluded by the Trust, whilst the internal enquiry is ongoing. The GMC is meeting on 6 July 2011 to consider the case. P a g e | 10
11. 103 DATE OF FUTURE MEETING
6 September, 2011 Good Hope Hospital.
.
...... Chairman
TRUST BOARD
Schedule of Matters Brought Forward and Action Points
Date Minute Detail Action Due Status Completed raised No
4 Jan A report on progress of Patient Experience LD Sept 2011 On 6/9/11 2011 at the Trust is to be provided agenda 26 Jan Update on HEFT University (Pre On 6/9/11 MS Sept 2011 2011 Registration Nurse Training) agenda 3 May On 6/9/11 11.72 Community Services Integration update CM Sept 2011 2011 agenda
7 June Business Plan – Overall programme and On 6/9/11 11.85.2 SH Sept 2011 2011 first quarterly update agenda
11.86.10 Doctor revalidation update report AA Nov 2011
Circulate to Directors a bullet point list of 5 July 11.96 issues around PCT/Cluster financing and AS Immediate 2011 cross subsidies Messrs Hunt an d Newbold to set up 11.97 PH/MN meeting with CE at Children’s Hospital More detailed review on categorisation of red rating on Risk Register and updated 11.98.1 SW register to come back to future Board meeting Gov & Risk Consider inviting City Coroner to future Comm to 11.98.1 PH Board meeting consider at end of year Update on clinical audit to go to Gov & 11.98.1 SW Risk Committee Board to receive assurance that the guidelines are updated and clinical audit 11.98.1 SW recommendations are referred to in ED monitoring On 6/9/11 11.98.4 Update on A&E winter planning AA Sept 2011 agenda
On 6/9/11 11.98.7 Staff survey results HG Sept 2011 agenda
11.98.7 Update on VITAL HG Nov 2011
Provide data as to what percentage 11.98.7 HG Nov 2011 reduction in absences means in real terms Horrop Inquest 11.98.11 Respond to Coroners letter when received MN Brief Governors PH Board Away Day to review next stage of 21 Oct Meeting 11.102.3 SH strategy development 2011 Booked
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A quieter period over the holiday season.
Visit from Secretary of State
Andrew Lansley visited the Heartlands site on Friday 26 August 2011 to announce new A&E clinical indicators. The Chief Executive has detailed more about this visit in his report.
Council of Governors Meeting
We had a very productive session at the Council of Governors meeting on 15 July 2011 at Solihull. The headlines are set out at agenda item 31.
Staff Recognition Awards
We held our annual Staff Recognition Awards Ceremony on 24 August 2011 at the Crescent Theatre in Birmingham City Centre. A quite special evening for us all. My congratulations to all the winners, nominees and the Events Team for organising such a splendid evening.
Monitor Induction Seminar
I attended the mandatory Chairman’s Induction Session on 23 August 2011. A very interesting and informative day.
NHS Confederation Annual Conference
Najma, Paul, Richard Harris and I attended the NHS Confederation Annual Conference in Manchester between the 6 and 8 July. The key points picked up from Conference were:
Re-Design/Re-Configuration
I went to a very good presentation re the Lister Hospital who have successfully undergone major re- configuration. Key is clinician and GP engagement at an early stage plus recognition of what is doable. Very much built around a clinical model of care embracing primary care. Recommended Independent reconfiguration panel web-site for lessons from previous attempts to re-configure. Used independent people like magistrates to chair public meetings.
Very strong communication is required and be prepared for a big investment in time. The whole process will take much longer than might be envisaged. Take care to identify all relevant stakeholders. High quality healthcare should be the driver and the key rationale for the proposed redesign. Nicholson urged politicians at local level to support reconfiguration.
As well as involving interested parties such as GPs, it is essential to consult widely outside the Trust to arrive at best ideas. This might/should involve some private sector healthcare firms, even if they do not end up actually participating in running any of the services.
The availability of key data is critical (eg of KPIs and financial data) so we know the starting point and what targets should be achievable in the new configuration.
General comments on issues relating to cost reductions and reconfigurations:
Private sector healthcare firms appear to have a lot to offer in terms of ideas and innovation and would be worth consulting. Firms that we saw or heard included:
Q:\BOARD\BOARD PAPERS\2011\SEPTEMBER\ITEM 5.1 CHAIRMANS UPDATE TB SEPT 11 MTG.DOC Care UK who operate GP surgeries, with a focus on keeping patients out of hospital. Perhaps this is a signal for HEFT to consider more of its activities being away from the hospital sites and out in the community. Circle. Impressive sounding patient outcomes, patient satisfaction, productivity and safety in acute hospitals. Serco and other technology companies. Unipart. A non healthcare example, with the focus on world class process redesign, and how to do this while keeping the workforce highly engaged and motivated.
Chris Ham and others at a break-out stressed: Long term stability and focus on a single strategy; quality as the unbending theme of the strategy; adopt specific and measurable goals; goal of integrated care; competition is not necessarily a solution (eg look at Sweden) but private sector may still have a role to play in outsourcing, supplier, joint venture roles etc.
Governors
Interesting session on FT Governors. Key messages were: Relationship has to be based on trust with the Chairman key to this. Chairs who want to promote the role of Governors can achieve a great deal. They can be a tremendous resource in reaching out to our local communities. Governors will need more and continuing training particularly around understanding what it means to hold NEDS to account without becoming shadow Directors.
Workforce Productivity
Hospital re-design doesn't always reduce costs because not always accompanied by staff skill-mix reviews. Essential to recognise that productivity has to be defined and focus has to be around pounds spent per patient day. Unless we have good data on productivity, gains won’t be achieved. Safety issue need to factored in as pushing patients through hospitals more quickly means more intense work. HCAs staffing model was explored which uses core staff around minimum requirement and flexes in additional staff when required Need to eliminate barriers to matching staff to demand and build a highly flexible - particularly nurses-workforce.
There was a strong message to give managers more autonomy around four goals- high outcomes, productivity, patient satisfaction and engaged staff. Real incentives for teams who achieve this. Big question- why so few FTs use freedoms re pay to improve productivity.
UCH London have focused on very heavy staff engagement in the process of achieving CIPs. Sharing knowledge is key focus on maintaining safety. UCH mentioned in particular savings were being achieved on agency spend, LOS reduction and improved theatre utilisation. Constant measurement of CIPs (eg ward by ward) and generating internal competition such as weekly awards of "ward of the week".
Patient Experience
There was a presentation from a South West Trust which had 29 check in areas , 40 different phone numbers, 50% of incoming calls were abandoned because people give up. 32 days longest time to get letter from Out Patients to GP. Lot of DNAs because patients didn't get appointment letters in time and re-scheduled appointments resulted. They had an 18 month action programme. Didn't work at first because staff not engaged. Went back to drawing board and achieved
big reduction in abandoned calls similar reduction in re-scheduled appointments
Q:\BOARD\BOARD PAPERS\2011\SEPTEMBER\ITEM 5.1 CHAIRMANS UPDATE TB SEPT 11 MTG.DOC much faster response rate of letters from O/P to GPs re-design of medical secretaries role.
Keeping patients out of hospital and end of life care: presentations from Southampton acute and BEN's initiative (Sophia Christie). Aiming to achieve patients' desire to die at home, engaged private sector firm "Healthcare at Home" to deliver 24/7 services to patient at home or care home following discharge. Great improvement in patient and family satisfaction, and marked cost saving, especially in saving bed cost at the acute level.
GPs should be encouraged to have more conversations with patients before they become too ill to make rational choices.
NHS Confederation
David Nicholson gave a clear message of support to the Confederation as the umbrella body for the NHS and, by implication, warning the Foundation Trust Network not to walk away.
Overall an enjoyable and useful event.
Lord Philip Hunt Chairman 30 August 2011
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Agenda Item 5.2
BOARD GOVERNANCE REVIEW
The review of Board Governance arrangements is ongoing
Board Committees
It has been agreed that 11 Board Committees should be constituted. Following discussions, I recommend that membership be
Appointments Committee Philip Hunt (Chair), all NEDs, Chief Executive
Audit Committee Richard Samuda (Chair), David Bucknall, Anna East, Paul Hensel (Adrian Stokes to be a permanent attendee)
Donated Funds Committee Paul Hensel (Chair), Anna East, Director of Corporate Affairs, a Governor nominated by the Trust Chair
Finance and Performance Strategy Committee Richard Harris (Chair), Philip Hunt, Director of Finance, Medical Director, Director of Human Resources and Organisational Development, Managing Director of Solihull Healthcare, Managing Director of Good Hope Hospital
Governance and Risk Committee Anna East (Chair), Philip Hunt, Paul Hensel, Richard Samuda Permanent attendees, Directors of Safety and Governance, Medical Director, Chief Nurse, Director of Corporate Affairs
Human Resources Strategy Committee Philip Hunt (Chair), Richard Harris, Najma Hafeez, Director of Human Resources and Organisational Development, Chief Nurse, Director of Corporate Affairs, Medical Director
Information Management and Technology Committee Paul Hensel (Chair), Director of ICT The Clinical IT Lead may also have a role on this Committee It would be helpful to have another NED to serve on this Committee.
Nominations Committee Philip Hunt (Chair), Anna East, Mark Newbold
Remuneration Committee Philip Hunt (Chair), all NEDs
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Stakeholder and Community Engagement Committee Najma Hafeez (Chair), Philip Hunt, Chief Executive, Managing Director of Solihull Healthcare, Managing Director of Good Hope Hospital, Commercial Director, Director of Asset Management
Standing Committee for Monitor Return approval Philip Hunt (Chair), Anna East, Chief Executive, Director of Finance
David Bucknall will continue to lead on Estates.
Terms of Reference for continuing Committees are being reviewed and proposals will be put to the November Board meeting.
Terms of Reference for the new Committees are being worked up and, I anticipate, will be discussed at their first meeting so that proposals can come to the November Board meeting.
Schedule of Matters Reserved to the Board
This is being reviewed with a view to bringing a proposal to the November Board meeting.
Division of Responsibilities and Roles of the Chairman, Chief Executive and Senior Independent Director
These are being reviewed with a view to bringing a proposal to the November Board meeting.
Standing Orders and Standing Financial Instructions
These are being reviewed by the Audit Committee with a view to bringing a proposal to the January 2012 Board meeting.
Philip Hunt
Chairman 26/8/11
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CONFERENCES AND EVENTS
Along with the Chairman I also attended the NHS Confederation Annual Conference and also later in the month I was invited to an FTN and Monitor event on the ‘Early warnings for the Board’. This looked at the financial challenges being faced by members and the need for provider Boards to be alert to any impact on quality and safety. This was a one day programme led by Ernst & Young exploring the issues of communicating with stakeholders when managing declines and assisting recovery and very interestingly for us, the opportunities and drawbacks of transactions such as ‘bolt - ons’ and integrations; mergers and acquisitions; and alliances and franchises. There remains much discussion on how those smaller organisations will be able to sustain safe efficient services delivering quality care within challenging financial circumstances.
COMMUNITY VISITS
Before Ramadan I visited two of our local Mosques with a team from engagement, patient information and consultants from our diabetes service. This was extremely well received and highlighted a number of areas for further development. It is clear that in some of the communities we serve visiting A&E is a preferred option to visiting local GPs or out of hours services, with issues of accessibility and quality of advice being cited as reasons.
The significant work already undertaken with regards to supporting the wishes of deceased patients’ families sometimes does not always deliver to their expectations. We are currently looking at how we can work closer with local funeral directors to understand what else we can do within the guidelines to improve this service.
I am planning to hold regular meetings with community representatives as well as attend a number of Mosques and Sikh Temples so that we can continue to capture feedback and engage more personally with members of our communities.
INSPECTIONS AND VISITS
Over the month we have received an inspection from the Care Quality Commission (CQC), whose team visited all three Hospital sites. Initial verbal feedback from the visit to all sites which looked at maternity and medicines management has been received and we are awaiting the written report which we will publish when it is received along with any action plan required as a result of comments and findings made. The overall assessment of maternity was very positive, reporting very positive comments indeed from our patients in all three units. The team did highlight some areas of improvement within medicines management and these have already been picked up – these related to storage facilities and the need to improve the pharmacy facility on Ward 19 at Heartlands Hospital.
Monitor has also visited Good Hope Hospital (5 th September) and I will update the Board on this at the meeting.
Joseph Caruana , Chief Executive Officer of Mater Dei Hospital in Malta spent a week with the executive team to learn about how to move his large 800 bed teaching hospital to a more autonomous model. This was a very successful visit as we found we have a great deal in common as well as many differences. It was agreed to continue the dialogue on how we could develop benchmark information as well as potential opportunities for sharing data under a twinning arrangement.
Q:\BOARD\BOARD PAPERS\2011\SEPTEMBER\ITEM 6 CHIEF EXECUTIVES REPORT TB SEPT 11 MTG.DOC I held an initial meeting with Midland Heart Housing Association to discuss how closer working relations could support the work currently being undertaken by elderly care to support the discharge of elderly patient. The Elderly Care Team is picking this up alongside the work on redesigning the pathway for frail elderly patients.
SECRETARY OF STATE VISIT
The Secretary of State (SoS) visited Heartlands Hospital on Friday 26 th August launch the new A&E indicators, and took time to meet staff and patients in the department. He also briefed the media on the new indicators. The SoS highlighted the importance of the work the Trust was doing, and was especially interested in the Advanced Practitioner model we utilize in our A&E units.
As the Board is aware, previously the measure focused solely on seeing, treating, discharging or transferring patients within a four-hour timeframe. A new set of clinical quality indicators have now been introduced nationally, to work alongside the four-hour access standard. These clinical quality indicators were informed by the work of Mathew Cooke who is National Clinical Director of Urgent and Emergency Care, Professor of Emergency Medicine at Warwick University and a Consultant here in the Trust, aim to move us away from a single measure (four hours), to one that measures and mandates improvement over several aspects of quality and safety within emergency departments.
The new eight patient focused indicators are:
1) Ambulatory care To reduce avoidable hospital admissions by improving the provision of ambulatory care in sensitive and emergency conditions such as DVT and Cellulitis.
2) Unplanned re-attendance rate (to be less than 5%) To reduce avoidable re-attendances at A&E by improving the care and communication delivered during the first attendance. This also includes unplanned return within seven days of original attendance.
3) Total time spent in the A&E department (95% of patients within 4hrs) To improve timeliness and monitoring of care to ensure patients do not have excessive waits before leaving the department – this is where the four-hour target remains as a standard for all patients where clinically appropriate with an absolute that no patients spends more than six hours within a emergency department.
4) Left without being seen (to be less than 5%) To improve patient experience and reduce the clinical risk to patients with high risk conditions who leave A&E before receiving the care they need.
5) Service experience To improve the experience of patients who use A&E services and their carers – to be measured through quarterly patient experience feedback.
6) Time to initial assessment (95% within 15 minutes) To reduce the clinical risk associated with the time the patient spends unassessed (ambulance arrivals).
7) Time to treatment (median time of one hour maximum) To reduce the clinical risk and discomfort associated with the time the patient spends before their treatment begins.
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8) Consultant sign-off To improve clinical processes and outcomes and reduce the risk patients are exposed to.
These measures will along with all performance measures be brought to the Board through the Board’s subcommittee of Finance and Performance.
VISIT FROM CAROLINE SPELMAN MP
The Chairman and I received a planned visit from Caroline Spelman MP on Friday 26 th August and we will update the Board of our discussions at the Board meeting.
STAFF RECOGNITION AWARDS
This year, yet again we received an unprecedented number of entries for our Staff Recognition Awards. We also continued our theme of greater local involvement with all of the entries being judged by independent panels, many containing patients and peers. Judging panels deliberated long and hard as the decision to appoint a winner was made very difficult by the high standards of the entries.
For those who were unable to make it the evening was a true celebration of the excellent work being undertaken across the Trust. It started on a very emotional note with patients and relatives saying thank you for the care they have received, including a very moving story from Robert Blackburn, a patient of the Trust.
The Award winners are listed below for reference and our in-house team have produced a video of the highlights. Ward 24 at Good Hope Hospital was mentioned in many awards and as well as winning my Chief Executive’s Award was selected by the Chairman as the overall winner, something which was extremely popular with the staff on the night.
Award Winner Chairman's Award Suzanne Blundell -Saunders Chief Executive's Award Ward 24 Good Hope Clinical Excellence Award Sarita Ja cob Non Clinical Excellence Hotel Services Waste Management Team Patient Safety Award Tissue viability team (joint winner) Patient Safety Award Hospital @ night team (joint winner) IMPACT Award Joint School Volunteer of the Year Paul Thornton Charity Community Award Dr Salman Ghani Chief Nurse's Award Rachel Morris Essence of Care Award Ward 11 Heartlands Patient Carer Elaine Smith Above & Beyond Karen Hodgson In the line of duty Mazar Akram, Ibrahim Bilow and Peter Luckman
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SAFETY MANUAL LAUNCH
Sarah Woolley and her team have formally launched an innovative new Safety Manual for Nurses. This is an excellent initiative and I attended three very successful events in our hospitals, all of which were well attended. We initiated the first ‘safety discussions’ and have now begun the creation of a true safety culture within the Trust
MEETING WITH THE POSTGRADUATE DEAN
I met with Professor Elizabeth Hughes on Friday 12 August to discuss medical training within the Trust, and in particular recent visits by the Deanery to Orthopaedics and Trauma, Maternity, and Paediatrics. We will receive an inspection visit from the General Medial Council in November – an important occasion for both the Trust and the Deanery.
CHIEF EXECUTIVE OF THE CLUSTER
I have continued to meet regularly with Denise McLellan Chief Executive of the Cluster. Recent topics have included the present contractual situation and an ongoing serious incident review relating to a patient with TB who had also been cared for at other local organisations.
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AUDIT COMMITTEE
Minutes of a meeting held at MIDRU, Heartlands Hospital on 5 July 2011
PRESENT: Mr R Samuda (Chairman) Mr D Bucknall Mrs A East Ms N Hafeez Mr R Harris Mr P Hensel
IN ATTENDANCE: Mr R Bacon (PWC) Ms R Blackburn Mrs A Jones Dr A Keogh Mr M Pye (Company Secretary) Mr I Ratcliffe (PWC) Mr D Sharif (KPMG) Mr A Stokes (Finance Director)
Mrs A Hudson (Minutes)
11. 38 APOLOGIES
Apologies were received from Ms C Little (PWC).
11. 39 MINUTES OF MEETINGS
3 May 2011
The minutes of the meeting held on 3 May 2011 were approved by the meeting and signed by the Chairman.
1 June 2011
The minutes of the meeting held on 1 June 2011 were approved by the meeting and signed by the Chairman.
11. 40 MATTERS ARISING
The Schedule of Matters Arising was noted.
Completion of Internal audit actions: these are now formally part of the senior executive ’s appraisal and form part of their objectives. Consultant Departures: Mrs Jones met with Ms Gunter who is covering the Direct or of HR & OD’s maternity leave and confirmed that HR updated their
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checklist to include communication of Consultant departures. Report on issues surrounding using merger accounting for TCS transaction to be presented to the November meeting. Action Plan for Risk 6 (Business Continuity) will be available by end of September and a report will be bought back to the November meeting.
11. 41 FINANCE DIRECTOR ’S REPORT
Mr Stokes presented a summary of his written report. Year end tasks for 201 0/11 are almost complete. The Annual Report and Accounts 2010/11 were signed on 2 June 2011 and sent to Monitor in time for the deadline. C opies are being printed for submission to Parliament, Monitor and the Trust AGM. The Charitable Funds audit 2010/11 has been completed with no major issues arising and will be presented to the July meeting of the Donated Fund committee and the September Audit Committee meeting. The 2010/11 Quality R eport is on the Trust website in line with Department of Heath require ments. The management responses for the detailed audit report are being finalised for submission to Monitor. Planning for the 2011/12 year has commenced with no new risks identified at the present time.
11. 42 EXTERNAL AUDIT
11. 42 .1 Internal / External Audit Protocol
A summary of the written report was presented by Mr Bacon and Mr Ratcliffe of PWC. The paper is a joint document produced by PWC and KPMG setting out the arrangements and coordination of work between the internal and external auditors for the coming year along.
Following discussion, the P rotocol was approved.
11. 42 .2 Update o n Bribery Act
Mr Ratcliffe presented an update on the Bribery Act following the significant changes to UK law that recently became effective. PWC h ave produced a series of web seminars discussing and explaining the updates to the Bribery Act, the link will be circulated to all Executive and Non Executive Directors. Mrs East asked if the Trust knew where it was at the present time in light of the changes and was reassured that the counter fraud work programme would highlight any issues. The meeting went on to discuss the Bribery Act updates and the consequences this had for the Trust, Mr Stokes assured the Committee that these would be reinforced with the directorates. Mr Bucknall asked whether the Trust needed to undertake a retrospective review of documentation and produce a paper setting out best practice and it was agreed that this would be beneficial and Mr Stokes will report back to a future meet ing.
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11. 43 INTERNAL AUDIT REPORT
11. 43 .1 Annual Plan 2011/12
Mr Bostock presented a summary of his written report. The plan has been produced following discussions with individuals based on the Core Business P lan and in conjunction with Dr Woolley’s team. Th e Plan correlates to the Board Assurance Framework. Mrs East advised that a draft of the Plan had previously been circulated for comment and reiterated the point that the overall cost savings plan needed to ensure that patient quality and safety were not com promised. The Committee reviewed the Annual Plan in detail. Mr Hensel asked how items in the plan are reviewed, Dr Keogh responded that these were tracked on the Strategic Risk Register and Board Assurance Framework. Mr Hensel welcomed the clinical audit review, the differences between clinical audit and peer review were discussed and Dr Keogh agreed to pull together a paper setting these out. Mr Harris asked if the programme timetable assessed issues by importance and it was agreed that this was the case. It was also stressed that the Plan was a daptable to change . Any proposed changes to the Plan will be presented to the Committee with a clear rational. Mr Bucknall observed that there was no mention of the cross-site strategy or of construction, Mr Stokes advised that they had not been included due to the considerable amount of work already undertaken in those areas.
The plan was approved.
11. 43 .2 Progress Report
Mr Sharif gave an overvi ew of the written report. The report sets out detail on the work planned and undertaken since the last C ommittee meeting. KPMG have been working clos ely both with the Trust and the previous internal auditors to ensure a smooth changeover. It was noted tha t a number of recommendations are outstanding and a tracking system is now in place to record progress including individual review meetings where no progress is reported. A discussion around how directorates follow up on audit recommendations was held and it was noted that executive directors will sign off agreed recommendations following which KMPG will track the m. There are two level one recommendations outstanding, one each with the Director of Finance and the Director of ICT both of which relate to IT issues. I t was agreed that a progress report and plan would be bought back to the next meeting.
11. 44 COUNTER FRAUD ANNUAL WORK PLAN 2011/12
Mr Sharif presented an overview of the C ounter Fraud annual work plan for 2011/12. The plan sets out the approach that KPMG will follow to investigate all suspected fraud and to coordinate fraud prevention activities . Any potential cases will be referred to the Director of Finance for review and decision on further ac tion. The Committee reviewed and approved the summary work plan for 2011/12.
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11.4 5 AUDIT COMMITTEE WORK PROGRAMME
Mr Pye presented the Audit Committee Work programme for 2011/12. It was agreed that future meetings will be held on separate dates to Trust Board meetings.
The work programme was approved.
11.4 6 SAFETY & HEALTHCARE GOVERNANCE
11.4 6.1 Assurance Framework Update
Ms Blackburn presented a update on the written paper. She noted that the Assurance F ramework and Strategic Risk Register had been presented to the Board earlier in the day where it was agreed that further work needed to be undertaken on scoring and ratings. Following the review and presentation at the next Board meeting it would be bought bac k to the Committee.
11.4 6.2 Up date On Quality Report
Ms Blackburn confirmed that t he 2010/11 Quality Report is now on the Trust website in line with Department of Heath requirements and within timescales. The management responses are being finalised for submi ssion to Monitor . Work has already commenced on next year’s report.
The Chairman thanked Ms Blackburn for the enormous amount of work that had been undertak en in producing the Quality Report.
The internal and external auditors, Ms Blackburn and Dr Keogh left the meeting at this point.
11.4 7 REVIEW OF EXTERNAL AUDITOR PREFORMANCE
As the external auditors were entering the final year of their contracted agreement a discussion on the performance of the external auditor was held in order to review their performance and give feedback. Mr Stokes began by saying he had found the quality of the current team and the organisation to be very good. There had been some issues raised early in the contract in relation to one of the partners but this had been resolved by Mr Bacon taking over the lead partner role. The PWC team had been extremely professional in the production of the year end accounts and quality account , taking on board any comments. Mr Hensel added that he believed that the PWC team had not become complacent and were always ready to both challenge and take on board alternative opinions. The consensus of the Committee was that service PWC offered was first rate.
The committee then discussed the upcoming tendering process for external auditors. Mr Stokes advised that the Monitor Code stated that Trusts should periodically test the market. Mr Harris raised his concerns about changing external auditors given that the Trust has just instructed new internal auditors.
It was agreed that the Trust needed to undertake a scoping exercise and consult with the Chairman and Council of Governors to gather opinion and views. A report and plan to be bought back to the next meeting.
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11.4 8 TECH NICAL LEGISLATIVE / UPDATE BRIE FING
It wa s agreed that this should be a standing agenda item. Briefings will be presented by the relevant Executive Director , as appropriate.
11.4 9 CONSIDER REQUIREMENT TO REVIEW SOs, SFIs etc
It was agreed that a review of Standing Orders and Standard F inancial Instruction s etc would be undertaken and, once concluded, a report will be presented to a subsequent committee meeting.
11. 50 ANY OTHER BUSINESS
Mr Bucknall asked whether the C ommittee would find it beneficial to benchmark itself against other organisations in order to understand where HEFT is in relation to other Trusts. This information is available from Monitor and will be circulated quarterly.
11. 51 DATES OF FUTURE MEETINGS
6 September 2011 1 November 2011
...... Chairman
DONATED FUNDS
Minutes of a meeting held at St Andrews Football Stadium on 18 July 2011
PRESENT: Lord P Hunt (Chairman) Dr S Smith Mr A Stokes
IN ATTENDANCE: Ms C Bilsland (PWC) Ms L Dunn Ms A Evans Ms E Hale Ms A Jones Mr M Mogan Mr M Pye (Co mpany Secretary)
Mrs A Hudson (Minutes)
11.12 APOLOGIES and WELCOME
Apologies were received from Ms N Hafeez.
11.13 MINUTES OF MEETING
The minutes of the meeting held on 8 April 2011 were approved by the meeting and signed by the Chairman.
11.14 MATTERS ARISING
The strategic review of investments will be undertaken by Ms Jones and presented to the next meeting. The Strategic Fundraising review will also come to the next meeting.
11.15 INVESTMENT PRESENTATION
The item has been defe rred to a future meeting.
11.16 INTERNAL AUDIT REPORT
None for this period.
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11.17 FINANCIAL REPORT
Ms Jones presented a summary of the written report. At the end of March 2011 the general charity fund has generated a surplus of £173k befo re gain on the valuation of our investments of £205k giving a net surplus of £307k. At the end of May 2011 the fund shows: A YTD net income deficit against plan of £127k. Legacy income was £9k with approximately £216k of legacy income pending. £104k of donations were received which was £16k more than planned. Expenditure was £298k which was £17k less than planned. Gains on revaluation of investments amounted to £97k YTD. The cumulative reserve of the unapportioned gain for 2010/11 amounted to £734k bringing the total reserve at 31 May 2011 to £831k.
Just over £1.8m is held in cash in the RBS Deposit account, earning interest at a rate of base plus 0.42%.
A discussion was held on how the Trust can boost Legacy Income and suggestions included writing out to previous donors with details on legacy donations as well as setting up an inpatient will -writing service with a caveat that sensitivity was paramount. Any recommendations in this area are to be bought back to the Committees for approval before imp lementation.
A Counter Fraud review has been undertaken with five recommendations falling out of the review, all of which have been actioned or will be incorporated in the Charitable Fund Policy and Fundraising Policy.
A discussion took place on how the Trust recognises the donations and fundraising it receives; currently the ward or the charitable fund for which the money is earmarked writes a letter of thanks. It was agreed that, going forward, a letter of thanks would also be sent to all donors and fundraisers from the Chairman’s office. A database is to be set up with all donors details.
11.18 GROUP FUNDS REPORT
Ms Jones presented a summary of the written report setting out the group fund analysis for the two m onths to 31 May 2011. There are a total of 360 funds totalling just under £7.2 million. All Groups have increased their spending this quarter. Low spending fundholders will continue to be contacted for plans for their funds or requests to merge funds i nto a central fund. A general discussion on the merging of individual fund, accounts into a central fund was held, Dr Smith advised that although some funds have amalgamated (eg Renal) many are reluctant to do so as they are concerned that they may not th en be able to access their funds when needed. Ms Jones advised that where there are small amounts left in funds Charitable Funds have contacted the holders to find out what plans they have for the remainder of the money. The Committee supported the approa ch of a central fund.
11.19 BUDGET 2011/2012 & CASH FLOW FORECAST
Ms Jones presented a summary of her written report. The budget and cash forecast report has been calculated with the current uncertain economic climate in mind and is also based o n the average income and expenditure figures for the last five financial years. Details of any known commitments have been sought from fundholders with large P a g e | 3
funds. Estimates of investment income for 2011/12 have been obtained from M&G and Schroder Investm ent Managers. The Charity is forecasting to have a full year net Income Deficit of £658k in 2011/12 compared to an actual net surplus in 2010/11 of £172k.
The committee discussed the 2011/12 forecast which was approved.
11.20 INVESTMENT REPORT
Ms Jones presented a summary of the written report. In the first two month to 31 May 2011 investments increased in value by £97k, an increase on the opening balance of £6.1m of 1.5%.
There was a 1.43% increase in the value of Schroder investments and a 1.68% increase in the value of M&G investments which compares to an increase in the FTSE100 index of 1.17% over the same period.
As at 31 May 2011 M&G investments hold 76% equities and 24% bonds and Schroder’s hold 65.9% equities, 12.0% bonds and 13.9% hedge funds and 8.2% property funds.
A discussion took place around how the Trust could benchmark itself against other similar charitable funds and Trusts in order to gain assurance that it is taking a prudent approach to investment. Mr Stokes agreed to undertake modest benchmarking exercise against other similar organisations and will report back to a future meeting.
11.21 FUNDRAISING REPORT
Ms Dunn presented a summary of her written report. The donation element of the webs ite is now fully functional and updates have been made to the content. The Chairman advised that he had tried to use the website and had difficulties with filling in bank details. Ms Dunn to investigate and rectify the issues.
Solihull League of Friends have raised over £42,000 for the surgical stack appeal which takes them to around half way towards their overall target.
Legacy project: a database of solicitors has been developed to incorporate those specialising in will -writing and located within the are a of the four sites. Leaflets and letters have been sent to all organisation. Advertising space has also been booked in the Law Society Gazette Charities and Appeal directory which is distributed to over 22000 solicitors.
Payroll giving . The implementat ion of the payroll giving scheme has been agreed by HR Committee and the Work and Well Being directorate will be taking forward the delivery of the project. The scheme still requires staff to agree to opt in, rather than the preferred opt out that many other organisations use. Mr Stokes to speak to the HR Director to understand and get agreement to use the opt out option, if possible.
Database. A database has been identified to record details of all individuals and organisations involved in the charity and this will be amalgamated with the community stakeholder database in order to recruit additional fundraising groups and individuals.
Fundraising. Ms Dunn introduced the members of the Committee to Mr Mogan who has been appointed to build fundraising at the Trust. Ms Dunn advised that he had been funded from within communications directorate. Mr Mogan added that he gives a P a g e | 4
‘money back guarantee’ that he is able to raise more than the cost of his services. Mr Stokes asked if the appointment had been through the correct procurement process and Ms Dunn confirmed this was the case.
A discussion on the potential fundraising strategy was held and included using the Governors and membership as a resource. It was suggested that a governor should chair t he fundraising group. Ms Dunn and Mr Pye to meet outside of the meet ing to discuss further. It was also agreed that a list of fundraising projects was required. Ms Dunn informed the meeting that she had met with Mike Archer and now has a list of last yea r’s capital bids which were not funded to use as potential fundraising projects going forward; however only those business cases with a sustainable future will be considered . Ms Dunn to bring back a proposal on the Fundraising approach for the Trust to th e September meeting.
11. 22 ISA 260 REPORT
Ms Jones presented the ISA 260 report on the General Charitable Fund for 2010/11 produced by PWC. They issued an unqualified audit opinion on the accounts. With no adjust ments. Mr Stokes asked that the committee recognise the huge amount of work undertaken by Ms Jones and Ms Evans and the Chairman and Committee added their thanks. The ISA 260 Report was approved.
11.23 ANNUAL AUDITED ACCOUNTS 2010/2011
Ms Jones pre sented the draft annual audited accounts for 2010/11 for approval. The report has been previously distributed for comments. The committee discussed the report and the following minor changes were noted:
Reference to the Good Hope League of Friends to be added. An explanation was required on the future plans for the Heartlands volunteer network programme to include reference to the cultural differences that Heartlands faces in respect of fundraising. Ms Dunn to draft.
Once agreed by this committee the draft report accounts will be presented to the next Audit Committee and then to the Board in November along with an explanatory report covering the prospects for Donated Funds.
The draft annual accounts were approved subject to the changes noted above.
11.24 MANAGEMENT LETTER OF REPRESENTATION
The draft Letter of Representation addressed to PWC was presented by Mr Stokes for approval.
The letter was approved.
11.25 COMMITTEE BUSINESS PROGRAMME 2011/12
Mr Pye presented the draft Commi ttee Annual Business Programme for 2011/12. This was approved.
It was agreed that the investment presentations would be half yearly, focussing on the level of assurances that could be given to the Committee. Mr Pye and Ms Jones to agree timings outside of the meeting. P a g e | 5
The next Committee meeting would include a detailed discussion around both Fund Raising and Investment management arrangements; this would require time to allow for a full debate on each topic
11.26 LOCAL COUNTER FRAUD SPECIALIST PROACT IVE EXERCISE 2010/11
Ms Jones presented the Internal audit report following the local counter fraud specialist exercise carried out in 2010/11. There are some minor recommendations falling out of the audit and these will picked up and actioned.
11 .27 ANY OTHER BUSINESS
None
11.28 DATE OF NEXT MEETING
To be agreed
...... Chairman Heart of England NHS Foundation Trust Safety and Governance Directorate Governance & Risk Committee – Minutes 25 th July 2011
GOVERNANCE & RISK COMMITTEE
Minutes of the Governance & Risk Committee meeting on Monday 25 th July 2011 Held in Committee Room 2, Devon House, Birmingham Heartlands Hospital
Name Title Present: Anwar, Aresh Medical Director AA East, Anna Non-Executive Director / Chair AE Hensel, Paul Non-Executive Director PH Hunt, Lord Philip Chairman PHu Sunderland, Mandie Chief Nurse MS Woolley, Sarah Director of Safety and Governance SW
In attendance Blackburn, Rachael Compliance Manager RB Alison Brahms NHS Birmingham East and North AB Budhoo, Misra Group Medical Director - Group 2 MB Dunn, Lisa Director of Corporate Affairs LD Galvin, Louise Head of Governance and Safety Improvement LG Keogh, Ann Director of Medical Safety AK Alison Massey Solihull Community Services AM Joy Payne Head of Midwifery JP Rees, Alison Executive Assistant to Sarah Woolley (Minutes) AR Roger Stedman Group Medical Director – Group 3 RS Presentations David Swain Consultant Elderly Medicine DS Observer Andy Bostock Head of Internal Audit for HEFT (KPMG) AB
1. Apologies for absence and minutes of the meeting held on 23 rd June 2011.
Apologies were received from: Sam Foster, Sunanda Gargeswari, Richard Harris, Malcolm Pye, Steve Smith, Mark Wake and Doug Wulff, Val Jones
Minutes from the meeting held on 23 rd June 2011 – The Stress Management Assurance Report noted that 80% of absences do not have the details of the absence reason recorded. AE asked that the new HR group pick this up and that it is an agenda item for the Octob er Governance and Risk meeting. SW to liaise with Hazel Gunter (Acting Director of HR). SW – AK asked that the Claims section be re-worded to provide more clarity with AK regards to claims made.
Subject to the above comments, the minutes were approved as a true record.
2. Matters arising / standing agenda items
See updated actions at the end of these minutes.
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Heart of England NHS Foundation Trust Safety and Governance Directorate Governance & Risk Committee – Minutes 25 th July 2011
Patient Safety Story
3. Fracture neck of femur update (David Swain)
David Swain, Consultant Elderly Medicine, provided an update following his presentation at the April Governance and Risk meeting. Since December 2010, a new pathway for fracture neck of femur has been in operation. David explained the changes and improvements since December 2010.
AWAITING RESPONSE FROM DR SWAIN. UPDATE TO BE INCORPORATED - NEED TO CHECK FACTUAL ACCURACY.
AE commended David’s excellent and informative presentation and to thank his colleagues for all their hard work. This was supported by the committee.
Strategy and Goals MATTERS FOR DISCUSSION (10 minutes per paper )
4. Patient experience report (Lisa Dunn)
Key points to note:
Three areas continue to remain green – (helping patients to eat meals, pain control and cleanliness). Of particular note were the improvements regarding response to call buzzers – although this still remains as amber, there was a 12% improvement in this area). Discharge remains red – LD confirmed that attention will be focussed heavily on this over the next two months in improving our understand ing of what patients and their relatives would like in terms of discharge. Over 200 questionnaires have been distributed so that we can obtain more information about what we can improve and the impact we can have. Patient Experience Survey – weekly questionnaires are sent by the engagement
team to patients that have been discharged. 190 people responded in June 2011 and
we are now benchmarking and tracking month on month.
A&E – No data was available this month but LD confirmed that she will bring this to LD the next meeting Complaints – LD reported that her team have been working very closely with the midwifery team and the changes to the complaints process has been received very positively in terms of turnaround with complainants. LD will bring a report to the LD October meeting regarding the new complaints process
5. Governance annual report (Louise Galvin)
The Safety and Governance annual report is a synopsis of what the directorate has accomplished over the past year, what they said they would do and how it has been achieved. The Safety and Governance directorate consists of the following teams:
Patient Safety Governance (audit, risk registers, confidential enquiries and guidelines) Investigations (claims, complaints, incidents and inquests management) Clinical Investigations (serious untoward incidents –SUIs – management) Information Governance Health & Safety
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Heart of England NHS Foundation Trust Safety and Governance Directorate Governance & Risk Committee – Minutes 25 th July 2011 Governance Information Compliance
SW reported that the document is in draft format and asked the committee to approve the report subject to two minor amendments:
Context to be added to the Hospital @ Night section. Wording to be amended regarding litigation and MRSA to ensure we have an appropriate policy in place).
The committee approved the document subject to the proposed amendments above.
The report was highly commended and AE gave thanks to the team.
6. Safety strategy priorities (Sarah Woolley)
This paper was brought to Governance and Risk following a request at the last meeting to provide further details about the priorities of the Safety Strategy.
In summary:
The main priority is to “Spread learning” (from error and adverse events) and Good Practice – SW confirmed that we are putting in place a Learning and Engagement Manager. There is a piece o f work linked in with KPMG with regards to how effective our governance committees are. There will also be a large piece of work around simulation training. There are four supporting work streams (mandating safety expectations, patient engagement, staff engagement and incident reporting systems) – these are designed to improve communication and safety cultures within the organisation.
SW will bring a quarterly report to the Governance and Risk Committee . SW
7. Insurances (Louise Galvin)
LG reported that the Trust undertook a re-brokering exercise for the renewal of all policies through Marsh in 2010 which led to a significant saving on our insurance premiums for our property top-up.
The Trust is now using one brokering service for all our insurances – we have four insurance schemes in place:
NHSLA (covering clinical liability by clinical negligence schemes for Trusts – CNST, non- clinical liability covered by liability to third parties scheme – LTPS and property expenses scheme – PES). Non-NHS income generation (travellers) Motor fleet insurance (Aviva) Property top-up
LG reported that there is currently one issue with regards to our periodic site survey which ensures we have the right valuation in place with regards to our assets. The l evel of contents insurance appears to be lower than first thought and this is in the process of being resolved.
The Committee sought assurance that the level of insurance cover was sufficient for our non-NHS income generation – SW to report back at October meeting. SW
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Heart of England NHS Foundation Trust Safety and Governance Directorate Governance & Risk Committee – Minutes 25 th July 2011
8. National reports and inquiries update
The purpose of this report was to provide the committee with an update of the Trust’s position against recommendations made in the National Reports and Enquiries between 2000 and 2010.
Key points to note
The majority of recommendations have already been completed or have work-streams already in place to address the issues being raised. Some of the reports go back 10 years (to the time of the Bristol enquiry) with some of the recommendations now obsolete or superseded. For example, clinical governance, in particular, has matured and more national regulations are in place.
With regards to a member of the Board being nominated as a patient champion and a second point that patient / public representatives should be included on all board committees and sub-committees, AK confirmed that she and SW will check the recommendations and SW report back at the October Governance and Risk meeting.
The committee noted the report.
9. LSA midwifery report (Joy Payne)
Joy Payne provided a summary of the Local Supervising Authority (LSA) Annual Report.
Key points to note:
The LSA are responsible for ensuring the safety of all midwifery processes. Our responsibility as a trust is to facilitate the supervisory function. Every year, the LSA officer has to undertake an annual audit supervision of the Trust. It is Important to note that this audit is expected annually and this in turn informs the LSA report that is submitted to the NMC on an annual basis.. There are five UK-wide local reporting standards and 51 indicators within these five standards. Two standards were chosen this year as part of our audit:
Standard 1 – this standard requires that supervisors of midwives (SoMs) support mothers in making appropriate birth choices. The audit confirmed we were compliant. Standard 3 – this is about the role that SoMs have in supporting pre registration student learning and the preceptorship of newly appointed or qualified midwives. The audit showed that midwives felt isolated in their envir onment and that supervision was not integrated with management. However, there was a strong message that SoMs are pivotal in supporting newly qualified midwives and there was a recommendation that the preceptorship programme was reviewed and evaluated to ensure an integrated approach. SoMs have also been tasked with providing the Head of Midwifery with an action plan to meet local recommendations by 31 st August 2011. JP has confirmed that this is in progress.
Commendations from the report stated that supervision was identified as supporting midwives through the recent service reconfiguration and that midwives and students spoke positives about the midwife led units.
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Heart of England NHS Foundation Trust Safety and Governance Directorate Governance & Risk Committee – Minutes 25 th July 2011 Operations
10. SIT REP (Louise Galvin)
Key points:
Strategic and operational risks - SW reported that we are currently reviewing our approach to reporting and reviewing strategic risks. A number of actions have been implemented to manage these risks and we will look to reduce the risk sc ores on some of the risks as part of the Q2 review.
SW confirmed that for operational risks, we are going to review our reporting arrangements. We need to improve our approach to gaining assurance on improvements and plans to mitigation from clinical and operational areas. SW will be encouraging a review of the red risks at Operations Committee as this is the main forum that should be able to pick up and monitor these risks.
Two new SUIs – Both were never events as follows: - Patient attended Solihull Ho spital for a knee replacement operation which took place on 24 th June 2011. It was identified that the incorrect size of knee replacement was used and the patient would have to return to theatre the following day for corrective surgery. Patient was infor med of the incident and an apology given by the surgical team. - A foreign body was left in a patient following an operation for resurfacing the knee joint. The patient was returned to theatre and the object removed. This has been discussed with the patient and an apology given. Aggregation of data - this is a new addition to the SIT REP detailing the top five category themes for incidents, complaints, claims and serious incidents for Q1 11/12. LG confirmed that more detail will be provided at the October Governance and Risk LG meeting. Incident reporting – An additional paper was tabled at the meeting. LG explained that there has been a gradual small increase in the total number of incidents reported but there has also been an larger increase in the number of orange incidents. There has been a large campaign with regards to reporting tissue viability incidents and the increased trend in orange incidents is most likely linked to this. Although incident reporting is increasing year on year, there is currently no evidence as to whether this is linked to campaigns that are running rather than expected increases. The committee agreed that the increase in reporting is positive but this needs to be kept under review. Closedown reports – Two new SUI closedown reports we re presented. It was agreed that as well as being on the Safety and Governance Intranet site, these reports will be circulated to the Chief Nurse and Medical Director for circulation to local managers. LG
11. Community services update (Alison Massey)
Alison Massey, the Interim Governance Lead for Solihull Community Services provided a summary report on the governance structure, governance work streams, reports and work plans for HEFT Solihull Community Services.
Of particular note was the learning lessons bulletin, specifically with regards to patients not attending clinic. The committee agreed the format of the bulletin could be adopted for HEFT.
SW reiterated the need for more work around integration between the c ommunity team and HEFT. SW requested a programme plan describing our approach to integrating the governance functions and including committee arrangement, how committees are linking
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Heart of England NHS Foundation Trust Safety and Governance Directorate Governance & Risk Committee – Minutes 25 th July 2011 into our Governance and Risk Committee and how business is done - LG confirmed that there an integration plan is already in progress and she is working closely with Roger Stedman and Fiona Burton with regards to quality & safety forum.
The report was noted by the committee.
Information and Assurance
12. Reports from the sub committees:
• Safety Committee – taken as read • Information Governance Committee – taken as read • Clinical Quality Review Group – taken as read • Safeguarding Committee (Children) – taken as read • Trust Infection Prevention Committee – taken as read
13. Director of Governance Report
SW informed the committee as a result of a discussion with Lisa Richards – Everton (whose husband died following the amphotericin drug error), Lisa is going to join the Governance and Risk Committee as an expert patient volun teer who has experienced the impact of a medical incident). SW has agreed with Simon Jarvis that Lisa will SJ undertake an induction and will meet key members of the board in advance of the next Governance and Risk meeting. Her remit is to bring the patient / carer’s perspective to safety to the committee. This decision was supported by the committee.
SW reported that Monitor have changed the quality declaration that we have to make. We will need to complete a piece of work to comply with these changes and this will factored into the work we are doing with KPMG.
14. Any other business
Nothing to report this month.
15. Date and time of next meeting: The next meeting will be on Monday 10 th October 2011 @ 1.00pm in the Board Room of Devon House. Please send through any apologies to [email protected] .
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Heart of England NHS Foundation Trust Safety and Governance Directorate Governance & Risk Committee – Minutes 25 th July 2011
GOVERNANCE & RISK COMMITTEE - Ongoing actions – July 2011
Date of Action Target date Owner mins
Jun 2011 SW to circulate the Executive Summary from the Kennedy report ASAP SW in the Bristol Enquiry. July 2011 AK to reword the section on claims from the June Governance ASAP AK and Risk minutes. July 2011 LG to forward SUI closedown reports to Mandie Sunderland and ASAP LG Aresh Anwar to circulate to local managers. Feb 2011 SW to bring a progress report to October Governance and Risk Oct 2011 SW meeting re: proposal for the use of the Hollier Centre with a particular focus on maternity. Apr 2011 Aresh Anwar to chase receipt of formal report from the Deanery, Oct 2011 AA with regards to their recent visit re: supervision of junior doctors. AA to prepare an interim report regarding this for the October meeting. Jun 2011 Back to the Floor metrics – LD to provide an exception report at Oct 2011 LD the next meeting relating to the Elderly Care Wards at Heartlands, Wards 8, 21 and 22 and Ward 20a at Solihull. Jun 2011 Sara Brown to update the Governance and Risk Committee in Oct 2011 SB October 2011 following the Organisational Dev elopment Steering Committee to discuss Stress Management issues. July 2011 SW to liaise with Hazel Gunter re: recording of absence. Stress Oct 2011 SW Management Report update to be provided at October meeting. July 2011 LD to provide data re: A&E as part of the Patient Experience Oct 2011 LD Report for October Governance and Risk meeting. July 2011 LD to provide report re: new complaints process at October Oct 2011 LD Governance and Risk meeting. July 2011 SW to report at October Governance and Risk meeting re: Oct 2011 SW insurance cover for non-NHS income generation. July 2011 SW and AK to report at October Governance and Risk meeting Oct 2011 SW/AK re: National Reports and Inquiries (patient champions and patient /public representatives on board commit tees and sub - committees). July 2011 LG to provide further information at October Governance and Oct 2011 LG Risk Committee re: aggregation of data (SIT REP) Jun 2011 Sunanda Gargeswari to provide an update at the December Dec 2011 SG Governance and Risk meeting with regards to progress with the guidelines intranet site. July 2011 SW to provide quarterly updates re: Safety Strategy Priorities. Dec 2011 SW GROUP 1 ACTIONS Feb 2011 SS confirmed that whilst the WMQRS was not entirely linked to ASAP SS Group 1, they would take it on and provide an action plan and forward to all Governance and Risk Committee members as soon as available. Jun 2011 Steve Smith to provide update at Oct Governance and Risk Oct 2011 SS meeting with regards to how issues re: Results Reporting will be resolved. GROUP 2 ACTIONS
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Heart of England NHS Foundation Trust Safety and Governance Directorate Governance & Risk Committee – Minutes 25 th July 2011 No actions this month GROUP 3 ACTIONS Dec 2010 RS to bring report to Oct Governance and Risk meeting to show Oct 2011 RS all the improvements / patient safety story / assurance re: Diabetes Risk. GROUP 4 ACTIONS No actions this month GROUP 5 ACTIONS No actions this month
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TRUST BOARD STANDING COMMITTEE Minutes of a meeting held at Devon House, Heartlands Hospital on 25 July 2011
PRESENT: Lord P Hunt (Chairman) Mrs A East Mr A Stokes
IN ATTENDANCE: Mr M Pye
11.09 APOLOGIES
Apologies were received from Dr M Newbold.
11.10 MINUTES OF THE MEETING HELD ON 26 APRIL 2011
The minutes of the meeting held on 26 April 2011 were approved by the Committee and signed by the Chairman.
11.11 MATTERS ARISING
Mr Stokes confirmed that the sole item in the Matters Arising Schedule had been completed by Dr Newbold .
11.12 APPROVAL OF MONITOR QUARTER 1 RETURN
Mr Stokes confirmed that Monitor Q1 Return had been completed in accordance with the Compliance Framework.
The following points were noted
The financial risk rating is 3 Q1 had been a difficult period financially due, in part, to lower activity/income which were predicated to remain flat. Continuing upward cost pressures were not sustainable and would require o renewed focus on CIPs o further work on areas where pay has increased o review of new to follow up issues o utilisation of nonrecurring provisions August will be a better indication of the more normal position, being the first month that will have fully reacted to the changes that have been previously implemented.
The governance rating is amber red due to overshoots of MRSA and CDiff targets. The governance declaration will be 2 because t wo issues have been triggered over the quarter.
o CDiff where there have been 37 cases against a target of 28. The number of
Q:\BOARD\BOARD PAPERS\2011\SEPTEMBER\ITEM 13 STANDING COMMITTEE MONITOR RETURN MINUTES 25 JULY 2011 1 TB SEPT 11 MTG.DOC cases now appears to have levelled off somewhat.
o MRSA where there were 3 cases against a target of 2. However, there have already been 3 cases in July for which no particular reasons can be a scribed.
Each issue triggers one penalty point resulti ng in an amber red governance rating. This could cause Monitor to declare a breach of Authorisation but this was thought unlikely due to the very low numbers involved.
Some benchmarking is being undertaken in both areas.
The Finance Declaration will be 1.
The Quality Board Statement Declaration will be 2.
The meeting also reviewed the level of DNAs currently running at 10% which is as low as has been recorde d recently but still considered too high to be acceptable. Mr Stokes agreed to review with Roge r Stedman and report to the Committee/Board.
Following due consideration , the Committee approved the Q1 Return for immediate submission to Monitor.
11.13 DATE OF NEXT COMMITTEE MEETING
21 October 2011
……………………………… Chairman
Q:\BOARD\BOARD PAPERS\2011\SEPTEMBER\ITEM 13 STANDING COMMITTEE MONITOR RETURN MINUTES 25 JULY 2011 2 TB SEPT 11 MTG.DOC
EXECUTIVE MANAGEMENT BOARD
Minutes of the meeting held at Maple House, Birmingham At 9am on Tuesday 18 th July 2011
PRESENT: Mark Newbold Chief Executive (Chair) MN Adrian Stokes Director of Finance AS Hazel Gunter Acting Director of HR & OD HG Lisa Dunn Director of Corporate Affairs LD Andy Laverick Director of ICT/Chief Information Officer AL John Sellars Director of Asset Management JS Aresh Anwar Medical Director AA Steve Smith Group 1 Medical Director SS Sarah Woolley Director of Healthcare Governance SW Claire Molloy Executive Site Lead Solihull CM Simon Hackwell Commercial Director SH Mandie Sunderland Chief Nurse MS Mark Wake Group 4 Medical Director MW Misra Budhoo Group 2 Medical Director MB Alistair Williamson Consultant Anaesthetist and Clinical Lead AW for Good Hope Sam Foster Deputy Chief Nurse SF
IN ATTENDANCE: Denise Purser Notes Sara Brown OD Business Consultant
11.120 1. APOLOGIES ACTION
Received from Itisha Gupta and Roger Stedman
11.121 2. STRATEGIC PLAN FOR NEXT THREE YEARS
Mark Newbold talked the Committee through this presentation, explaining that upon appointment it was communicated that the new CEO would complete a listening exercise, this presentation contained the outcomes. Previous values have now be en replaced and are due to be launched imminently.
It was felt that Solihull and Good Hope Hospitals are business units with Board level leadership , they need to work out the direction in which they are heading over the next three years.
Discussion was necessary to look at the Trust and ascertain where it is at present, goals for the future and where the Trust is heading.
Aresh Anwar discussed a focus on health and questioned where does social market fit into long term plan? The inability to control the non health sector could be a challenge and would the Trust get involved in this? Mark Newbold suggested that this is an issue for Group 1 to consider. SS
1 Claire Molloy raised the point regarding reshaping clinical services across Birmingham and Solihull an d is there any collaboration to look at how each area completes this? Mark Newbold did not think this has commenced but could be GMDs something for G roups to consider.
Simon Hackwell stated that there is no mention of investment, some has been MN completed and more is planned. It was agreed to add this to the presentation.
It was agreed that this is the correct approach by all.
Reshaping HEFT/Strategic Priorities
Simon Hackwell discussed the reshaping of HEFT which follows on from a recent Board discussion. This involves responding to the economic challenge through service reconfiguration. Various feedback was received:
Point 2 - Aresh Anwar queried bed reduction and how to convey this message to staff. Hazel Gunter also queried if you need to call it workforc e reduction rather than workforce redesign. A discussion arose regarding being open and honest with staff when changes are being made and communicating appropriate messages.
Misra Budhoo suggested redesigns of entire services need to ensure G eneral Managers and Clinical Directors are all aligned.
Point 3 - ‘improved internal working between specialities’ S am Foster queried what this means. Sam suggested that changing pathways would be an alternative as there are some positive examples.
Process: Mandie Sunderland queried if community ser vices should be on there. Sam Foster suggested that therapies be on the list – it is believed that therapy pathways that could help clinical pathways to learn.
Aresh Anwar suggested HR should complete a large project ar ound manpower as there is a gap that needs addressing , this could consider future requirements.
Sarah Woolley feels communication with Group Operations Directors ( GODs) needs to be improved and work together more closely.
Mark Newbold wished to know who would be leading the plan, Simon Hackwell would like the Executive Management Board to manage this, suggested whether GOD’s should be invited. S arah Woolley feels the correct forum should be developed so that they can feel engaged. Mark Newbold to meet wi th the GODs MN and General Managers.
The strategic priorities and associated targets have previously been agreed by the Board for 2011 -2014. The next stage wa s to decide which Executive Director is responsible for each priority. A position statement will need to be produced against each p riority for September Board.
List of agreed Executive Directors against priorities:
1 Sarah Woolley 2 Lisa Dunn 3 Hazel Gunther 5 Adrian Stokes 6 Aresh Anwar 2 7 Hazel Gunter 8 Adrian Stokes 9 AA/CM/SM 10 Aresh Anwar / Claire Molloy / Susan Moore 11 Lisa Dunn 12 Sarah Woolley 13 Simon Hackwell 14 Simon Hackwell 15 Lisa Dunn 16 Mandie Sunderland Mark Newbold requested a meeting with GODs and General Managers to bring MN them up to speed, should also include Matrons .
11.122 3. FINANCIAL CHALLENGE
Adrian Stokes felt that the challenge has grown but not the level of response. Quarter 1 shows a decline and this is th e first quarter that income has not been higher than the previous year across most areas. Adrian explained the reasons why income is low.
Aresh Anwar stated that this topic had been discussed at Operations Committee and staff are frustrated at not being able to deliver and the resulting fines.
A series of short term actions are required which consisted of: Immediate pay controls New to follow up solution Drive CIP Turnaround for Group 1 – this Group is most financially challenged.
Sam Foster suggested that erostering could assist with efficient workforce planning.
Andy Laverick feels there is a need for change with how clinicians work, some clinics work more effectively. There is no new redesign when some areas are changed.
There are still ongoing i ssues with the correspondence being sent from the out patients department.
Steve Smith to discuss follow up ratios with Clinical Contracting Group. SS
John Sellars enquired asked if a discussion had taken place regarding the stopp ing of increments. Hazel Gunter explained that discussions took place with the Unions and the matter is still being discussed with them on a regional basis.
11.123 4. ACCOUNTABLE CARE PARTNERSHIPS
Claire Molloy presented this report, t he purpose of which was to set out an overview of the agreement made by key partners to develop a form of an Accountable Care Partnership (ACP) to lead the transformation of services and delivery of integrated care within Solihull.
This d iscussion document will serve as a statement of progress to date and provide a briefing for parties less actively engaged in the development to-date. In addition, the document can form the basis for further discussion between HEFT and partners across the local health and social care economy about the potential application of the model elsewhere. 3 The document sets out the suggested work priorities for the first year which consisted of four areas. When questioned, clinicians were of the opinion that work should be focused on first three.
The inaugural meeting of the ‘Accountable Care Partnership Board’ is scheduled for the following week and a paper regarding the contents will be submitted to the Committee.
Aresh Anwar tabled a document and enquired regarding future i mplementation and i f the Trust should drive the whole pathway or d o it as a collaboration with an other provider. Claire Molloy responded that a decision will have to be made and the service model be examined.
Clare Molloy was unclear where this Board should report to, Mark Newbold confirmed it should report to Executive Management Committee.
A d ebate took place regarding running a similar service for the Good Hope and Heartlands sites.
11.124 5. HIGH LEVEL ORGANISATIONAL DASHBOARD
Mark Newbold discussed the possibility of having an organisational dashboard, which would consist of something similar to the daily snapsho t which is currently circulated daily . It would be for staff members to view as well as members of the public. It could also be featured at Team Brief and a llow time for answering questions.
Suggestions were requested for data to be included: Staff nursing level on the Intranet Sickness/turnover NCEPOD classification of death - measure an average number that could be classed as preventable. SHMI Times since bacteraemia by site/ward Falls Pressure areas
Patient experience
Positive measures to reflect a balanced picture
Mark Newbold will work with Andy Laverick and Adrian Stokes produce an initial MN / AL / draft for discussion. AS
11.125 6. OPENNESS AS OUR ‘OPERATING PRINCIPLE’
Mark Newbold would like the Committee to give some thought to how this is ALL reflected in their day to day activity and feedback with some suggestions.
Lisa Dunn explained that the Trust is working on becoming open and items such as Freedom of Information requests will be published on the Trust website. Other items such as ward data and patient experience are to go live soon. Expenses are also being considered for website inclusion. LD
11.126 8. STAFF SURVEY RESULTS
Sara Brown attended to present the staff survey results, the full detailed results SB will be circulated later in the week. 4 Each area will be able to discuss results within their teams and identify specific actions for their areas.
Unfortunately the rate of take up has been significantly reduced compared to last year. Adrian Stokes questioned if the volume of questionnaires being circulated is off putting. Sara Brown stated that all issues will be examined. SB Mark N ewbold felt that an innovative more real time m easure of how staff are feeling would be beneficial.
11.127 9. MINUTES OF MEETING HELD ON JUNE 21 ST 2011
11. 118 Hazel Gunter provided an update regarding potential strike action. Contingency plans are in place for strikes at present, the p lans form part of business contingency plans. H azel will discuss this item at the Committee when updates are available. Lisa Dunn requested to be kept informed. Hazel has completed a paper for HG HR Committee and will circulate this for information. 11.112 Sarah Woolley wished to point out an error in the spelling of SUI and record a debate had also taken place regarding the risk register and the reviewing of corporate risks.
11.128 10. PERFORMANCE UPDATE
Adrian Stokes highlighted some key issues: It has been a good month for performance in June. A&E and Stroke were highlighted last month as not achieving target but have both been achieved for June. Areas of concern are MRSA and Cdiff rates, both have failed Q1 Monitor risk rating , Mandie Sunderland explained these items will be discussed at Trust Infection Control Committee next week . The patterns for infection do not have a recurring theme. The Root Cause Analysis should be comp leted by next week but it was felt that an awareness campaign should be launched to supplement this. There are presently issues with ambulance target, the other items were taken as read. Mark Newbold wished to have it minuted that both A&E results and str oke have been very good recently.
11.129 11. OPERATIONS COMMITTEE MINUTES
Aresh Anwar summarised this regular agenda item, they are w orking together to drive several plans forward which includes the winter plan which will commence soon. The Emergency Care Improvement Board is trying to address internal issues around performance, phase 1 is concerned with internal pathways, 2 & 3 will look at integrated path design programme. Also working on the planned care forum which has not been successful so far which was i nitiated to discuss surgical planned care and outpatients.
11.130 12. SITREP
Sarah Woolley explained that there has been e xtensive discussions about risk reporting, a large scale review will be completed around how they are reported and escala ted. Strategic risks will have a detailed review of what is on the register at present . It was felt that operational risk s hould be discussed in more detail at Operations Committee which is the appropriate forum .
5 There needs to be stricter controls around issues and whether they should be classified as a risk. Assurance is to be sought that they are being mitigated and managed appropriately for this Committee.
Sarah Woolley is due to meet with Adrian Stokes to discuss data quality. SW/AS
There is one new SUI to note this month which is still under investigation.
11.131 13. QUALITY ACCOUNTS
Sarah Woolley presented this update paper which lists the progress to date this year, consultations are planned for September which will take place with community groups and stakeholders.
11.132 14. SUMMARY PAPER REGARDING CQC VISIT
This paper was provided for assurance and information by Sam Foster describing the u nannounced CQC compliance visit at Good Hope Hospital (GHH) in April 2011 regarding dignity and nutrition for older people.
GHH was selected as part of the CQC targeted inspection programme of unannounced visits to assess how well older people were treated during their hospital stay. The only concerns raised were rated by CQC as mi nor and another hospital will be spending time at HEFT to make observations on practice in this area.
11.133 15. HOSPEDIA – UPGRADE OPTION
Andy Laverick discussed a proposal to upgrade the Patient Line terminals which are located at the end of ward b eds to a new T3 terminal. These will be a larger size, better quality, as well as providing better access and enhanced touchscreen usability. There is also the possibility of hosting a hospital channel at no cost.
Mandie Sunderland raised a point that some terminals had been removed when they were not making a profit in a ward where some patients were not well enough to use them but others may have benefitted from them.
It was agreed in principle by all if clarification was received around the concerns that were raised.
The questions were: If there are any stipulations regarding their costs and would they increase them? Would the prices remain the same for standard functions? Could the detail be examined if there is a change in bed base numbers ? Would machines be upgraded at some point? What would happen if cards were lost?
A response was received during the meeting: If wards close the company would recover the hardware and relocate it to another ward. The prices are tied into the retail price index. The software would be updated on regular basis. Would l ook at a machine refresh in 7/8 years.
6 11.134 16. DANWOOD
The purpose of this report was to update the Executives on the progress of the Print Improvement Project within the Trust. The Trust is 6 months into a 3 year 6 month print management services contract with Danwood and there have been some questions raised with regards to the contract.
Adrian Stokes discussed the reasons behind the revised contract and sought support from the Committee. Staff are being actively encouraged to print in colour as little as possible and be more stringent about overall printing. Paperless working should be implemented where possible and management make use of their IPAD s.
11.135 17. END OF YEAR MEDIA REPORT
For information only.
DATE OF NEXT MEETING
Tuesday August 16 th at Maple House 9am.
7 Report to Executive Directors &Trust Board By Director of Infection Prevention and Control 25 th August 2011 From: DIRECTOR OF INFECTION PREVENTION AND CONTROL
Title: Director of Infection Prevention and Control Report
The purpose of this report is to update and inform the Board on infection prevention and control performance and issues in May, June & July 2011.
Summary/Key Points: MRSA Bacteraemia (post 48 hour) : 1 case each in May & June 2011 and 3 cases in July 2011. Points for action Meticillin sensitive staphylococcus aureus (MSSA) mandatory surveillance Contract variation: reduction in cases not required, surveillance continues. C difficile infections- 56 cases of post 48 hour against trajectory of 39 until July 2011. C difficile diagnosis by dual test agreed; in implementation phase. MRSA Screening- July outturn 93.88 and 98.01% in emergency & elective respectively Ecoli Mandatory Surveillance commenced from June 2011
…….
1. MRSA BACTERAEMIA (MAY, JUNE & JULY 2011) The MRSA trajectory for 2011-12 is 7 post 48 hour bacteraemias. Year to-date position is 6 cases: with 3 cases in July’ 11 (Appendix 1- MRSA dashboard ).
Month Post 48 hour Wards Pre ( not in trajectory) April 1 This section has been removed - under Section 40(2) and 41 of the
Freedom of Information Act 2000 May 1 0 June 1 2 BEN July 3 1 BEN Key findings from RCA investigations
This section has been removed under Section 40(2) and 41 of the Freedom of Information Act 2000
MRSA post 48 hour bacteraemia 2010-11 RCAs summary- Appendix 2
The detailed analysis of MRSA bacteraemia from last year is attached. Most common focus of infection was skin and soft tissue. 4 patients had stay over 30 days before bacteraemia and only one was re- screened and out of 3 who were positive on admission screen only one was decolonised on time.
Action Plan for MRSA bacteraemia This has been presented to Performance Committee and CQRG and includes site assurance and reporting, RCA reporting by clinical teams to TIPC and discussion with Chief Nurse and Medical Director to improve engagement and raise profile. Reviewing communication internally to the staff. Promoting decolonisation and monitoring re-screen in long stay patients. One issue of dealing with previous positive cases is to be raised at Cluster’s health -economy meeting.
2. METICILLIN SENSITIVE STAPHYLOCOCCUS AUREUS (MSSA) BACTERAEMIA Mandatory surveillance of MSSA bacteraemia commenced in January 2011. A contract variation was submitted regarding removal of 5% reduction of MSSA in 2011-12 on the 2010-11 out turn. This has been accepted and we are no longer required to achieve a trajectory. Monthly mandatory surveillance will continue via MESS national database and PCT HCAI reduction plan submission. This was submitted as the letter from DH stated that ‘ organisations are not yet required to set reduction plans at this stage for MSSA and Ecoli’.
1 Report to Executive Directors &Trust Board By Director of Infection Prevention and Control 25 th August 2011 3. CLOSTRIDIUM DIFFICILE INFECTIONS Trajectory for May, June& July 2011 was 10 cases The table below shows CDI cases in detail, according to sites (in Appendix 3).
Month Post 48 hour Pre 48 hour Community Total 2 11 22 9 May BH -1, GH-1, Sol- 0 BH -3,GH- 5 Sol- 1
11 8 5 24 June BH - 6,GH-3,Sol- 2 BH -6, GH -1,Sol -1 4 7 29 18 July BH -1,GH-3,Sol- 0 BH - 12,GH- 5,Sol- 1
Outbreak investigations
Type of Cluster BHH GHH Sol
PII- not confirmed BH10 (May) and 28 - -
Outbreak - Ribotype BH 3 (O15), BH 30 (106) in GH 17 ( May ) & GH 10- (June ) both - July of O27, GH 24 (July)- 005
Fortnightly meetings at GHH continue to review each Cdiff patient and issues with IPC/GHH site managers and senior nurses. Cleaning Plan done to deep clean the affected wards with sterinis- GH 17& GH10. This action has been completed.
Increase in Incidence of Cdiff at BHH in July ’11 - 12 cases of Cdiff positive at BHH site has led to initiation of weekly incident meetings. All cases are being investigated in detail. Antibiotic review on BH27 Cdiff cohort ward did not highlight any inappropriate antibiotic prescribing in Cdiff cases. It has been identified that the cleaning with the new company G4S is in transition and procedures are still in the process of being established for the wards. This has led to un- clarity within the wards with regards to cleaning. The company has been asked to expedite the development of service specification with the wards. Deep cleaning of outbreak wards has been completed and further cleans are being organised.
Antibiotic stop & review dates- a promotional campaign is being organised in the trust
30 day mortality for C.difficile in Quarter 4, 2010-11 the data is attached in Appendix 4 30 day mortality for Q4 was 20% and there were 2 deaths with C.diff mentioned in Part 1. All RCAs have been completed.
4. CLOSTRIDIUM DIFFICILE DIAGNOSIS DUAL TEST STRATEGY- this has been agreed at the Trust Infection Prevention Committee and is in the implementation phase. Algorithms and reporting mechanisms are being developed; likely to commence in the first week of September.
Most trusts in the region have already moved towards dual test and it is recommended both nationally and regionally by SHA. It is anticipated that the numbers of Cdiff are going to rise following this; however as per SHA’s recommendation the current test will continue in parallel for about 6 months and will be able to provide assurance that the increase in numbers is due to change in testing rather than failure of infection control measures. The Cdiff national Objective and target will remain unchanged but commissioners will be requested to apply flexibility in assessment. This rise in numbers should be short term as this dual test (screening + confirmation) system will provide better control mechanism for Cdiff in detecting cases which are been missed by the current test and leading to silent transmission and minimise the false positives.
It is expected that DH will consider this year as the baseline year and this flexibility is unlikely to be available after this year. It is therefore important that this change in diagnosis is made as soon as possible to take 2 Report to Executive Directors &Trust Board By Director of Infection Prevention and Control 25 th August 2011 advantage of maximum time possible in this financial year to be able to set the new baseline for next year’s Objective setting. More guidance is expected from DH in autumn.
The commissioners were informed at the CQRG of this impending change and they were supportive of this as clinical quality improvement measure. More formal notification will be provided at Contract Management Board in September.
5. MRSA SCREENING Elective admission screen compliance remains over 95% and emergency screening over 90% for Q1 and July 2011. The focus on screening continues to maintain this standard and also on re-screening of long stay patients and improving decolonisation.
Type Apr-11 May-11 Jun-11 Jul-11 Elective Admissions 97.91% 97.08% 97.46% 98.01% Emergency Admissions 93.55% 91.88% 93.22% 93.88%
6. ECOLI MANDATORY SURVEILLANCE : commenced from June 2011. June and July’s data was signed off to include Ecoli details. Additional focus of infection and other details as required by the HPA form are voluntary fields. A dataset is been designed to collect detail information on all post 48 hour cases for surveillance purposes. We are unable to do this additional surveillance on pre48 hour cases and hence have requested PCT to provide this. This will be discussed at the Cluster health-economy group.
Month Post 48 hour Pre 48 hour Total June 8 32 40 July 14 27 41
Itisha Gupta Director of Infection Prevention & Control 26th August 2011
3 Infection Control Report MRSA Bacteraemia Performance Dashboard August Report - July 2011 Data
The cumulative number of Post 48hr 8 cases across HEFT is 6. 7
6
5
4
3
2 1 1
0 0
In July, there were 3 Post 48hr 4 cases. Infection Control Report MRSA Bacteraemia Performance Dashboard August Report - July 2011 Data cases. 3
2 2
1 1
0
-1
-2 Apr-09 Jun-09
In July, there was 1 Post 48h case at GHH and 2 at SOL. 3.5 Heart of England MRSA Bacteraemias 2010 - 2011
Cumulative no. of MRSA bacteraemias against DoH target Pre and Post 48h by hospital site for 09/10 and 10/11 16 9 14 8 12 7 10 6 8 5 4
6 Number 3 4 2 2 1 There0 were 9 MRSA bacteraemias at the end of 2010/11 (Post 48hr).48hr). This is a 36% decrease in There has been a reduction in PrePr 48h bacteraemias at all sites. PostPost 48h bacteraemias have reduced comparison to 2009/10. at both BHH and GHH but not at SOL. 0 BHH Pre 48 BHH Post 48 GHH Pre 48 GHH Post 48
Cumulative YTD Cumulative Target 2009/10 2010/11
Non-Compliance with Policies Focus of Infection 2.5 Blood culture not taken according to policy 2
Decolonisation not 1.5 documented There have been 4 types of non-compliances but 'poor documentatdocumentationion of line insertion/removal' has The predominant focus of infectionsinfectitions were skin/soft tissue and UTI.UTI. been the greatest non compliant. Poor Number 1 documentation of documentation of Heart of England MRSA Bacteraemias 20100 -11 line monitoring 0.5 Poor documentation of line … 0 Skin and Soft UTI PVC Contaminant 0 1 2 3 4 5 Tissue
Length of stay prior to bacteraemia For patients who had a stay greater than 30 days prior to 5 bacteraemia, were they re screened? 4 of the 9 patients stayed in hospital for more than 30 dadaysys priorprior to the MRSA bacteraemia. Out of the 4 patients that stayestayedyedye in hospital3.5 for more than 30 daysdays prior to the MRSA bbacteraemia,acteraemia, only 1 was re screened. 4 3
2.5 3 2 Number 2 1.5 Number ofpatients Number 1 1
0.5 0 0 < 6 days 6 - 10 days 11 - 20 days 21 - 30 days > 30 days Yes
All 9 patients were screened for MRSA as pre MRSA screening policy. 3 out of 9 Out of the 3 patients that were screened positive on admission, 1 was decolonised and 2 were not. patients were screened positive. Infection Control Report C-Difficile Performance Dashboard August Report - July 2011 Data
In July, the trust was over its target as Post 48h cases against a target of 10.
Clostridium difficile all cause and attributable mortality data for HEFT patients: Q4, 10/11
The percentage of patients with a positive C difficile test that die within 30 days of the result was 20% in Q4, 10/11.
Of those who died within 30 days in Q4 10/11, there were 2 deaths on part 1 of the death certificate.
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 08/09 08/09 08/09 08/09 09/10 09/10 09/10 09/10 10/11 10/11 10/11 10/11 Number of positive 166 123 83 72 81 83 73 81 52 97 78 84 patients Number of deaths 43 36 22 18 29 22 20 19 13 16 19 17 within 30 days Percentage of 26% 29% 27% 25% 36% 27% 27% 23% 25% 16% 24% 20% deaths Number of deaths 8 5 3 6 9 5 4 1 0 4 0 2 on Part 1 Number of deaths 16 6 6 6 6 4 2 5 7 4 3 4 on Part 2 Percentage of deaths that were 56% 31% 41% 67% 52% 41% 30% 32% 54% 50% 16% 35% attributable* Number of deaths 38 32 20 15 29 19 19 18 13 14 15 16 in Hospital Number of deaths 5 4 2 3 0 3 1 1 0 2 4 1 in community
Table 1: C difficile 30 day all cause mortality data and (*) attributable mortality recorded on part 1 and 2 of the death certificate.
FINANCE EXECUTIVE SUMMARY & KEY PERFORMANCE INDICATORS Month 4 to 31 st July 2011
Adrian Stokes, Finance and Performance Director
EXECUTIVE SUMMARY
The Trust has a deficit of £1.0m in July and £1.4m deficit year to date.
The in month loss represents the continued trend experienced in quarter 1 . Income is lower than last year and again reduced due to new to follow up ratio breaches. The position is impacted further due to re- admission fines. Pay expenditure remains a key concern and continues at unaffordable levels, £32.0m in month. We continue to see a slow response to the key challenges outlined at previous Finance and Performance Committees, namely new to follow up ratios, reduced pay expenditure, d elivery of CIP and reduction in length of stay.
From a performance perspective C.Diff , MRSA bacteraemia and performance against the ambulance handover time indictor are of concern alongside emergency length of stay.
Contractually a number of performance issues against the PCT contract have rolled over from last year and although payment is being withheld, there are plans in place to meet the required level of performance and have the payments released. These relate to the management of stroke patients and the inclusion of a patient pathway identifier in our external data submissions.
The table below summarises our current Finance & Performance position:
Category July Headlines
Breaches on outpatient new to follow -up ratio Pay expenditure remains high Finance Cost of a dditional measures
CIP delivery C.Diff MRSA bacteraemia Performance Ambulance handover time Emergency LoS remains above target
1 open performance notice at risk of escalating Contracting 2 open exception notices with income being withheld
Overall Position
The current run rate would place the Trust in a recurrent £3.0m deficit at the start of 2012/13 which is detailed in the attached presentation. EMB have agreed to set up a sub-group to proactively tackle these challenges to improve this position.
A Stokes
Finance and Performance Director, Heart of England NHS Foundation Trust. July 2011
From: Adrian Stokes
Title: Finance Executive Summary & Key Performance Indicators The purpose of this report is to update and inform the Trust Board on the financial position for 2011/12
Z Income has over performed against LDP contracts by Z Run rate provides for non recurrent surplus of £7.0m, £2.8m. This is £3.4m lower than last year on a like for recurrent deficit of £3.0m. like basis.
Z Presentation provides further information. Z Pay position is £3.1m deficit against operational
budgets.
Z Above assumes current run rate continues and full PCT Z Non pay position is £6.1m deficit against operational efficiency collected. budgets .
STRATEGIC ISSUES
Z Finance and Performance Directors perspective on position attached (attachment 1)
Z Against the budgeted position, the Trust has a (£8.8m) overspend year to date.
Z Income is lower than previous years whilst pay costs are increasing.
Z The Trust is planning an overall full year financial risk rating of 4. The Trust has performed below on the key Monitor targets achieving a Monitor risk rating of 2 at the end of July.
Z Current run rate would result in a recurrent deficit for the Trust at the start of 2012/13.
RISKS FORWARD LOOK
Z Slow start to CIP delivery in 2011/12 particularly wit hin Z Monitor will no longer apply a score of 1.0 to Group 1. governance risk rating where a failure of one of the cancer targets is due to a single patient breach across Z Pay costs particularly Medical Staffing and additional a quarter. measures i.e. extra cost of flexed wards. Z Additional data to be provided as part of accounts Z Adherence to new to follow up policy. process as a result of alignment.
Z Re-admissions. Z A&E to be monitored on the 4 hour waiting time, 95 % performance with a governance score of 1.0. Z Rectification delivery. Z Community services governance indicators for 2011/12 published.
KEY ISSUES
Z The 2011/12 over performance is £2.8m against plan.
Z Trust wide pay is over spent by £3.1m at the end of July. Pay costs need to significantly reduce.
Z Total medical expenditure remains unaffordable at £33.2m year to date with no sign of recommendations made by the Medical Staffing Task & Finish Group taking effect.
Z Drug costs are met through NICE contract uplift in year and over performance.
Z Non pay is over spent against operational budgets by £6.1m mainly due to energy cost, demand management and shortfall against CIP.
Z The year to date shortfall against CIP plan is £2.1m and £3.2m against budget.
KEY ISSUES
Z Operational capital expenditure plan for block allocations has been finalized with orders being raised.
Z The total commitment against the capital plan at July is £10.9m with total expenditure of £5.2m. This is behind the th planned numbers in the Monitor Plan so a capital reforecast must be provided to Monitor by 12 September. The main under spend is on Ward Block 1.
Z CPG met in August to review Q1 progress and forecast for 2011/12.
Z NHS Trade Debtors higher than plan due to delays in payment of the majority of PCT efficiency support money agreed as part of the year end PCT settlements. This is offset by higher deferred income in respect of this as this income as the plan assumed it would be paid in by quarter 1.
Z The cash balance at the end of July 2011 was £98.6m. This is £1.2m below the plan with adverse operating performance of £3.6m and delay in debtors payments being offset by other favourable working capital movements and an under spend on capital expenditure.
KEY ISSUES
Z Month end cash balance at £98.6m, this is £1.2m below the plan .
Z £30m has been placed for 12 months (maturing March 2012) with Lloyds Banking Group at a rate of 2.05%. A further £25m has been placed in a RBS fixed term bond (maturing February 2012) at a rate of 1.6%. £20m was placed with Barclays for 6 months in June at the rate of 1.11%, £10m has been placed in the Trust’s Yorkshire 30 day notice account at a rate of 0.85% being returned in early August and a further £10m has now been placed with RLCM.
Z Forecast based on delivery of £7.0m surplus. .
YEAR TO DATE FORECAST
Z The weighted average interest rate achieved on funds Z No planned borrowing in next 12 months. at the end of July was 1.45% compared to base rate of 0.5%. Z Capital spending is forecast to increase sharply in quarters 3 and 4.
2 August 2011
To: NHS Foundation Trust Chief Executives 4 Matthew Parker Street London
SW1H 9NP
T: 020 7340 2400 By email F: 020 7340 2401 W: www.monitor-nhsft.gov.uk Dear colleague
Re: Changes to A&E indicator in the 2011/12 Compliance Framework
Following completion of the Annual Plan Review and consideration of the amendments to the 2011/12 Operating Framework relating to the A&E indicators, issued on 23 June 2011, Monitor’s Board has agreed to make a change to how Monitor will use the A&E clinical quality indicators to assess governance risk in the Compliance Framework . This change is effective from Q2 and is as follows:
Monitor will only score trusts for failing to achieve the indicator relating to total time in A&E; This will be monitored using the % of patients who have waited less than 4 hours (with the threshold set at 95%); and Monitor will score this indicator 1.0 for the purposes of our governance risk rating. With regard to the other A&E clinical quality indicators, foundation trusts are reminded of the requirement in their terms of Authorisation to comply with the terms of their contracts with their commissioners. Where Monitor has evidence that a foundation trust is in material breach of its contractual obligations, to the extent that this is indicative of governance concerns, we may consider whether this amounts to a significant breach of the terms of Authorisation and accordingly whether further regulatory action is appropriate.
As a result of this change Monitor has reviewed the APR submissions of trusts and amended the governance risk rating, where appropriate, to reflect the above change. This is the only change that has been made to trust submissions.
If you have any questions please contact your relationship manager.
Yours sincerely
David Bennett
Chair and Interim Chief Executive
Cc: David Flory, Director General - Department of Health Cynthia Bower, Chief Executive - Care Quality Commission The game has changed
1. Back ground 2. Income 3. Costs 4. Surplus lower than plan 5. Forecast 6. Response ‘All bets are off, we need to move away from the NHS being built for growth to being able to sustain itself in a prolonged limitation on resources’
David Nicholson, NHS CEO, June 2009
‘with the Health Service facing a £15bn shortfall in funding over the next 10 years .... the next 2 years will be tough but manageable.’
NHS Confederation, June 2009
The game has changed Falling income, rising fines and the CIP challenge have changed the game
Previous Years This year
Income Pay Income Pay
Contract Contract CIP CIP Fines Fines
The game has changed PCT continues downward pressure as it sees HEFT continuing to over perform
HEFT Month 4 YTD Acute Income £m
• Although Acute income is above plan at Month 4, it remains below 10/11 levels
The game has changed Q1 income trend continues and has worsened
‘....this is the first quarter since the Trust achieved FT status that income has not been higher than the corresponding quarter in the previous financial year.’
Finance and Performance Committee, July 2011
‘The downward trend on Income has continued. Income remains lower than last year.’
Finance and Performance Committee, Aug 2011
The game has changed Pay cost and CIP delivery remain off plan
• Pay cost risen by 23% since 2007/08, an average of 7% year on year • Additional £68m in 3 years across the Trust • Average cost per WTE is increasing • Staff numbers have crept back up from turnaround in 9/10
• Increasing year on year shortfall against CIP target • CIP target has substantially increased • Pay remains a low priority in CIPs
The game has changed Pay overspends
Additional measures – flexed capacity and flow £0.4m per month
Further pay reductions required in line with reduced income levels for 2011/12 and to bridge the CIP Gap The game has changed Income is falling whilst costs are rising
The forecast reflects :
• New to follow up fines • Reduced activity YTD vs YTD • Reduced tariff in 11-12
•But excludes re-admission impact.
• Pay has risen from 69% of income to 72%
The game has changed CIP performance
• £14.3m, 61%, low risk
• £4.5m, 19%, medium risk
• £4.7m, 20%, high risk
Jul - In Month Year To Date
GROUPS Plan Actual Rec Actual Non Rec Variance Plan Actual Rec Actual Non Rec Variance
Emergency 430.9 75.0 48.7 (307.2) 1,725.0 288.2 137.0 (1,299.8)
Planned Inpatient Care 362.3 217.2 14.2 (130.9) 1,282.7 833.1 76.0 (373.6)
Ambulatory Care 222.0 222.0 0.0 0.0 871.2 871.2 0.0 0.0
Clinical Support 254.1 149.7 86.6 (17.8) 876.6 435.4 367.5 (73.7)
Womens & Children 209.5 124.0 55.0 (30.5) 759.9 472.2 144.0 (143.7)
Community Service 89.8 34.2 60.8 5.2 289.1 164.3 107.2 (17.5)
Facilities 110.3 101.7 0.0 (8.6) 371.5 335.3 0.0 (36.2)
Corporate 203.9 182.2 0.0 (21.7) 879.8 759.2 0.0 (120.6)
TOTAL 1,882.7 1,106.0 265.3 (511.4) 7,055.7 4,158.9 831.7 (2,065.1) 58.7% 14.1% 58.9% The game11.8% has changed 72.8% 70.7% At Month 4 our surplus is £5.1m less than plan
£m
3.2
-1.4
2.0 -2.9 1.5
The game has changed FY Impact – Recurrent deficit £3m, Non recurrent surplus £7m
Current Run Rate Projection 2011/12 £7.0m surplus
• CIP Delivery • PCT Efficiency Payment • Rectification/Turnaround impact • Further Income Reductions • New to Follow up Correction • Contract Fines • Readmission Agreement • CQUIN Non Delivery • Delayed Discharges Monies • Income Disputes> £ 3.1m • Income Disputes < £3.1m Upside Downside
The game has changed EMB Response
• EMB sub-group
Ensure plans are in place to deliver pay cost reduction Provide additional scrutiny and support to efficiency plans Drive the upside potential
But...... We have been anticipating this change in activity and in the long term it is what is required to ensure a health economy that lives within its means as opposed to financial balance for us at the expense of commissioners.
The game has changed KEY PERFORMANCE INDICATOR REPORT JULY 2011
MONITOR COMPLIANCE FRAMEWORK STATUS COMMENTS Monitor Target 7 cases for the year. There were 3 cases in July giving a total of 6 MRSA bacteraemia Q1 risk ytd. Possible risk of escalation by Monitor if we have any further cases . rating red 18 cases in July against an in mon th target of 10. Ytd target is 39 . Ytd Clostridium difficile amber outturn =56 cases. Poor performance in both April and July. EXCEPTION NOTICES STATUS PENALTY COMMENTS Performance above 80% for May (80.21%), 80% Stroke patients spend 90% of 2% contract value Ongoing June (80.71%) and July (80.99%) hopeful that stay on stroke ward withheld the Exception Notice will therefore be lifted. 1% contrac t value Patient Pathway Identifier Ongoing Expect to deliver 95% target by August. withheld PERFORMANCE NOTICES STATUS PENALTY COMMENTS Performance deteriorated from 13.55 in July to Choose & Book slot availability Ongoing None 15.02. The 13% target to be met by September. Outpatient DNAs New & Follow Up Ongoing None Ongoing monitoring continues by PCT
A&E Ambulance Handover Plan New None Action plan to improve performance requested. Service Development Plans for As Above New None Nurse Responsible Clinics Service Development Plans for New None As Above Advice and Guidance PCT OTHER STATUS COMMENTS Trust participating in review with PCT – action plan being developed for 18 Week RTT Capacity Review Ongoing agreement with PCT. Feedback expected from PCT by mid August .
KPI SUMMARY POSITION JULY 2011 KEY ISSUES
CDIFF : There were 18 cases in July almost double the monthly target of 10. The year to date target for April – July is 39, so far there have been 56 cases. The fin ancial consequences of failing this target are high, for every case over last year’s outturn (169) the Trust could be fined up £450k. AMBULANCE HANDOVER: Following up on their concerns regarding performance against this indicator in June, the PCT issued t he Trust with a Performance Notice for this measure. EMERGENCY LENGTH OF SPELL : The emergency length of spell has fallen to its’ lowest level so far this financial year at 8.26 days however it remains above the in -month 7.57 days target.
ALERTS
18 WEEK RTT – Whilst the Trust continues to deliver the 18 week RTT target this is being put at risk through the increasing backlog of patients waiting over 18 weeks to be treated, particularly in Trauma and Orthopaedics and General Surgery. Plans to address th is are being developed and will be monitored thorough the Finance and Performance Committee BREASTFEEDING: The position fell from June’s 68.4% high to 65.3% in July against the in month target of 66.15%. The yearend target has yet to be met for this indicator. It is likely that the PCT will issue a Performance Notice for this at the next Contract Management Board in September, if Augusts’ performance is not significantly improved.
SUMMARY
A total of 3% of the contract value will be with held until performance relating to Stroke and the Patient Pathway Identifie r are resolved. Having achieved the stroke indicator for the 3 rd consecutive month it is possible that the PCT may release the monies currently being held.
Performance against the Infection Control In dicators continues to be an emerging concern that will impact both on Monitor compliance and PCT contractual requirements. The summary Key Performance Indicator dashboard attached as Appendix 1 of this report provides a high level overview of our performan ce against a number of other indicators.
KPI EXECUEXECUTIVETIVE In monthmo nth In monthmo nth TRUST MONITOR COMPLIANCE FRAMEWORK TARGETARGETT 10/1110/1 1 APR-11APR-1 1 MAY-11MAY-1 1 JUN-1 JUN-111 Q1 JUL-11JUL-1 1 REF DIRECDIRECTORTOR Trajectory Change YTD
M1 Reduction of Incidence of Clostridium (post 48 hrs) MS < 131 10 168 18 9 11 38 18 ↑ 56
M2 Reduction of Incidence of MRSA Bacteraemia (post 48 hrs) MS < 7 1 9 1 1 1 3 3 ↑ 6 Patients first seen by a specialist within two weeks when urgently M3a MB > 93% 94.04%94.0 4% 94.10%94.1 0% 94.67%94.6 7% 93.1 93.10%0% 94.00%94.0 0% mia ↓ 94.00%94.0 0% referred by their GP or dentist with suspected cancer mia Patients first seen by a specialist within two weeks when urgently M3b referred by their GP with any breast symptom except suspected cancer MB > 93% 94.81% 93.60% 97.41% 96.10% 95.80% mia ↓ 95.80% mia Patients receiving their first definitive treatment within one month (31 M4a MB > 96% 98.62% 98.50% 96.15% 99.00% 97.90% mia ↑ 97.90% days) of a decision to treat (as a proxy for diagnosis) for cancer mia Patients receiving subsequent treatment (surgery and drug treatment M4b only) within one month (31 days) of a decision to treat - Anti Cancer MB > 98% 100.00% 100.00% 100.00% 100.00% 100.00% mia ↔ 100.00% Drug Modality mia Patients receiving subsequent treatment (surgery and drug treatment M4c only) within one month (31 days) of a decision to treat - Surgery MB > 94% 98.43% 97.90% 100.00% 99.20% 99.10% mia ↓ 99.10% Modality mia ` Patients receiving their first definitive treatment for cancer within two M5a months (62 days) of GP or dentist urgent referral for suspected cancer MB > 85% 85.62% 87.40% 83.59% 87.60% 86.40% mia ↑ 86.40% mia Patients receiving their first definitive treatment for cancer within two M5b months (62 days) of urgent referral from the national screening MB > 90% 99.44% 100.00% 100.00% 92.90% 97.00% mia ↓ 97.00% service mia
M6 Referral to treatment waiting times - admitted (95th percentile) mia RS < 23 weeks 21.99 18.94 18.93 18.93 mia ↓ 18.93
Referral to treatment waiting times - non admitted (95th percentile) M7 RS < 18.3 weeks 11.77 14.58 15.21 15.21 mia ↑ 15.21 mia M8 Total time in A&E (95th percentile) Site GMD 95% in 4hrs 95.28% 93.92% 96.15% 95.10% 97.04% ↑ 95.59%
6 questions measured at 6 questions 6 questions MS 6 questions at level 4 ↔ M9 Access to Healthcare for People with a Learning Disability levels 1 (low) to 4 (high) at level 4 at level 4 PCT Contract Indicator
KPI EXECUTIVE In month In month TRUST PCT MAIN CONTRACT INDICATORS TARGET 10/11 APR-11 MAY-11 JUN-11 Q1 JUL-11 REF DIRECTOR Trajectory Change YTD Patients receiving their first definitive treatment for cancer within two months (62 PC1 days) of urgent referral from a consultant (consultant upgrade) for MB > 85% 80.00% 100.00% 94.74% 86.40% 94.40% mia ↓ 94.40% suspected cancer mia
PC2 A&E Time to initial assessment (95th percentile) Site GMD < 15 minutes 37.35 45.55 38.00 40.00 32.00 ↓ 38.00
PC3 A&E Time to treatment decision (median) Site GMD < 60 minutes 50.00 58.00 53.00 54.00 52.00 ↓ 53.00
PC4 A&E Unplanned reattendance rate Site GMD < 5% 6.29% 5.95% 5.72% 5.99% 5.97% ↑ 5.98%
PC5 A&E - Patient left without being seen Site GMD < 5% 3.41% 3.49% 3.16% 3.36% 2.65% ↓ 3.18%
PC6 % of Stroke Patients Spending 90% or more of their stay on Stroke Unit SS > 80% 80.00% 68.67% 64.52% 80.21% 80.71% 75.99% 80.99% ↑ 77.51%
Satisfaction of the Provider's obligations under each A&E/Ambulance PC7 SS 90% of patients 0% 37.90% 32.20% 33.56% 34.55% 35.22% 34.71% Services Handover plan in < 17 minutes ↑
PC8 Delayed Transfers of Care SS < 3.5% 3.68% 5.17% 4.68% 4.70% 4.84% 4.28% ↑ 4.68%
PC9 Emergency readmissions GMD tbc 0.00% n/a n/a n/a n/a n/a ↔ n/a
PC10 Admitted Patients Treated within 18 Weeks of Referral mia RS > 90% 90.00% 90.51% 94.24% 93.69% 92.80% mia ↓ 92.46%
PC11 Non-Admitted Patients Treated within 18 Weeks of Referral mia RS > 95% 97.82% 98.99% 97.62% 97.22% 97.88% mia ↓ 97.58% Referral to treatment waiting times - incomplete (95th percentile) PC12 RS < 28 weeks 14.52 16.91 16.39 16.39 mia ↓ 16.39 mia PC13 Referral to treatment waiting times - admitted (median) mia RS < 12.27 weeks 10.96 11.46 10.63 10.63 mia ↓ 10.63
PC14 Referral to treatment waiting times - non admitted (median) mia RS < 4.39 weeks 4.30 5.36 4.71 4.71 mia ↓ 4.71
Hospital-Led Cancelled Operations on the Day for Non-Clinical Reasons, PC15 RS < 0.8% 0.747% 0.490% 0.370% 0.570% 0.480% 0.310% 0.439% as % of Elective & Daycase Episodes ↓
Breach of clause 31.5 (cancelled operations rebooked within 5 calendar PC16 RS < 12 per year 1 97.33% 0 0 0 0 0 ↔ 0 days following admission and cancellation)
Sufficient "appointment slots" are made available on the DBS C&B PC17 RS < 13% 24.40% 14.36% 20.40% 12.35% 13.55% 15.01% 15.02% 15.01% system ↑ Percentage of women in contact with the service who have seen a PC18 midwife or healthcare professional for health and social care SH > 90% 84.29% 83.62% 85.66% 85.76% 85.46% 85.33% ↓ 85.42% assessment of needs risks and choices by 12 completed weeks of pregnancy PC19 Increase in Breastfeeding Initiation Rates SH > 69.19% 66.15% 67.05% 63.18% 65.13% 68.40% 65.57% 65.33% ↓ 65.49%
PC20 DNAs at First Outpatient Appointment RS < 10% 12.79% 11.64% 12.04% 10.73% 11.45% 11.22% ↑ 11.39%
PC21 DNAs at Follow-Up Outpatient Appointment RS < 10% 11.68% 10.78% 10.53% 10.41% 10.57% 10.10% ↓ 10.45%
PC22 Follow-up Cataract outpatients RS 0 0% n/a 3mia 3mia n/a 3mia n/a
PC23 Breach of the mixed sex accommodation requirements MS 0 469 7 7 4 18 10 ↑ 28
PC24 Failure to agree the EMSA Plan in accordance with clause 4.25 AS Plan agreed n/a n/a n/a n/a n/a ↔ n/a
PC25 Breach of an EMSA Plan milestone AS No breaches n/a n/a n/a n/a n/a ↔ n/a
PC26 % SUS data altered (from working day 5 to final position) AS < 3% 0% 2.44% 0.51% 2mia 1.43% 2mia ↓ 1.43%
No. of SUIs with a report of investigation outcomes, including Rolling YTD % for PC27 preventative and follow up actions, within 45 working days of the SW 14.29% 0.00% 0.00% 0.00% 0.00% mia 0.00% closed SUIs completion of the investigation (excluding complex cases) Rolling YTD % for PC28 No. of SUIs with extended deadlines agreed within timescale SW 0% n/a n/a n/a n/a mia n/a SUIs closed >45 days
PC29 Respiratory TB MB > 65% diagnosed 0% 66.67% 3mia 3mia 66.67% 3mia 66.67%
1 in 8 treated PC30 Erdington Sexual Health - treatment by consultant doctor HW 7.15% 6.22% 6.33% 4.76% 5.69% 3.34% 5.69% (<12.5%) ↓ PC31 BCG vaccination prior to discharge after birth SH tbc 82.47% 82.55% 83.28% 82.77% 77.15% ↓ 79.96% In month Change mia = "data available 1 month in arrears" Green arrow indicates positive change in month versus previous month, in relation to the target Red arrow indicates negative change in month versus previous month, in relation to the target
KPI SCORECARD Q:\Board\Board Papers\2011\SEPTEMBER\ITEM 16.4 FINANCE n PERFORMANCE REPORT TB SEPT 11 MTGExternal 11-12 KPI EXECUTIVEEXECU TIVE In monthmo nth In monthm onth TRUSTTRUS T WORKFORCE TARGETTARGE T 10/1110/1 1 APR-11APR- 11 MAY-11MAY- 11 JUN- JUN-1111 Q1 JUL-11JUL- 11 REF DIRECDIRECTORTOR Trajectory ChanChangege YTD BetweenBetw een 95% and W1a Staff in Post v Budget Established - Percentage MC 95.41%95.4 1% 95.93%95.9 3% 95.42%95.4 2% 95.85%95.8 5% 95.8 95.85%5% 95.87%95.8 7% 95.85%95.8 5% 100% ↑
W1b Staff in Post v Budget Established - WTE Vacancies MC n/a 403.82 357.51 405.20366.80 366.80 365.50365. 50 ↓ 366.80
W2 Nursing Requests Filled by Bank/Agency MC 80% 83.12% 86.38% 87.13% 86.92% 86.92% 86.82% ↓ 86.92%
W2a Nursing Requests: No. of Requests MC n/a 93,056 8,466 8,080 7,979 7,979 8,384 ↑ 7,979
W2b Nursing Requests: Total No. Filled MC n/a 77,351 7,313 7,040 6,935 6,935 7,279 ↑ 6,935
Nursing Requests Filled by Bank Proportion of all Filled W3 MC 85% 89.58% 86.77% 87.00% 87.16% 87.16% 89.09% ↑ 87.16% Requests
W4 Medical Requests Filled by Bank/Agency MC 90% 92.15% 97.09% 98.27% 98.72% 98.72% 98.71% ↓ 98.72%
W4a Medical Requests: No. of Requests MC n/a 10,040 825 984 1,095 1,095 1,082 ↓ 1,095
W4b Medical Requests: Total No. Filled MC n/a 9,252 801 967 1,081 1,081 1,068 ↓ 1,081
34% (Review if Medical Requests Filled by Bank Proportion of all Filled W5 MC Zircadian system 34.76% 46.00% 37.00% 38.85% 38.85% 37.73% ↓ 38.85% Requests introduced) 11 Weeks - W8 Average Time to Recruit in Weeks - All Staff Groups MC 11.58 11.00 11.00 11.00 11.00 11.00 ↔ 11.00 (review in August)
W9 Voluntary Turnover MC < 7.25% - phased 7.42% 7.23% 6.99% 6.90% 6.62% 6.62% 6.59% ↓ 6.62%
< 3.90% by W10 Sickness - YTD Moving Annual Average MC 3.98% 4.05% 3.77% 3.57% 3.94% 3.94% 4.10% 3.94% Mar-12 ↑ New Starters Attending Corporate Induction - Doctors only W11 MC > 90% 94.4% 69.0% 83.0% 100.0% 100.0% mia ↑ 100.0% mia
New Starters Attending Corporate Induction - Excluding W12 MC > 98% 99.4% 98.0% 100.0% 100.0% 100.0% mia ↔ 100.0% Doctors mia
W13 Trustwide Agency Spend mia AS To be determined 4.21% 4.40% 4.72% 4.69% 4.61% mia ↓ 4.61%
Clinical Staff Undergoing Mandatory Training 2,000 (approx.) by W14 MC 610 2,101 164 150 193 507 161 ↓ 668 Since Start of Programme Mar-12
W15 Number of Appraisals Completed - Cumulative MC 8,000 by Oct-11 4,000 7,910 38 424 858 858 1,659 ↑ 1,659
KPI EXECUTIVE In month In month TRUST QUALITY AND SAFETY TARGET 10/11 APR-11 MAY-11 JUN-11 Q1 JUL-11 REF DIRECTOR Trajectory Change YTD Hospital Standardised Mortality Ratio (HSMR) QS1 AA <=100 88.10 88.10 88.70 2mia 88.40 2mia ↑ 88.40 2 MONTHS IN ARREARS
QS2 Reduction of Incidence of MSSA (post 48 hrs) MS < 37 39 3 8 3 14 2 ↓ 14 Baseline to be QS3 E-coli MS 5 9 8 22 15 22 set in 2011/12 ↑
QS4 MRSA Elective Screening Rates (% patients screened) MS 100% 93.00% 97.91% 97.08% 97.47% 97.49% mia ↑ 97.62%
QS5 MRSA Emergency Screening Rates (% patients screened) MS > 95% 82.63% 93.55% 91.88% 93.22% 92.64% mia ↑ 93.12%
QS6 Diagnostic waits MW <6 weeks 0.00% 99.75% 99.13% 99.87% 99.59% 99.82% ↓ 99.65%
QS7 New to follow-up rates All GMDs tbc 1.95 2.63 2.65 2.57 2.61 2.60 ↓ 2.61
Patient Reported Outcome Measures (PROMs) in Elective QS8 MB > 68% 67.99% 79.00% 76.90% 78.50% 79.10% 78.50% ↔ 79.00% Surgery
QS9 Patient Reported Outcome Measures (PROMs) - Hips MB > 68% 67.77% 83.00% 73.17% 77.30% 78.20% 75.00% ↓ 78.20%
QS10 Patient Reported Outcome Measures (PROMs) - Knees MB > 68% 67.96% 76.00% 68.85% 81.30% 79.40% 73.90% ↓ 79.40%
QS11 Patient Reported Outcome Measures (PROMs) - Hernia MB > 68% 69.24% 81.00% 78.00% 80.00% 82.60% 84.60% ↑ 82.60%
QS12 Patient Reported Outcome Measures (PROMs) - Vascular MB > 68% 67.12% 79.00% 76.90% 75.40% 75.90% 80.00% ↑ 75.90%
QS13 Nursing Metrics - Quality of Care MS >95% 93.00% 92.00% 91.00% 92.00% 91.00% 92.00% ↔ 92.00%
QS14 Nursing Metrics - Patient Experience MS >95% 85.00% 86.00% 88.00% 90.00% 88.00% 90.00% ↔ 90.00%
Compliance with national complaints policy - 75% resolved QS15 All GMDs 75% 72.26% 77.80% 68.97% 57.97% 62.56% mia ↓ 62.56% within 25 days mia PCT Target > QS16 Data Quality of Inpatient Ethnic Groups All GMDs 92.81% 94.43% 93.93% 93.45% 93.96% 94.03% 93.98% 90% ↑
QS17 Elective Length of Spell All GMDs tbc 3.83 3.67 3.93 3.57 3.72 3.65 ↑ 3.70
QS18 Emergency Length of Spell All GMDs 7.57 days 8.26 8.52 8.81 9.34 8.87 9.01 8.26 ↓ 8.82
QS19 Daycase Rates for all Procedures MB > 80% 81.49% 84.92% 85.54% 84.43% 84.93% 82.36% ↓ 84.28%
QS20 30 day elective to emergency readmissions AS tbc 0.00% n/a n/a n/a n/a n/a ↔ n/a
Initial notification to the commissioner within one operational 100% within 1 QS21 SW 100.00% n/a n/a 100.00% 100.00% mia ↔ 100.00% day of an incident being classified as a SUI day
Number of SUIs formally reported within 72 hours of 100% within 3 QS22 SW 85.71% n/a n/a 75.00% 75.00% mia ↔ 75.00% declaration of SUI operational days
No. of SUIs with a report of investigation outcomes, QS23 including preventative and follow up actions, within 5 days of SW >=90% 50.00% n/a n/a 100.00% 100.00% mia ↔ 100.00% the completion of the investigation In month Change mia = "data available 1 month in arrears" Green arrow indicates positive change in month verus previous month, in relation to the target KPI SCORECARDRed arrow indicates negative change in month verus previous month, in relation to the target Q:\Board\Board Papers\2011\SEPTEMBER\ITEM 16.4 FINANCE n PERFORMANCE REPORT TB SEPT 11 MTGInternal 11-12 FINANCE COMMITTEE
Minutes of the Finance Committee meeting held on Monday 22nd August 2011 at 13:00hrs, in the Board Room, Devon House at Heartlands Hospital.
PRESENT: Mr Richard Barratt Finance Business Consultant, Group 2 RB Mr Misra Budhoo Medical Director, Group 2 MB Mr Malcolm Clark Finance Business Consultant, Groups 7 & 8 MC Mr Andrew Clements Finance Business Consultant, Group 1 AC Mr Jonathan Gould Finance Operations Director JG Mrs Hazel Gunter Deputy Director of HR and OD HG Mr Mark Houghton Operations Director, Group 4 MH Mrs Sue King Head of Performance SK Ms Erica Loftus Acting Operations Director, Group 3 EL Mr Aidan Quinn Deputy Finance Director AQ Mrs Sarah Rose Operations Director, Group 2 SR Mr John Sellars Director of Asset Management JS Dr Steve Smith Group Medical Director, Group 1 SS Mr Adrian Stokes Finance & Performance Director AS Mr Baljit Takhar Business Consultant, Group 5 BT Mr Steve Tyler Head of Commissioning ST Mr Mark Wake Medical Director, Group 4 MW
In attendance: Lynn Bowyer General Manager, Group 5 LB Ryan Irwin General Manager, Group 4 RI Dr Keith Struthers Consultant in Infection Control KS
Mrs Lynn Stevens Executive Assistant - MINUTES LS
1 APOLOGIES FOR ABSENCE ACTION
Apologies were received from Mrs Gloria Cooke, Mr Richard Harris, Mrs Angeline Jones , Mrs Claire Pooni, Mr Simon Hallion and Mr Gary Upton.
2 MINUTES OF MEETING HELD ON 25 th July 2011
The minutes of the Finance and Performance Committee meeting held on 25 th July 2011 were agreed as an accurate record.
3 MATTERS ARISING
There were no matters arising not already covered in the agenda.
4 MATTERS FOR DISCUSSION
4.1 Finance and Performance Director’s Report Month 4
Mr Stokes reported on the following
Income and expenditure position in July was a deficit of £1.0m which represents the worst month seen this year as July activity tends to deliver high income. 1
Against the operational budget the Trust is overspent by £3.0m in July and £8.8m year to date. CIP delivery is short by £2.0m against the year to date plan. There is a cost to delivering activity with excess capacity and medical staffing – pay controls are essential moving forward We are looking at a year end recurrent deficit of £3.0m. Over performance in Month 4 was £300k.
4.2 Income and Contracting Report Mr Tyler reported that the downward trend on income has continued and remains lower than last year.
Keyy headlines Total Income for July is £44.1m which is above plan but below forecast Over-performance is £0.3m against the plan of £43.8m Activity 2011/12 is lower compared to 2010/2011 The forecast out-turn at the end of month 4 showed a reduction in income of £8.5m compared to last year
Income This is the first year since becoming a Foundation Trust that income has not been higher than the previous year Forecast income for the year is £534.1m Emergency activity is down on plan by 171 spells in July
Critical Care is down by 568 days year to date
New to follow up ratio penalties are forecast to be £4.2m by year-
end
Commissioning headlines
Performance notices against delivery on advice and guidance, A&E ambulance hand-over and the increase in nurse led clinics have been issued
New to follow up The PCT has randomly picked 100 patients from each of T&O, Respiratory and Urology specialties, however Dr Smith concerned that it would be difficult to get the level of detail from the notes. Dr Smith agreed to provide HEFT clinical support, Mr. Gould to take JG forward. Mrs. Rose met with Mr. Gould last week to discuss the work currently being done in the specialties; a follow up meeting is planned. Ms Bowyer confirmed that a lot of work is being done in Group 5 and they are looking to reduce telephone clinics by 50% in September – Miss Dale has prepared a paper.
2 4.3 Expenditure Report Mr Quinn reported o n the following key areas of concern:
Pay Cost s and shortfall against CIP remain key areas of concern.
Medical Pay Overspent by £5.9m in 2010/12 with no change in expenditure levels in 2011/12. As at the end of July, medics are overspent by £1.8m
Additional Measures To support A&E and Acute Med on all three sites and Therapies at Good Hope an additional cost of £1.4m.
CIP A total of £1.4m delivered against the planned target of £1.9m, with 73% delivered in July. Group 1 remains the highest risk delivering only 25% of plans year to date.
4.4 CQUIN Report
Mrs King reported on the following:
MRSA bacteraemia – there were no further cases C-Diff – there has been a further 18 cases in July which is above the monthly target of 10 and puts the Trust at 56 cases ytd against a target of 39. The A&E 95% performance continues to improve since the paper was published Monitor has changed their approach to monitoring A&E an updated position will be provided next month. From a contractual perspective we continue to fail against 2 of the 5 indicators, The Monitor risk score based on current performance is 0.5. Ambulance handover - HEFT achieved 35% in July LOS is still an issue,
ALERT 18 weeks is an issue for Group 2
CQUINs Maternity baselines still to be agreed
Patient experience is the biggest concern
Smoking and Alcohol is still to be signed off by the PCT SK £5.3m amber risks need to be delivered. Mrs King to provide a level of risk paper to the next meetings.
Mr Stokes asked the group’s to ensure processes are in place so that there are no financial surprises at the end of the year.
3
5 RECTIFICIATION PAPERS
5.1 Group 1 – Performance Report Dr Smith reported on the following:
From the start of the year, LOS has dropped from 10.3 to 9.1 days (12% fall) and only 10.1 to 9.1 days (9% drop) in month, this is ahead of the trajectory. It There is a lot of work ongoing in Cardiology, the key elements are: emergency care group programme, transformation looking at decreasing LOS. Regional actions include ring-fencing cardiology day beds, this is improving. Ward 8 has had an immediate effect on throughput. There are good health economy wide pathways which Dr Smith is involved with, these are nearly completed.
Mr Stokes asked what Group 1 were aiming for and how they will measure any impact. Dr Smith advised this would be through admission avoidance and being able to take beds out of the system as soon as possible, the group are aiming for 90% occupancy but this will be down to the site teams. Asked what the triggers are on the sites, Mrs Rose advised that it will be done through the escalation process, there is also a bed model that links in to the financial plan which is discussed at the winter planning meetings.
Mr Stokes requested that evidence was needed on how Group 1 managed this performance and asked Dr Smith to bring this back to the next SS meeting.
With regard to ambulance handover, there has been a push on CAD. Current performance across all three sites shows we are 55% compliant. Mr Stokes asked if the group could build up some benchmarking data. Mr Gould confirmed that the PCT are keen to see the trajectory and should accept what we are delivering. Mrs King advised that Heartlands needs to be using CAD more and this should be the first target. A realistic trajectory will be required to be presented at the next Finance & Performance Committee meeting. SS/GC
Group 1’s financial performance had detoriated further in month. Dr Smith confirmed significant work had been completed following the recent turnaround meeting and immediate actions were being implemented to reduce expenditure. Dr Smith agreed to send a copy of the vacancy controls being put in place to Mrs Gunter. SS
Due to the group’s finances, this will be escalated to the Chief Executive.
5.2 Group 2 – Finance Report
Mrs Rose reported that the Group position has deteriorated due to performance against LDP. The number of cancelled theatre lists had reduced in month 4 and indications were that August performance 4 continued this improvement, with the exception of T&O day cases. There are daily theatre monitoring exercises and weekly LDP meetings in place. There is currently a review in progress of pathways in T& O and Surgery.
New to follow up T&O is expected to achieve the target from October, although Respiratory remains a risk.
Mr Barratt confirmed that the actuals demonstrate a small improvement, however new to follow ups need to be addressed and the Group must maximise use its Theatre capacity.
18 weeks Mr Stokes asked whether a plan was in place to address this and whether the group have liaised with Ms Loftus. Mrs Rose advised that this is being worked on. Ms Loftus stated that 18 weeks (800 patients currently) can only be achieved if the backlog is not added to and that everyone is seen in date order. Mr Budhoo confirmed that there was still a lot of work to be done and the groups would be looking to complete this in the next few months. Mr Stokes advised that there is a monitor consequence of missing 18 weeks and was not assured by the timescales outlined.
Mr Stokes advised the group that their finances will be escalated to the LS Medical Director, and that they will be required to present an 18 weeks action plan for T&O and General Surgery to the next meeting. MB/SR
5.3 Group 4 – Performance Report Mr Irwin reported on the following:
MRSA There are 6 cases year to date against a trajectory of 7. There are no specific links attributed to any one directorate or specialty between the cases. The PCT have confirmed that they are happy with the action plan in place to tackle this. There are ongoing improvements, audits and communication plans including a 28 day re-screening audit. Asked if we were doing enough with regard to communication, Dr Struthers advised that a lot of work was done during the last year.
C-Diff There are a number of problems behind the increase in cases including inappropriate specimen testing. At Good Hope work is being undertaken to ensure consultant buy in. A business case for more Sterinis machines is currently in consideration. There are plans to introduce a more accurate test for c-diff which my help HEFT to renegotiate targets with the PCT. It has been proposed that the current testing is run alongside the dual testing with negotiation required around contract implications. The cost implication for the Trust is £100k. Mrs King agreed to pick up the contractual issues. SK
5 5.4 Group 5 – Finance Report Ms Bowyer reported that the Group are £828k overspent year to date, for month 4 the Group have delivered £180k CIP against a target of £210k.
New to follow up Gynaecology will be reducing telephone clinics by 50%, CD has agreed that the Pesary clinic & minor operations patients can be returned to the GPs.
A&C Review Paediatrics have identified savings over a 5 year period Obs and Gynae A&C review is still being worked on.
Other Sickness absence workshops are being held across the directorate Further savings have been identified with operational / financial controls being implemented in Obs & Gynae rota management. A Task and Finish group will be working over the next 6 weeks to review savings, a consultation is in progress and is due to finish at the end of September.
Mrs King expressed concern regarding the Obs & Gynae A&C Review stating that the specialty need to ensure the service does not lose too many administrative staff as her team would be unable to cover. Ms LB Bowyer agreed to take forward Mrs King’s concerns with Miss Dale.
Mr Stokes congratulated Group 5 on achieving their CIP for the first month ever and stated he felt they are on the right path, however the challenge remained to achieving both CIP & Rectification targets.
5.5 Group 7 – Finance Report
Mr Sellars reported that year to date Group 7 are £834k overspent ( Energy £587k) and are off track against the previously reported rectification plan by £100k mainly attributable to the following:
£53k Additional pay costs - (overtime and enhanced payments to ancillary staff) £18k reduction in Category C income from the catering units. £35k reduction in anticipated over performance income.
Mr Sellars also advised that Energy spend had been better than expected in month and as such had a positive impact on the Group’s bottom line position.
Mr Sellars outlined proposed actions to address the Group’s underlying overspend and bring the rectification plan back on track. These include;
External review of Energy costs Group review of Pay costs Trust Wide review of Postage, Medical Gases, Cleaning and other Group “demand / activity driven ” services
6
Mr Stokes stated that energy is the most uncontrollable spend and asked JS Mr Sellars to undertake an urgent energy review.
Mrs Gunter agreed to help Mr Sellars identify the pay issues/overtime HG/JS payments.
ANY OTHER BUSINESS
Mr Stokes stated that there needs to be a balance across all groups and they need to get a sense that we are all in this together. The size of the challenge is growing each month, there are a lot of anomalies. With regard to the vacancy freeze, this should not just be in Group 1, but across all the groups. There will be work-streams arising from EMB.
The Finance & Performance Committee changes in September. Lord Philip Hunt will be joining and there will be a two part agenda; the first part to be held between Executives and Non Executives namely: Lord Philip Hunt, Richard Harris, Adrian Stokes, Aresh Anwar, Claire Molloy, Sue Moore and Hazel Gunter on behalf of Mandy Coalter. The second part of the agenda will cover individual Group recovery plans whereby group’s will be invited to attend at an LS allocated timeslot.
Mr Stokes confirmed the following group actions:- 1. Group 1 to provide LOS trajectory and update 2. Group 2 to provide 18 weeks trajectory linked in to activity assumptions 3. Group’s 5 and 7 to check trajectories 4. Group 1 finances to be escalated to stage 2 (Chief Executive) LS 5. Group 2 finances to be escalated to stage 1 (Medical Director) LS
DATE AND TIME OF THE NEXT MEETING
The next meeting is scheduled for 26 th September 2011 at 09.00 hrs in the Boardroom.
7 PURCHASE APPROVAL
Presented To Trust Board – September 2011
IPROC SUPPLIER VALUE DESCRIPTION OF GOODS NARRATIVE REQ. + VAT RECEIVED NO. 629260 Abena UK Ltd £375,000.00 Standing order for incontinence Solihull Care Trust participated products and home deliveries to clients in a West Midlands Regional in Solihull for a one year period. exercise which resulted in all PCT’s awarding to Abena. 637633 Synergy Health £331,000.00 General and Surgical Linen. To cover The legacy contracts held by period of 01.09.11 - 31.03.12 for Good Heartlands and Good Hope will Hope site only. be replaced by a new contract currently out to bid to be awarded for 1:1:12. 632254 National Blood £2,800,000.00 Supply of Annual Blood and Blood National supplier of Blood and Service Components to Heartlands, Good Hope associated products. and Solihull Hospital Blood Banks 640636 AGFA Healthcare £840,024.00 Annual charge for Agfa PACS system. This contract has previous Trust Ltd Board approval.
642069 Solihull £2,693,621.00 Solihull Community - estates Funding is provided by PCT to Community memorandum of occupation charges for cover costs. 2011/12. INV NO OP/ I010146. Annual charge from Solihull Care Trust for estates sites inherited by heft on behalf of the Solihull Community Trust transfer. Costs to be recharged accordingly quarterly within facilities directorate according to moo schedule
AGENDA ITEM 18 HR COMMITTEE MINUTES OF THE MEETING HELD ON WEDNESDAY 3 RD AUGUST 2011, AT 2.00PM IN THE BOARDROOM, DEVON HOUSE, BHH
Present : Hazel Gunter (Chair), Director of HR & OD Acting Ray Reynolds, Head of HR Information & Analysis Frieza Mahmood, HR Business Partner Daniela Locke, HR Business Partner Claudette Asgill, Interim Head of HR Helen Barlow, HR Business Partner (part) Diane Aucott, Health & Safety Manager Surinder Sidhu, HR Business Partner (SCT) Dee Rowe, Corporate Financial Accountant Julie Steward, OD Business Partner Nicola Bullen, Work & Wellbeing Manager Paul Quinsey, Head of Technical Services, Facilities Rachel Blackburn, Compliance Project Manager Mark Sowden, Head of Shared Services Andrea Ashley, HR Business Partner Jennie Reynolds, HR Business Partner Kerry Jones, Faculty Dean Pam Chandler, Head of Equality and Diversity ACTION 1. Apologies
Apologies were received from: Aresh Anwar, Alison Money, Dee Rowe, Claire White, Helen Barlow.
2. Minutes of the meeting held on Wednesday 1 st June 2011, matters arising and action points
The minutes were agreed as a correct record and an update on action points provided:
Sickness Absence Briefing Sessions to include referrals and OH support . Nicola NB Bullen will be liaising with Leanne Stokes to se t these up alongside HR consultancy training on sickness that are already in place.
Employee Benefits . Vouchers are now being sent to staff who are on maternity leave. A communications strategy is in pla ce and will be launched alongside the new website in October, which will include weekly prize draws, promotion of MS Dec More4U. A full report on success and uptake to be provided at the December HR Committee.
HR Compliance . Rachael Blackburn will be attending the informal HR Management Team meeting in September to discuss NHSLA compliance.
HR Committee . The committee were advised that it is the intention of the board to have a HR Strategy Committee which may change the way HR Committee operates and that the Trust Chairman, Lord Philip Hung is chairing the new Strategy Committee. Further details will be provided once decisions are made on the Terms of Reference. ACTION 3. HR KPIs
The proportion of medical locums filled by in ternal bank was now over 40% year to date which is a significant improvement /achievement; turnover has also reduced and is shown as 6.62% year to date.
KPIs showing red were noted as:
Sickness year to date is reported as 4.01% which is just above the tar get of 3.99%. In month sickness was below target at 3.94%. By site sickness is high at Good Hope (4.77%) and Solihull (4.13%). By group high sickness is reported in Group 1 (4.53%); Group 2 (4.11%; Group 5 (4.10%) and Facilities (4.55%). Total turnov er 6.62% year to date and is below the Trust target of 7.43%. By site turnover is high at Solihull (8.64%) and within Group 1 (9.73%). The number of clinical staff undergoing Mandatory training is 507 which is just below the target of 510 set to be done by June 2011. The KPI data showed that the number of appraisals completed were 858 which is below the target of 2500 by June. The overall target is to have 8000 completed by October, however, latest figures show that we are well below target with around 1800 appraisals completed. Hazel requested that emphasis on completion of appraisals and the tracker is continued. There was a consensus that appraisals are taking place and the figure is higher than reported but the tracker is not being completed due to additional information required. HRBPs and Manager s to ensure this is followed up. Hazel to raise at formal HR Management Team. HG
4. Resource Plan Update
The activity report identified the Trust’s position in terms of funded vs actual headcount and recruitment by directorate. To note is that nursing and senior medic staffing establishments have improved, although there are a high number of WTE nursing posts that have not yet been submitted for EVAS authorisation . In an effor t to address this th e shared service team are communicating with Head Nurses and C linical Directors and HR Business Partners are raising at their Group meetings.
Winter pressures recruitment to support flex capacity is now underway with a number of qualified and HCA staff recruited for Solihull and Good Hope. The flex capacity at BHH remained open and recruitment are working closely with the BHH site leads and Head of Planning to support any additional requirements.
In terms of senior medics the Trustwide figure is showing amber, a contributing factor in this is that there are currently 27.20 WTE vacant posts where no EVAS requests have been submitted. The medical workforce team and HR Business Partners are working with Groups and Directorate Leads to address this. Mark Sowden will ask Simon Birley to provide information to the relevant HR Business Partners and an update will be MS Oct provided at the October meeting.
In terms of medical recruitment , partnership arrangements continue with HCL for the attrac tion and supply of medical candidates, in addition the team are taking an account management partnership approach for hard to fill vacancies and we are currently exploring social media forums to support this. It was noted that the cap on Tier 2 sponsorship may cause issues with our overseas attraction strategy and alternative solutions are currently being discussed with ke y clinical areas.
ACTION 5. Agency Workers Directive
A report was presented to the committee outlining the necessary actions to ensure compliance by the Trust. Legislation comes into force on 1 st October 2011 which requires agency workers to receive the same pay and working conditions as a workers recruited directly by the organisation. In addition it als o introduced “day 1 Rights” which will mean that the Trust has an obligation to ensure that agency workers ha ve the same access to shared facilities as their permanent counterparts, this includes information relating to vacancies within the Trust, access to collective facilities and amenities (staff canteen, transport services, common rooms, prayer facilities, car parking, onsite gym). If an agency worker completes a 12 week qualifying period with the Trust in the same role they will be entitled to the same basic terms and conditions of employment as directly employed staff, which includes key elements of pay, duration of working time, night work, rest periods, rest breaks and annual leave, furthermore pregnant agency workers who have completed the 12 week qualifying period will be entitled to paid time off for antenatal appointments. The regulations do not extend to sick pay, maternity/paternity pay, redundancy, notice pay, payments related to pension entitlement or bonuses not based on individual performa nce.
In terms of the Trust as a hirer it should provide the worker with up to date information in relation to terms and conditions.
The HR Committee were asked to note the report and endorse the recommendations which included :
that it only uses agencies that are Buying Solutions compliant; where existing SLAs and relationships are in place ensuring transparency in relation to pay and conditions; if an agency worker is booked from a non-Buying Solutions organisation confirmation is provided on a booki ng by booking basis that the Trust will remain AWR complaint when booking the worker; the Trust does not employ agency staff on a continuous basis for more than 11 weeks; all temporary staff are booked via the central bank system; the bank continues to expand its service; recruitment of additional bank workers to increase the bank fill rate and reduce the necessity to employ external agency staff.
It was agreed to report the current position in the HR Operations Report. CA
6. Staff Survey Results
A presentation was given on the results of the employee survey undertaken in 2011 which shows an overall response rate of 20% (down from 42% in 2009). The views of those present were that the low response rate may be due to the surv ey only being available on line and a number of IT problems.
A breakdown of responses by directorates was provided and high returns shown from Corporate areas; General Management (81%); Human Resources (88%); R & D Directorate (82%). In terms of site responses Heartlands and Good Hope had a total of 17%, Solihull 25% and Solihull CT 22%.
There has been positive feedback, those above 2009 trend results for comparable questions were : -
ACTION I support the vision and goals of this organisation I am proud to work for the Trust I would recommend the Trust as an employer I have confidence in the way senior leaders are leading the Trust I am able to deliver the patient care I aspire to
Those below trend were:-
I feel valued and recognised by the Trust Job satisfaction
The OD team will now be identifying areas were we need to improve and will be working with Leaders and Line Managers. The OD team will be circulating directorate reports over the next few days.
It was noted that it is likely t hat survey’s will be done annually and that the Board have requested regular data.
7. Contingency Plan for possible Industrial Unrest
The HR Committee were informed that there is some uncertainty with respect to the national industrial relations outlook and that the current discussions in relation to pay review, pensions and changes as a consequence of the White paper give potential for unrest. As a result t here is a need to ensure robust contingency plans are in place and the SHA has requested that all NHS organisations have plans and processes in place for dealing with risks. The various forms of industrial action include;
Work to Rule Overtime ban Ban on non-contractual oncall Withdrawal of discretionary effort Strike Action – short and long term Picketing Lock-ins
The HR Director will be liaising with the Trust Convenor to understand the likely forms of
action to be taken by specific union/staffside organisations and reviewing our own internal data relating to membership.
The Trusts’ con tinuity plans are currently being developed through the capacity team for all scenarios and these will be taken into account when Directorates set out their plans.
The HR Director will ensure that partnership working with the Unions remains positive
and will work closely with the communications team to alert the organisation
appropriately.