Agenda for a Public Meeting of the Trust Board of Directors to be held on 27 March 2012 at 10:30 in the Conference Room, Trust Headquarters, Marlborough Street, Bristol, BS1 3NU
Item Sponsor Page
1. Chairman’s Introduction and Apologies Chairman To note apologies for absence received.
2. Declarations of Interest Chairman In accordance with Trust Standing Orders, all members present are required to declare any conflicts of interest with items on the Meeting Agenda.
3. Minutes and Matters Arising from the Previous Meeting Chairman To consider the Minutes of a Public Trust Board meeting dated Tuesday 28 February 2012 for approval.
4. Chief Executive’s Report Chief To receive this report to note. Executive Quality, Performance and Compliance
5. Summary Quality and Performance Report Executive To receive the standing Summary Quality and Performance Report to Leads note. a. Overview – Director of Strategic Development b. Quality – Medical Director and Chief Nurse c. Workforce – Director of Workforce & Organisational Development d. Access – Chief Operating Officer
6. Histopathology Action Plan Update Chief To receive this report to note. Executive
7. Infection Control Annual Programme 2012/13 Chief Nurse To receive this report to note.
8. Outpatient Feedback, including Results of the 2011 Chief Nurse National Outpatient Survey To receive this report to note.
9. Patient Experience and Involvement Strategy Chief Nurse To receive this report and consider the recommendations for approval.
Finance and Governance
10. Committee Chairs’ Reports Committee To receive reports on the activities of Board Committees by their Chairs respective Chairs and consider any recommendations to note. a. Finance Committee dated 22 March 2012, including the Report of the Finance Director Page 2 of 2 of an Agenda for a Public Meeting of the Trust Board of Directors to be held on 27 March 2012 at 10:30 in the Conference Room, Trust Headquarters, Marlborough Street, Bristol, BS1 3NU
Item Sponsor Page b. Quality and Outcomes Committee dated 26 March 2012. c. Audit Committee dated 26 March 2012.
11. Resources Book including Capital Programme Director of To receive this report and consider the recommendations for approval. Finance
12. Summary Monitor Quality Governance Framework Self- Chairman Assessment Report To receive this report to note. Monitor Reports
13. Report Results of Quarter 3 Compliance Framework Chief Monitoring Exercise Executive To receive this report to note.
Risk
14. Review of Board Risk Management Strategy Chief To receive this report and consider the recommendation to ratify the Executive decision of the Risk Management Group to approve the strategy.
Strategy and Business Planning
15. Policy Review – Capital Investment Policy Director of To receive this report and consider the recommendations for approval. Strategic Development
Information and Other
16. Any Other Business Chairman To consider any other relevant matters not on the Agenda.
17. Date of Next Meeting Chairman Public Meeting of the Trust Board of Directors, Monday 30 April 2012 from 10:30 – 13:30 in the Conference Room, Trust Headquarters, Marlborough Street, Bristol, BS1 3NU.
Minutes of a Public Meeting of the Trust Board of Directors held on 28 February 2012 at 10:30 in the Conference Room, Trust Headquarters, Marlborough Street, Bristol, BS1 3NU
Board Members Present John Savage – Chairman Robert Woolley – Chief Executive Emma Woollett – Vice Chair Alison Moon – Chief Nurse Iain Fairbairn – Senior Independent Deborah Lee – Director of Strategic Director Development John Moore – Non-executive Director James Rimmer – Chief Operating Officer Kelvin Blake – Non-executive Director Paul Mapson – Director of Finance Lisa Gardner – Non-executive Director Sean O‟Kelly – Medical Director Paul May – Non-executive Director Steve Aumayer – Director of Workforce Selby Knox – Non-executive Director and Organisational Development Present or In Attendance Jackie Cornish – Head of Division – Anne Ford – Public Governor Division of Women‟s and Children‟s Pauline Beddoes – Public Governor Services Sue Silvey – Public Governor Mark Callaway – Head of Division –
Division of Medicine Ken Booth – Public Governor Joan Bayliss – Partnership Governor Helen Morgan – Deputy Chief Nurse (shadowing Alison Moon) Clive Hamilton – Public Governor Charlie Helps – Trust Secretary Anton Horne – Head of Teaching & Learning Victoria Church – Management Assistant to the Trust Secretary Christine Perry – Director of Infection Prevention & Control Sarah Pinch – Head of Communications Jeanette Jones – Partnership Governor Vicki Mathias – Bristol Evening Post Fiona Reid – Head of External Relations Matthew Silver-Vallance – Covidien plc
Item Action
1. Chairman’s Introduction and Apologies There were no apologies to note. The Chairman and Board congratulated Helen Morgan on her appointment as Deputy Chief Nurse. 2. Declarations of Interest In accordance with Trust Standing Orders, all members present are required to declare any conflicts of interest with items on the Board Meeting Agenda. No declarations of interest were made. 3. Minutes and Matters Arising from Previous Meetings The Board considered the Minutes of the Public meeting of the Trust Board of Directors dated 26 January 2012 and approved them as an accurate record. All items on the Board Schedule of Matters Arising were noted as complete as reflected in the Schedule.
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4. Chief Executive’s Report The Board received and considered a report by the Chief Executive, which included the activities of the Trust Management Executive to note. Robert Woolley took the opportunity to talk about the Trust Board‟s dedication to quality, particularly with regard to Histopathology, and highlighted the following items of relevance: University Hospitals Bristol NHS Foundation Trust commissioned an Independent Inquiry in 2009 to review allegations about its Histopathology Service and to consider whether appropriate action was taken by the Trust to address the concerns. Recently, some alarmist reports had appeared in the media repeating allegations that thousands of diagnostic errors may have been made by the Trust over a ten-year period. The allegations were based on a crude extrapolation from a review of an audit of discrepancy rates submitted to the Independent Inquiry, evaluated by them and made public as part of their report. The Independent Inquiry, conducted by a panel of experts and chaired by Jane Mishcon, a leading barrister, published its report and recommendations on 08 December 2010. Patients may be reassured that the author of the review, Professor Peter Furness, President of the Royal College of Pathologists, concluded that, although he detected issues in the working practices in the department, he did not believe the audit identified a systematic pattern of error. The Inquiry found no evidence to suggest that the Histopathology department at University Hospitals Bristol NHS Foundation Trust provided anything other than a safe service. However, it did criticise the Trust for the quality of its response to concerns about clinical services. The recommendations from the Independent Inquiry were under implementation through an integrated action plan, jointly owned by University Hospitals Bristol NHS Foundation Trust and North Bristol NHS Trust, which was reported publicly at the Trust Board, Membership Council and to the Bristol Health Scrutiny Commission. The Trust had undergone unprecedented scrutiny of the quality of its Histopathology services over the last two years but had been found to be meeting essential quality and safety standards. Nonetheless, the Trust remained committed to addressing the recommendations from the Independent Inquiry and would continue to publish its progress. Robert Woolley issued a public apology on behalf of the Trust Board for the fact that a small number of patients had been harmed as a result of diagnostic mistakes and that concerns about Trust services were not promptly and thoroughly investigated at the time that they arose. The Care Quality Commission (CQC) undertook its own review of histopathology services at University Hospitals Bristol NHS Foundation Trust in 2011. They found that the Trust was meeting all six of the essential standards of quality and safety which it reviewed. The review suggested that the Trust made improvements in three areas in order to maintain compliance,
2 Page 3 of 14 of Minutes of a Public meeting of the Trust Board of Directors held on 28 February 2012 at 10:30, in the Conference Room, Trust Headquarters, Marlborough Street, Bristol, BS1 3NU and the Trust had set-out the actions being taken in those areas. The Trust had invited the Independent Inquiry panel to return to Bristol shortly, to ascertain what progress had been made against their recommendations for improvement. The Trust would publish the outcomes from this review. Iain Fairbairn confirmed that in the light of the letter of allegations with regard to the Code of Conduct for NHS managers, he had been asked to conduct an inquiry in his capacity as Senior Independent Director into whether there was a prima facie case to answer. Having assessed the allegations and responses of the Chair and Chief Executive, he confirmed that there was no case to answer. Iain Fairbairn planned to contact Mrs D Havercroft to notify her of his findings. The Public Governor, Ken Booth, said that he remained concerned that he had not received a convincing explanation of the statistics used in the claim and the possibility that hundreds of patients may have been misdiagnosed. Robert Woolley asserted that this had not been proven, and was a flawed and unfounded extrapolation. The fundamental issue was not if errors had occurred, but whether there were systems, practices and behaviours in-place to capture the error and limit the opportunity for harm. The Panel found there had been issues with the systems and practices at the Trust, but these had been addressed in their recommendations, and effected in the Trust‟s action plan. The Inquiry resulted because of concerns at another Trust, and yet when approached, they identified only 26 cases. Of these, four were identified as serious errors by Professor Peter Furness of the Royal College of Pathology, who concluded that they did not indicate a pattern of unsafe practice. John Savage reiterated that the Trust remained wholly committed in being open and transparent, and expressed his utmost faith in Trust staff giving patients the very best treatment. Governor Clive Hamilton, who was in attendance, explained that at a recent Governors‟ Quality Working Group meeting there was a “strong feeling of the need to move on from the Histopathology Inquiry”. He pointed out that the errors happened in the period prior to Foundation Trust status, and governors were committed to the future of quality and safety of services at the Trust. The Chairman recognised the commitment of the Governors to Trust quality and safety. Paul May reminded the Board of the role and function of the Quality and Outcomes Committee in extending the monitoring and scrutiny role of the Executive by the Trust Board of Directors. Kelvin Blake reflected on his experience working at the Council, and the fact he had spoken-out about Council issues in the past. He felt that the Trust had taken every possible step to address the concerns raised and that he would always give his opinion if he felt it had not. He said that the alarmist claims of Mrs Havercroft were not in the best interest of patients. The Chairman accepted that Kelvin Blake‟s comment was his personal opinion. There being no further questions or discussion, the Board resolved to note
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Quality, Performance and Compliance 5. Summary Quality and Performance Report The Board received and considered this report by members of the Trust Executive to note. a. Overview The Director of Strategic Development, Deborah Lee, introduced the Performance Report and noted that overall, the „health‟ of the Organisation had remained similar to that of last month, with the number of Green and Red indicators remaining unchanged. Significant pressures meant that the Accident and Emergency 4-hour standard remained Red rated. For the Trust to retain its Green rating against Monitor‟s Compliance Framework at the end of Quarter 4, the Accident and Emergency 4-Hour Standard must be achieved. Whilst this was still possible, there was a significant risk of this standard not being met.
With regard to Patient Complaints, work was underway to investigate potential data quality issues and as such the figures for the month could not be confirmed as robust. b. Patient Experience Alison Moon presented the Patient Experience Report. The account described the experience of an 82 year old lady with paraplegia who had been admitted to the Bristol Royal Infirmary and the Bristol Haematology & Oncology Centre on a number of occasions. During these spells in hospital, the patient had developed a pressure sore. As a result of this, the patient‟s family have had little confidence in the standards of care she received when admitted to hospital, and felt that they had to be present to ensure she was given the correct type of mattress. Specific learning had taken place to ensure for any future admissions the patient be identified at risk and proactive care given. Following the patient‟s most recent admission to hospital, the family fed back that there had been better awareness and care during the admission, and that improved pressure area care had been witnessed.
Individual Learning
Matron would compile information that the patient could bring into hospital with her, stating the need for a pressure mattress immediately. A copy of this, once approved by the family, would also be placed in the patient‟s notes. The patient‟s family had been provided with contact details for the Head of Nursing and Matron so that they can make contact, to help ensure the patient received the correct care on hospital admittance. Departmental Learning The patient‟s story and photographs would be referred to in the Medicine sisters‟ meeting, the weekly Tissue Viability meeting, and the
Medicine Clinical Governance meeting to share learning with staff.
A „flag‟ had been placed on the Patient Administration System (PAS), 4 Page 5 of 14 of Minutes of a Public meeting of the Trust Board of Directors held on 28 February 2012 at 10:30, in the Conference Room, Trust Headquarters, Marlborough Street, Bristol, BS1 3NU so that whenever the patient was admitted to hospital the matron concerned was automatically alerted to her presence. The matron would then ensure that the patient and family‟s needs were being consistently met. Organisational Learning The Tissue Viability Team was adopting an approach to ensure the availability of pressure relieving mattresses in admission areas.
The „Being the Best‟ programme was progressing, and monitoring of practice showed that pressure ulcer risk assessments were completed for 100% of patients, 98% of patients were on the correct pressure-relieving surface, and 94% of patients had intentional rounding carried out and 8- hourly skin checks recorded; this remained an area for continued focus. Further discussion included: Lisa Gardner recognised that practices had been revised and the appropriate care provided, which was an encouraging indicator of improvement and learning.
Alison Moon spoke about the use of information technology systems to flag specific care needs originating from the patient‟s General Practitioner, and highlighted the aim of employing „e-mis‟ for this purpose. Alison Moon responded to a query by Kelvin Blake, saying that awareness of care requirements for patients in wheelchairs was increasing. c. Quality The Chief Nurse and Medical Director presented the Quality element of the Summary Quality and Performance Report. Alison Moon informed the Board of the good news that assessment of patients with learning difficulties had reached 100%. Serious Untoward Incident reporting was highlighted at the Trust Management Executive meeting and the delays previously noted at Trust Headquarters had been eliminated.
Sean O‟Kelly noted the improvements made in antibiotic compliance.
Although not quite at target, the Trust saw the greatest improvement ever recorded in the last month‟s figures. Referring to Stroke Care, Sean O‟Kelly reported that all patients who required thrombolysis had been CT (computerised tomography) scanned in under an hour. A recent Dr Foster report named the Trust as being one of just five Trusts nationally with significantly low mortality in stroke patients. Discussion included: John Moore recognised the increases in antibiotic prescribing compliance.
Paul May, speaking in his capacity as Chair of the Quality and Outcomes Committee, re-asserted the importance of mitigating action to deal with incidents and complaints as they arose, in an attempt to eradicate the causes wherever possible. Iain Fairbairn referred to stroke patient admission, CT scans, patient psychiatry and pressure sores in highlighting the need for “first viewing” of a patient at the front door.
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Mark Callaway reported that thrombolysis was provided to high risk Transient Ischaemic Attack (TIA) patients who required it, which was the most important element. He referred to the high-profile government campaign on educating about stroke and its prevention. Selby Knox queried the 69% figure reported within the timescale on page 49 of the report regarding “Serious Incidents Reported within 48-hours”.
It was agreed to correct the figure.
The variations in divisional pressure sore numbers were noted, but Alison Moon reassured the Board of the Trust‟s robust reporting culture. Responding to a query by Selby Knox regarding the legibility of prescriptions, Alison Moon stated that nurses and doctors all now have name stamps. A “change of gear” was noted within the Trust, with reference to pressure ulcers, and achieving hourly intentional care rounding. The Trust had benchmarked externally in this regard, and a visit to University Hospitals Birmingham NHS Foundation Trust (where the work was exemplary) was scheduled for March. Of note, the Trust had introduced „micro-teachers‟ into clinical areas. Christine Perry reported that the Division of Surgery, Head and Neck was undertaking targeted work to address pressure sore performance discrepancy. d. Workforce The Director of Workforce and Organisational Development, Steve Aumayer, introduced the Workforce element of the Summary Quality and Performance report. The main points of relevance were: Appraisals continued to present a challenge, and just over 80% were achieved for January 2012. The new appraisal process was becoming established and an audit plan for next year was planned, to address the quality of appraisals. A new pilot scheme was being deployed, with plans to include an early Occupational Health assessment, and the use of an appraisal to address sickness absence. Overall, it was reported that year-to-date, there had been a 7% achievement of the sickness absence target compared to the previous year. It was agreed that stretch targets would continue to be set around sickness. In regards to sickness levels, a new pilot scheme was being deployed, with plans to include early Occupational Health intervention and a change of process for line managers. Experience in other trusts was that this approach had made a difference to sickness levels over time. John Moore requested evidence of benchmarking with comparable Trusts regarding sickness absence. Steve Aumayer added that across the South-West the Trust compared more favourably, but this was not the case against the other major teaching trusts. He would provide further data to the Quality and Outcomes Committee, which had identified this as an area requiring its scrutiny.
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Alison Moon relayed her experience of diabetic ward staff who smoked, and how a more proactive HR approach could be applied to improving health outcomes for staff, which was a very positive effect of the policy. Paul May said that the Quality and Outcomes Committee had discussed sickness and a report was being prepared to include bullying and harassment surveys and details regarding the support staff received following a return to work after stress-related sickness. Steve Aumayer confirmed to John Moore that the Divisions learned from each other, and shared experiences of managing sickness. This had resulted in a more consistent approach across the Trust. Estates and Facilities sickness figures remained higher, but they also showed the biggest decline in absence in the Trust. Alison Moon raised the role of the Trust as employees in supporting and encouraging the good health of our staff which would then lead to less sickness absence. The Chairman noted the approach of caring for Trust staff, to help them avoid becoming ill, rather than managing them when they are absent. e. Access The Chief Operating Officer, James Rimmer, introduced the Access element of the Summary Quality and Performance Report, saying that performance had been challenging in February due to the significant pressures of the winter period. Flagged exceptions were: Last-Minute Cancellations – This was nevertheless a good result compared with previous years. Work was underway to improve patient experience. Reperfusion – Most failures were attributable to clinic or partnership issues. 31-Day Subsequent Surgery for Cancer Patients remained tight but was expected to be achieved for the quarter. 4-hour Emergency Department – The figure was 92.5% for the quarter to-date. There was a significant risk to achievement in this quarter, and this had been flagged to Monitor. The Trust was working with Great Western Ambulance Service (GWAS) and North Bristol NHS Trust on the movements of patients. Discussion commenced: Iain Fairbairn thanked James for arranging the visit to the Emergency Department, Medical Assessment Unit and Surgical Trauma Assessment Unit, which reflected the Board‟s focus on current challenges. James Rimmer responded to Clive Hamilton that the acuity of patients was a key factor in performance figures, plus staffing pressures in February, which was noted to be reflected across the whole community. Mitigating measures were to focus on the front and back doors and discharge processes. John Moore asked if staffing pressure were the result of sickness or planned absence. James Rimmer replied that it had been a mixture of both, plus changes to nursing shift patterns.
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Emma Woollett referred to the 76% of out-of-hours breaches noted in the Reperfusion Call-to-Balloon Time standard. James Rimmer briefly iterated the complexity of the data and suggested this was not a “pre- admission pathway problem”. There being no further questions or discussions, the Board resolved to note the Summary Quality and Performance Report.
6. Infection Control Quarterly Report The Board received the report by the Chief Nurse to note. Alison Moon invited Christine Perry to present the Infection Prevention & Control Report. Christine highlighted the continued achievements made in Infection Control, and noted the forthcoming challenges for next year. The National Institute for Health & Clinical Excellence (NICE) had recently issued guidance regarding „Outcome 9 – Healthcare Associated Infections‟ and a presentation was available to access in this regard. Discussion included: Director of John Moore expressed concern at the drop in cleanliness figures in the Infection Trust. Christine Perry confirmed to John that Dental Hospital figures were Prevention & not included in the outcome, due to being incomplete. John questioned Control whether verification required two months. Following a request for clarity by Emma Woollett, Christine Perry Director of confirmed that she would provide a breakdown of cleanliness figures across Infection the Trust, with a focus specifically on the Bristol Royal Infirmary and Bristol Prevention & Heart Institute. Control Alison Moon informed the Board that the implementation of the new laundry contract had been met “very positively” by staff. Alison Moon referred the Board to page 91 of the Report, saying that a significant action plan with recommendations regarding an employee with active tuberculosis, was soon to be published. The contents of the Plan would be shared with North Bristol NHS Trust, as they were noted as using the same Occupational Health provider. Iain Fairbairn commented that despite the immediate “blips” in the figures provided to the Board, there was a lot to be congratulated for and the Trust was now a different area of diminishing returns for efforts. Robert Woolley gave assurance that the Capital bid for Central Sterile Services Department equipment was under consideration in the „capital round‟. There being no further questions or discussions, the Board resolved to note the Infection Control Quarterly Report. Finance and Governance 7. Committee Chairs’ Reports The Board received and considered reports on the activity of Board Committees by their respective Chairs to note. a. Finance Committee dated 21 February 2012, including the 8 Page 9 of 14 of Minutes of a Public meeting of the Trust Board of Directors held on 28 February 2012 at 10:30, in the Conference Room, Trust Headquarters, Marlborough Street, Bristol, BS1 3NU
Report of the Finance Director The Chair of the Committee, Lisa Gardner, presented a verbal report of the meeting. Lisa noted that the members present at the meeting did not constitute a quorum of the Committee, but reiterated the individual responsibility of all members of the Board to consider finance matters equally. As a consequence, the Terms of Reference and Committee Self-Assessment of Performance could not be considered and would be deferred to a future meeting. Iain Fairbairn commented that a proportion of the Cash Releasing Efficiency Savings was on a non-recurrent basis, but whilst there were other elements of the business that did not match this through income, it highlighted the ability to budget from “the bottom up”. He requested a better understanding of whether it was possible to develop systems to undertake bottom-up budgeting. Paul Mapson responded that no trust in the country had undertaken bottom-up budgeting, but Service Line Reporting was undertaken, which indicated wide variations. Paul gave an example of an oncology budget that would be possible to establish, but would have been rendered invalid by the change to the tariff, which was unexpected.
Deborah Lee noted the point that although savings were important, there were three elements which constituted a balanced Operating Plan, these were: cost reduction, investment, and income generation. Iain Fairbairn asserted that it was important for the Trust Board of Directors to make fully informed decisions. He added that there were valid reasons for running some elements at a financial loss if they gave an overall contribution to other objectives such as reputation, service quality, and sustainability.
Emma Woollett expressed concern about „control‟ in the context of the escalation process and associated agreed targets. Robert Woolley confirmed that the escalation process was clear, and set-out what action would be taken if Divisions had not achieved previously agreed targets. This could include implications for the leadership of clinical divisions. The Finance Committee agreed that teams worked well collaboratively, and there was a sense that the message was being understood in the Divisions. Notes from the Finance Meeting on 21 February 2012: 1. The Trust had delivered a surplus of £5.863m for the ten months to 31 January. This was £1.116m or 4.1% better than the Annual Plan projection for this stage of the year. The Trust‟s Financial Risk Rating was unchanged at 4 (actual = 3.65). 2. The Committee were concerned at the adverse movement of £627k recorded by the Surgery, Head and Neck Division in January. It was noted that this had changed the Division‟s RAG status to Red (previously Amber / Red from October to December) and was to be followed up by the Chief Executive, holding a further Board to Board meeting shortly to ensure delivery of the Division‟s financial outturn within the agreed control total for the year. 3. A progress report was received on the project, which was looking at 9 Page 10 of 14 of Minutes of a Public meeting of the Trust Board of Directors held on 28 February 2012 at 10:30, in the Conference Room, Trust Headquarters, Marlborough Street, Bristol, BS1 3NU the profitability and efficiency of specialities within the Division of Medicine. This was in the context of the Division having significant trading losses under Service Line Reporting and being well above average for the Reference Cost Index. The project would examine relative high cost areas, as well as taking a more detailed look at the Finished Consultant Episodes (FCEs) v Spells ratios, which might impact on income receivable. The final report was due in April. The expectation was that the approach used for the Division of Medicine could be applied for similar reviews with other clinical divisions.
4. A report providing a year-to-date comparison of activity and patient flows for the first nine months of 2010/11 and 2011/12 was received. The report provided a high level overview of activity changes. A further report explaining, for example, recording changes, historical growth and GP referrals v changes in capacity / practice, capacity, out-patient conversion rates etc. at specialty level is to be provided next month. 5. A progress report on CRES plans and achievement was received. The forecast savings for the year currently totalled £21.101m or 79% of the 2011/12 target of £26.636m. For 2012/13 the CRES target was £27.8m. It was noted that schemes to deliver savings of £27.4m had been identified in the January submissions from Divisions. This had been subject to a preliminary risk assessment which indicated that the schemes could deliver £22.36m or 81% of next year‟s target. A further submission of CRES plans is to be made on 29 February. The Committee also received a report from the work-stream group set up to „reduce and control non-pay‟. 6. Looking ahead, the Finance Committee received a presentation from the Director of Finance on Resources 2012/13. The headline message at this stage was to develop a budget for next year, having a planned income and expenditure surplus of £6m, a financial risk rating of 3 and to be able to support capital expenditure of £75m in 2012/13 and £61m in 2013/14. This was to be considered more fully at a Board seminar in early March. 7. Governance – the Committee received a report covering the annual self-assessment, Terms of Reference and the Trust’s Capital Investment Policy. These would be formally considered at the quorate meeting in March, with recommendations brought to the March meeting of the Trust Board for consideration and approval. Discussion included: Paul Mapson commented on the positive trend noted this month, which had created the ability to change the forecast. Iain Fairbairn said that he would welcome a breakdown of assumptions behind income predictions for forthcoming budget planning. A Trust Board Development Seminar was scheduled for 06 March 2012, and the Board would be briefed in this regard. John Moore asked that trend graph information on areas such as cash balance and payroll also be provided at the seminar and this was agreed.
In response to a question from John Moore, Paul Mapson confirmed that the Trust aimed to pay at least 90% of undisputed invoices within 30 days. In December, the Trust achieved 76% and 90% compliance against the Better Payment Practice Code for NHS and Non-NHS creditors. Lisa Gardner commented that this had been discussed by the Finance Committee, and the
10 Page 11 of 14 of Minutes of a Public meeting of the Trust Board of Directors held on 28 February 2012 at 10:30, in the Conference Room, Trust Headquarters, Marlborough Street, Bristol, BS1 3NU changes being made to electronic authorisation were having an impact. In response to a comment from Emma Woollett, Robert Woolley advised that the Executive Directors led the Transformation Programme. The Programme reported into the Trust Management Executive which, in turn, reported to the Trust Board. It was acknowledged that there would be elements inside the programme which would be routinely reported in other forums, for example, the Quality and Outcomes Committee and Finance Committee. b. Quality and Outcomes Committee dated 27 February 2012 The Chair of the Committee, Paul May, gave a verbal report on the main issues discussed at the Quality and Outcomes Committee meeting in February:
Follow-Up to New Ratio, Waiting List Size and Waiting Times – This was a six month follow-up report. The Committee felt that the document could have been more „quality-related‟ and some of the data seemed to be in conflict with the report notes. As a result, it was agreed that a more detailed report would be brought to the next meeting, to include the increase in ophthalmology demand and actions being taken to reduce the overdue lists. Volunteering Strategy – The purpose was to give the report a full evaluation. The strategy was noted without negative comment and there was support for the report and proposed action plans.
It was noted that the report was based upon best practice elsewhere and extensive surveying of existing and past volunteers and agencies. A fine balance between patient needs and staff reactions was required, and the arrangements required resourcing, without being overly bureaucratic. There was also a requirement to widen patient engagement within the Divisions. Further analysis of the numbers and locations of existing volunteers would also be provided. It was noted that the Governors‟ group had been briefed on the issue. Last-Minute Cancelled Operations & 28-Day Readmissions – The report highlighted the considerable progress being made, and the frustrations of the target not quite being achieved. The reasons for cancellations were listed for the Committee. The Chief Operating Officer was closely monitoring the situation through the Divisions and saw the issue being resolved by
March 2012. The Committee noted that sometimes a target could create a false balance between costs and effectiveness. Clinical Quality Group report – This was the first time the Committee had considered the regular report provided in detail. Serious Incidents had doubled in one month and some of the actions had not been completed within timescales set. The Board were requested to support the Heads of Division in prioritising incidents being reported and actions being completed, to minimise future potential harm from similar events. It was noted that the increase was as a result of new safeguarding reporting and did not reflect increased harm.
The Committee were informed of the good news that the new Quality
Intelligence Group were picking-up outlier alerts and acting on them.
Update on the Quality Report Objectives for 2011/12 – The
11 Page 12 of 14 of Minutes of a Public meeting of the Trust Board of Directors held on 28 February 2012 at 10:30, in the Conference Room, Trust Headquarters, Marlborough Street, Bristol, BS1 3NU objectives related to patient safety, patient experience and clinical outcomes. The major concerns related to patient safety processes within the South-West Patient Safety Programme. Once again, there was a balance between the targets set and the real needs of patients. The issues raised could not be resolved at the meeting and the Medical Director planned to report further on progress of the targets. It was noted that the forward commitment had been made and that the Trust needed to deliver the targets over prolonged periods of time.
Committee Terms of Reference – The key change related to the frequency of meetings and the removal of the need to tie the meetings in to the Board programme. Some changes were recommended for discussion with the Trust Secretary.
Discussion included:
Alison Moon stressed the importance of Trust staff reporting serious incidents. There was also a requirement to report safeguarding issues which took place outside of the Trust.
John Moore informed the Board that six tender applications had been received from candidates to replace the present External Auditor. Corporate Governance
8. Review of Terms of Reference – Nomination and Appointments Committee The Board received and considered this report by the Trust Secretary for approval. There were no material changes to the Terms of Reference recommended. The Board agreed a minor amendment to „Clause 2 – Authority‟ to TSec reflect the statutory authority of the Committee.
There being no further questions or discussions, the Board resolved to approve the Review of Terms of Reference – Nomination and Appointments Committee. 9. Review of Terms of Reference – Remuneration Committee The Board received and considered this report by the Trust Secretary for approval. The Trust Secretary drew the Board‟s attention to the significant revisions presented for consideration. Following discussion, the Board agreed to rephrase the duty to take into account the responsibility to “Recommend and monitor the level and structure of remuneration for senior management”, which was derived from the Monitor NHS Foundation Trust Code of Governance Provision E2.2. The addition of this element to the Terms of Reference would require the Trust Board of Directors to consider whether the Remuneration Committee should consider the remuneration and terms of service for senior managers, and if so, at what level the Committee‟s responsibility ended.
The Trust Secretary agreed to redraft this section to allow for the participation of the Committee in “monitoring the levels of remuneration for Senior TSec
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Management, whilst not unduly encroaching on the responsibilities of the Trust Executive to operationally manage the business of the Trust”. There being no further questions or discussions, the Board resolved to defer the Review of Terms of Reference – Remuneration Committee for approval once redrafted.
Strategy and Business Planning
10. Operating Planning Process - Updates The Board received the report by the Director of Strategic Development to note. Deborah Lee highlighted the key points set out in her report, as follows: All key milestones were on-target. Work had been completed around a more robust capacity planning model. Operating Planning Process guidance encouraged the move from transactional savings to transformational Cash Releasing Efficiency Savings. In response to John Moore, Deborah Lee explained how each Division planned to consider iterations of their Cash Releasing Efficiency Savings plans in the next round of the Operating Planning Process. A series of metrics existed, which the Executive would apply, to assess whether there were grounds for cross-funding. Deborah Lee thanked Ben Hume for his contribution to the Operating Planning Process, and wished him well in his new undertakings. There being no further questions or discussions, the Board resolved to note the Operating Planning Process – Update. 11. Volunteering Strategy The Trust Board received and considered this strategy presented by the Chief Nurse for approval. Alison Moon introduced the document. Chris Swonnell, who had developed the strategy, explained the consultative approach adopted in the development of the strategy, and the particular involvement of the Governor Quality Working Group. He added that the Patient Experience Group planned to monitor the on-going development of the Strategy. Discussion included: Kelvin Blake commended the quality of the strategy, and asserted that it was important for there to be no bias around introducing equalities in terms of taking-up volunteering opportunities and schemes. Paul May welcomed that strategies being presented to the Board were becoming more consistent in their approach. There being no further questions or discussions, the Board resolved to approve the Volunteering Strategy. 12. Bristol Community Health Partnership Agreement The Trust Board received and considered this report by the Chief Executive for approval. Robert Woolley introduced the paper and described the origins of Bristol 13 Page 14 of 14 of Minutes of a Public meeting of the Trust Board of Directors held on 28 February 2012 at 10:30, in the Conference Room, Trust Headquarters, Marlborough Street, Bristol, BS1 3NU
Community Health and the intention to bring the partnership agreement to the Trust Board of Directors, to ensure that it received the endorsement of the agreement. Paul May stressed that the primary factor in consideration of collaborative working with Bristol Community Health (BCH) was the benefit to patients. There being no further questions or discussions, the Board resolved to approve the Bristol Community Health Partnership Agreement. Information and Other 13. Any Other Business There was no other formal business of the Trust Board.
14. Date of Next Meeting Public Meeting of the Trust Board of Directors, Tuesday 27 March 2012 from 10:30 – 13:30 in the Conference Room, Trust Headquarters, Marlborough Street, Bristol, BS1 3NU.
14
Cover Sheet for a Report for a Public Trust Board Meeting, to be held on 27 March 2012 at 10:30 in the Conference Room, Trust Headquarters, Marlborough Street, Bristol, BS1 3NU
Item 04 – Chief Executive’s Report
Purpose To report to the Board on matters of topical importance to the Trust, including a report of the activities of the Trust Management Executive.
Abstract The Board will receive a verbal report of matters of topical importance to the Trust, in addition to the attached report summarising the key business issues considered by the Trust Management Executive in the month.
Recommendations
The Trust Board is recommended to note the key issues addressed by the Trust Management Executive in the month and to seek further information and assurance as appropriate about those items not covered elsewhere on the Board agenda. Report Sponsor
Robert Woolley, Chief Executive Appendices
• Appendix A – Trust Management Executive Report
15 APPENDIX A
TRUST MANAGEMENT EXECUTIVE
REPORT TO TRUST BOARD – MARCH 2012
1. INTRODUCTION This report summarises the key business issues addressed by the Trust Management Executive in the month.
2. COMMUNICATIONS The Trust Management Executive noted a new monthly report on the activities of the Communications Department, including support to the Building a Better Bristol Programme, the closure of the Bristol General Hospital and the opening of South Bristol Community Hospital, the Transforming Care programme, the launch of Bristol Health Partners and other initiatives. A key area of work is the refinement of patient information leaflets cross the Trust.
3. QUALITY, PERFORMANCE AND COMPLIANCE The group noted that Trust compliance with the total accident and emergency wait time target in Quarter 4 was seriously at risk, following a combination of increased emergency demand and capacity restrictions caused by Norovirus outbreaks, and that Monitor had been notified accordingly. A commitment had been given to restore forward compliance by the end of March. Other service pressures were under active management by the Service Delivery Group, including those relating to last minute cancelled operations. The group agreed that continued focus on compliance with nutrition and essential training standards was necessary. The beneficial impact on compliance with cancer treatment time standards of improved patient treatment list management by Divisions was welcomed.
The Trust Management Executive noted a consolidated summary of patient feedback about outpatient services from a variety of sources, including the Care Quality Commission, the 2011 National Outpatient Survey and the Trust’s local surveys. These showed that the greatest patient concerns relate to communications, administration issues, including cancelled appointments, and delays in clinic. The action plan in response to these findings incorporated ambitious targets for improvement and had been aligned to the Productive Outpatients work-stream inside the Trust’s Transforming Care programme.
The group approved the revised Patient Experience and Involvement Strategy and action plan, based on the principle of deeper involvement of patients and the public at all levels of the Trust.
The Trust Management Executive approved a proposal to develop the role of ward sisters and charge nurses across the Trust by formalising their clinical supervisory status responsible for the delivery of excellent patient care, in anticipation of significant benefits to patient outcomes and operational efficiency. This proposal was part of the Nursing Workforce project inside the Transforming Care programme. A
16 development programme and performance indicators would be prepared prior to implementation.
The group approved a proposal to adopt a new testing and reporting methodology for Clostridium Difficile infection, following new guidance from the Department of Health about the potential benefits to patient care. A detailed plan would now be developed, taking into account technical, training and financial implications, prior to implementation.
Reports from subsidiary management groups were noted, which included the following items:
operational planning for the spring and summer months, taking account of Easter and other public holidays the achievement of a £1 million milestone in commercial research turnover in 2011/12, set against significant under-performance against end of year targets for recruitment to clinical research trials the scope of the Infection Control Programme for 2012/13 the Trust’s position in the Dr Foster Hospital Guide 2011 the planned development of an acute oncology service a successful joint bid to Macmillan Cancer Support by UH Bristol, North Bristol Trust and Bristol Community Health Services to support co-ordination and access to acute services for cancer patients and survivors.
4. STRATEGY AND BUSINESS PLANNING The Trust Management Executive approved the process for signing off Divisional Operating Plans for 2012/13.
The group approved a proposed list of local Commissioning for Quality and Innovation indicators for inclusion in 2012/13 contracts with commissioners, noting the impact on both clinical staff and data collection staff of these and the specialised services indicators.
The group approved proposed new actions and milestones for delivery of strategic objectives inside the current three year Annual Plan, subject to minor changes prior to consideration by the Trust Board.
5. RISK, FINANCE AND GOVERNANCE The Trust Management Executive noted the revised Risk Management Strategy being submitted to the Trust Board for approval and noted a new Procedural Document Framework drawn up in line with NHS Litigation Authority best practice recommendations.
The Trust Management Executive considered proposals for changes to car parking tariffs for patients, visitors and staff. The group approved the proposal to introduce facilities for debit and credit card payment and pay-on-exit facilities where possible but asked for further work to set other proposals in the context of the Trust’s strategy for addressing accessibility issues, demand pressures and Green Travel Plan
17 commitments and benefits. The group agreed that the availability of parking concessions for regular hospital users should be routinely publicised.
The group approved the Trust’s response to recommendations of Internal Audit reports concerning patient safety arrangements, business planning processes and contract income collection.
The group noted the status of the action plan to deliver the recommendations of the Independent Inquiry into Histopathology Services in 2010 and an update about completion of corporate governance commitments.
The group noted risk exception reports from Divisions.
6. RECOMMENDATIONS The Board is recommended to note the content of this report and to seek further information and assurance as appropriate about those items not covered elsewhere on the Board agenda.
Robert Woolley Chief Executive 19 March 2012
18
Cover Sheet for a Report for a Public Trust Board Meeting, to be held on 27 March 2012 at 10:30 in the Conference Room, Trust Headquarters, Marlborough Street, Bristol, BS1 3NU
Item 05 – Quality and Performance Report
Purpose To brief the Board on the Trust’s performance against Quality, Workforce and Access standards.
Abstract The monthly Quality & Performance Report details the Trust’s current performance against national frameworks, and against a range the Quality, Workforce and Access standards. Exception reports are provided, for areas requiring further attention, along with examples of learning and improvement from complaints, incidents and patient stories. Recommendations
The Board is recommended to note the current performance of the Trust and to ratify the actions being taken to improve performance. Executive Report Sponsor or Other Author
‘Health of the Organisation’ - Deborah Lee (Director of Strategic Development) ‘Quality’ - Alison Moon (Chief Nurse) & Sean O’Kelly (Medical Director) ‘Workforce’ - Steve Aumayer (Director of Workforce & Organisational Development) ‘Access’ – James Rimmer (Chief Operating Officer)
Authors: Xanthe Whittaker (Head of Performance Assurance / Deputy Director of Strategic Development) Anne Reader (Assistant Director of Governance & Risk Management) Heather Toyne (Assistant Director of Workforce Planning)
Previous Meetings
Trust Other Finance Finance Executive Outcomes Committee Committee Qualityand Management Executive Team Audit Committee 26 Mar 2012
19
SUMMARY QUALITY & PERFORMANCE REPORT
March 2012
20 CONTENTS
PERFORMANCE OVERVIEW:
A Performance Overview B Organisational health barometer C Monitor‟s Compliance Framework
1. QUALITY
1.1 Actual patient experience 1.2 Quality dashboard 1.3 Summary 1.4 Changes in the period 1.5 Exception reports 1.6 Supporting Information
2. WORKFORCE
2.1 Summary 2.2 Exception Reports 2.3 Supporting Information
3. ACCESS STANDARDS
3.1 Summary 3.2 Access dashboard 3.3 Changes in the period 3.4 Exception reports
21 PERFORMANCE OVERVIEW
SECTION A – Performance Overview
Summary
Overall, the „health‟ of the organisation has deteriorated slightly, with the number of GREEN rated indicators decreasing by four. The number of RED rated indicators has stayed the same.
Three of the four measures of „Being Efficient‟ are now GREEN rated following an improvement in the Emergency Length of Stay. Both measures of Delivering High Quality Care are now RED rated, due to an increase in the Number of Inpatient Falls in the period. The Hospital Standardised Mortality Ratio (HSMR) is now AMBER rated, but remains well below the national average. HSMR continues to be closely monitored at both a Trust and a specialty-level. Financial performance has remained strong, with three of the four measures being GREEN rated for a fourth month running. CRES (Cash Releasing Efficiency Savings) Achievement remains AMBER rated for the year to date. However, there was an improvement in performance in the month. Both measures of „Delivering our Contracts‟ have remained GREEN rated.
Although one of the Cancer Standards wasn‟t met in January, all standards remain on track to be achieved for the quarter as a whole. The A&E 4-hour standard can no longer be achieved for the quarter. So the Trust is now forecasting an AMBER- GREEN rating against Monitor‟s Compliance Framework at the end of Q4.
22
SECTION B – Organisational Health Barometer Providing a Good Patient Experience
ID Indicator Previous Current YTD Thresholds Trend Notes
Green: >= 74.4 Current month is January 2012. Trend arrow is triggered if change is +/- 2 points from A01 Patient Climate Survey (Overall CQUIN Score) 74.8 74.3 N/A Red: <72.4 Previous to Current
Green: <120 A02 Number of Patient Complaints 151 122 1360 Red: >=135
Same Sex Accommodation Breaches (Number of Green: 0 A03 0 0 65 Patients Affected) Red> >0
Delivering High Quality Care
ID Indicator Previous Current YTD Thresholds Trend Notes
Incidence of Hospital Acquired Pressure Sores Green: 0 No RAG rating for YTD. B01 3 4 29 (Grades 3 or 4) Red: > 1
Green < 5.6 B02 Number of Inpatient Falls Per 1,000 Beddays 4.85 5.60 4.85 Red: >= 5.6
Keeping People Safe
ID Indicator Previous Current YTD Thresholds Trend Notes
C01 Number of Serious Incidents (SIs) 16 7 80
C02 Number of C.Diff cases 4 3 51 Below Trajectory
Being Accessible
ID Indicator Previous Current YTD Thresholds Trend Notes
Green: >=90% D01 18 Weeks Admitted Pathways 91.8% 91.4% 91.7% Red: <85%
Green: 0 Previous is confirmed Quarter 3 2011/12. Current is Jan 2012. YTD is Apr-Dec quarterly D02 Number of Cancer Standards Failed 0 1 1 Red: >=2 performance.
Green: >=98% D03 A&E 4 Hour Standard 94.08% 91.50% 96.34% Red: <95% 23 PERFORMANCE OVERVIEW Being Effective
ID Indicator Previous Current YTD Thresholds Trend Notes
Green: <80 Previous is August and Current is September 2011 E01 Hospital Standardised Mortality Ratio (HSMR) 73.6 86.4 Red: >=90
Data is now based on month of discharge (rather than month of re-admission). Previous is E02 30 Day Emergency Readmissions 374 339 3814 Below 10/11 volumes December 2011 and Current is January 2012
Being Efficient
ID Indicator Previous Current YTD Thresholds Trend Notes
Green: <= 3.64 F01 Elective Length of Stay Reduction 3.06 3.31 3.50 Red: >= 3.83
Green: <= 5.07 F02 Emergency Length of Stay Reduction 5.25 5.02 4.99 Red: >= 5.34
Theatre Productivity - Percentage of Sessions Green: >= 90% F03 96.7% 95.9% 94.8% Used Red: < 90%
Green: <2.03 F04 Outpatient Follow-Up To New Ratio 2.07 2.19 2.08 Red: >=2.03
Valuing Our Staff
ID Indicator Previous Current YTD Thresholds Trend Notes
current month and ytd budget current month over budget, ytd over budget, movement static over previous ytd figure G01 Workforce Costs 0.36% 0.39% 0.60%
Amber: Above Forecast (over 0.5% of target) [ Parameters 0.5 percentage points above G02 Staff Sickness 4.5% 4.6% 4.0% See note target = red 0.2– 0.5 above target = amber on target or less = green]
Promoting Research
ID Indicator Previous Current YTD Thresholds Trend Notes
Green:>Same Period Last Year Previous is Apr-Jan cumulative total. Current (and YTD) is Apr-Feb cumulative total. Note H01 NIHR Income (£000s) £3,189 £3,189 £3,189 Red: Green: > YTD Last Year Previous and Current are rolling 3 month totals Oct-Dec 2011 and Nov 2011-Jan 2012 H02 Weighted Patients Recruited Into NIHR Trials 1,881 2,136 24,938 Red: < YTD Last Year respectively). YTD is Apr11-Dec12 24 PERFORMANCE OVERVIEW Governing Well ID Indicator Previous Current YTD Thresholds Trend Notes Green: < 1 Previous now shows the confirmed Q3 reported position. Current shows forecast Q4 J01 Monitor Governance Risk Rating 0 0 N/A Red: > = 4 posiiton. Delivering Our Contracts ID Indicator Previous Current YTD Thresholds Trend Notes Financial Performance Against CQUINs > 50% Green YTD/Current = Forecast year-end rewards. The Trust is taking a prudent view at this stage K01 £2.84 £2.78 £2.78 (£millions) < 50% Red and has assumed 75% of the forecast. Green: Below Plan Previous is movement in Dec; Current is movement in Jan; YTD is April to Jan. Data is K02 Contract Penalties Incurred (£millions) -£0.70 -£0.10 -£0.28 Red: Above Plan variance above (+) or below (-) plan, with a higher negative value representing better performance. Managing Our Finance ID Indicator Previous Current YTD Thresholds Trend Notes Green: >3 For financial measures except CRES, Current and YTD is Current Year To Date. For CRES L01 Monitor Financial Risk Rating 4 4 4 Red: <3 there is a separate total for latest month and YTD. Previous is previous month's reported data. Green: 100% L02 EBIDTA (Compared To Plan) 104% 107% 107% Red: <95% Green: >=90% L03 CRES Achievement 79% 87% 81% Red: <75% Green: 25+ days L04 Liquidity (in Days) 30.7 28.6 28.6 Red: <=14 days Notes Unless otherwise stated, Previous is January 2012 and Current is February 2012 YTD (Year To Date) is the total cases/cumulative score for the year so far, from April 2011 up to and including the current month RAG (Red/Amber/Green) rating only applied to YTD where an agreed target number of cases/score exists for the year. 25 PERFORMANCE OVERVIEW 26 PERFORMANCE OVERVIEW 27 PERFORMANCE OVERVIEW 28 PERFORMANCE OVERVIEW 29 PERFORMANCE OVERVIEW 30 PERFORMANCE OVERVIEW 31 PERFORMANCE OVERVIEW 32 PERFORMANCE OVERVIEW 33 PERFORMANCE OVERVIEW 34 PERFORMANCE OVERVIEW 35 PERFORMANCE OVERVIEW 36 PERFORMANCE OVERVIEW 37 PERFORMANCE OVERVIEW Please note: The baseline measurement of the Follow-up to New ratio was re-calculated in November. The data has been back-dated based upon this new calculation. The adjustment was made because of data reclassification and service changes which were giving a false picture of the underlying follow-up rates. 38 PERFORMANCE OVERVIEW Organisational Health Barometer – exceptions summary table Indicator in exception Exception Report Additional information Incidence of Hospital Acquired In the Quality section of this report Pressure Sores Number of Inpatient Falls In the Quality section of this report A&E maximum wait (4 hours) In the Access section of this report The target is currently flagged as RED, with a deterioration in the month from a ratio of 2.07 follow-ups to one new, to 2.19, against a target of 2.03. Work continues to understand what action can be taken to reduce any clinically un-necessary Outpatient Follow-up to New Ratio See additional information follow-ups, across all areas where we are currently under-performing against contract. Performance against this and other contract limiters is reviewed at the monthly Divisional Review meetings with the Chief Operating Officer and the Director of Finance. Recruitment into National Institute for Health Research (NIHR) studies remains off target year to date. A project has commenced to formally identify why recruitment is below target, using a number of methodologies including root cause analysis. It is Weighted Patients Recruited into See additional information unlikely that the agreed target will be reached this NHIR Trials financial year. The Western Comprehensive Research Network has been advised of the expected shortfall and we are working closely with them to identify ways of addressing the shortfall in the short, medium and long term. 39 PERFORMANCE OVERVIEW SECTION C – Monitor’s Compliance Framework At the end of February the Trust is forecasting achievement of all of the targets in Monitor‟s Compliance Framework during quarter 4, except the A&E 4- hour standard. The Trust is forecasting full achievement of all the cancer standards for the quarter. An Exception Report is therefore provided in the Access section of this report for the following indicators: A&E 4 –hour maximum wait The A&E 4-hour standard is weighted 1.0 in the Compliance Framework. This will give the Trust an AMBER-GREEN Governance Risk Rating. This is the second lowest rating out of four. Please see the Monitor dashboard on the following page, for details of current forecast for quarter 4 2011/12. 40 PERFORMANCE OVERVIEW Monitor's Compliance Framework - dashboard Forecast Q4 Governance Number Target Weighting Target threshold Year To Date Q1 11/12 Q2 11/12 Q3 11/13 *Q4 Q4 Forecast Notes rating Trajectory: Q1 19; Q2 17; Q3 13; 1 Infection Control - C.Diff Infections Against Trajectory 1.0 < or = trajectory 51 7 Achieved Q4 15 Trajectory: Q1 1; Q2 2; Q3 1; Q4 2 Infection Control - MRSA Bloodstream Cases Against Trajectory 1.0 < or = trajectory 2 0 Achieved 2 3a Cancer - 31 Day Diagnosis To Treatment (Subsequent - Drug) 98% 99.8% 99.6% 3b Cancer - 31 Day Diagnosis To Treatment (Subsequent - Surgery) 1.0 94% 96.5% 94.6% Achieved Cancer - 31 Day Diagnosis To Treatment (Subsequent - 3c 94% 99.5% 98.2% Radiotherapy) 4a Cancer 62 Day Referral To Treatment (Urgent GP Referral) 85.0% 87.0% 88.4% 1.0 Achieved 4b Cancer 62 Day Referral To Treatment (Screenings) 90.0% 93.9% 98.4% Monitor Referral to treatment time for admitted patients (95th Achieved each Achieved Achieved Achieved Achieved Compliance 5 1.0 23 Achieved percentile) - in weeks month each month each month each month each month Framework Referral to treatment time for non-admitted patients (95th Achieved each Achieved Achieved Achieved Achieved 6 1.0 18 Achieved percentile) - in weeks month each month each month each month each month 7 Cancer - 31 Day Diagnosis To Treatment (First Treatments) 0.5 96% 98.0% 98.7% Achieved 8a Cancer - Urgent Referrals Seen In Under 2 Weeks 93% 95.6% 95.4% 0.5 Achieved 8b Cancer - Symptomatic Breast in Under 2 Weeks 93% 98.2% 99.0% The 4-hour standard can no 9 A&E Total time in A&E 4 hours (95th percentile) 1.0 5% 96.3% 92.8% Not achieved longer be achieved in Q4. To be confirmed 10 Stroke indicators - to be confirmed 0.5 Not applicable Not scored Not scored Not scored (TBC) Self certification against healthcare for patients with learning Agreed standards Standards Standards 11 0.5 Standards met Achieved disabilities (year-end compliance) met met met CQC Agreed standards CQC Actions CQC Actions CQC Actions Not Not CQC standards or over-rides applied Varies Compliance Achieved met completed completed completed applicable applicable actions AMBER- AMBER- AMBER- rating AMBER-RED GREEN GREEN GREEN GREEN 1.0 Please note: If the same 1.0 weighted indicator is failed in three successive quarters, an automatic RED rating is applied. *Q4 to date Cancer figures based upon confirmed for January and draft for February AMBER-GREEN 41 QUALITY 1.1 PATIENT EXPERIENCE Patient Z is an 11 year old boy who was admitted to the Bristol Royal Hospital for Children in November 2011 as an emergency patient. He was admitted to Ward 35 (Adolescent Ward) initially and his care needs at this time were of a high dependency level. His diagnosis revealed he needed to have surgery to remove a phaeochromcytoma (tumour on his adrenal gland). Following surgery, he was admitted to the Paediatric Intensive Care Unit (PICU) and when his condition was stable he was transferred to Ward 31 (Surgical Ward). On Ward 35 Patient Z was cared for under a 1:2 nurse to patient ratio and on PICU the nurse to patient ratio was 1:1. This level was reduced to a 1:4 nurse to patient ratio when he was transferred to Ward 31 in line with his condition, which had stabilised. In his mother‟s complaint letter, she explains that her son‟s admission to Ward 35 and PICU were excellent. However, her experience and that of her son on Ward 31 was of poor nursing care, involving several elements that were below the normal standard expected. Patient Z was also unable to sleep as staff appeared to do nothing about the noise created by other patients. Also nursing staff failed to deal with large numbers of visitors with a patient in the bed opposite and they were allowed to eat in front of her son who was nil by mouth. Investigation The investigation revealed several factors that contributed to the poor experience of the mother and Patient Z. Communication: Patient Z was extremely poorly prior to his surgery and immediately post surgery whilst on the PICU. His nursing needs were such that he required a higher than normal nurse to patient ratio. On admission to Ward 31, it was not explained clearly to his mother that these ratios would be reduced owing to the fact her son was now stable and making a good recovery. Communication: His mother felt that Patient Z had not received appropriate nursing care. For example, she felt that her son had not been assessed by the nurse on admission to Ward 31 and that he was not given regular fluids overnight. However, he had been assessed on admission but this process had not been fully explained to her. With regard to the offer of regular fluids, Patient Z felt nauseous and the medical staff advised only to offer sips and to keep the intravenous infusion running. In all there were 11 complaints of poor nursing care and when investigated these were not substantiated, although poor communication to the patient‟s mother clearly caused her concern. Practice: The ward has an open visiting policy for family members during the day, although the staff actively encourage parents to restrict the number of visitors. Eating in front of other patients is not tolerated and in this instance staff failed to prevent this from occurring. Practice: We are aware that the Children‟s Hospital does have an issue with noise at night and this is not only applicable to this patient‟s experience and we are working hard to improve this as shown below. 42 QUALITY Departmental Learning The ward has introduced a buddy system, whereby staff identify another member of staff to take over their patients‟ care when they take a break, rather than handing the patient over to the nurse-in-charge. This practice has been adopted from another ward and has improved communication with patients and families, particularly during handover and at break times. There has been inconsistency across the wards with numbers of visitors allowed per bed space. Ward 31 and Ward 32 (cardiac ward) are working more closely to ensure consistent information is given to parents as both wards share the same parents‟ room. Improved communication between wards due to the re-structure of the Sisters‟ Forum and Matron re-alignment, with all in-patient wards falling under one Matron make the learning much easier to transpose across more than one area. Noise management on the ward: silent bins have been purchased and are in place across the hospital; Changing the lighting configuration to enable nurses to turn lights off or dim to make conducive to night setting; Introduction of the Patient Experience Action Group whose members consist of Head of Nursing, Matrons and Youth Development Worker to ensure patient feedback is listened to and actioned. Divisional Learning The ward is establishing a parental contract when children are admitted, which will provide an agreement about what care parents wish to be involved with and which aspects of care will be carried out by the nursing staff. This would have helped alleviate some of the concerns the mother raised as she would have been clear of staff expectations and it would have been explicit about what care and observations/records she was happy to carry out when she was on the ward with Patient Z. This also maintains regular dialogue with the family, ensuring any concerns they have are addressed at the time. Organisational Learning The Trust is focussing on transition of patients from critical care areas to general ward areas. This will in particular focus on the preparation for the patient and family for leaving the intensive care environment and following up by checking with the patient how they doing are after they have transferred. 43 QUALITY EXPERIENCES OF THE BRISTOL GENERAL HOSPITAL This month, as the new South Bristol Community Hospital is about to be opened, we are also recognising the contribution of the Bristol General Hospital for its many years of providing healthcare to the people of Bristol by including some past experiences from patients who received care there. Roy Everitt – had cancer and his voice box Terry Threader – admitted with meningitis June Terry – a patient during the war and removed in 1988 in 1948, aged 13 from 1968 worked as a cleaner for 27 years “I know I had really good care because I “I had lumber punctures then a mastoid “I was a patient in the ENT ward on the top recovered and was able to go home on the operation behind my right ear, performed by floor during the Blitz. My mother had a bad eleventh day - one of the quickest they could Mr Angell James. I was cared for on Fenwick feeling, so against doctors‟ advice, she took remember. The first three days were awful but Richard‟s Ward and my treatment consisted me home. It happened that the ward I‟d been the nursing staff were all very good, they got of brilliant nursing and also penicillin by in was hit by an incendiary bomb. No one me through the ordeal.” injection every four hours. This wonderful was hurt, but the ward was gutted.” care and treatment saved my life and I will be forever grateful.” Denise Taylor – admitted in 1965 for an Anne Nash – admitted in 1962 to the Mrs I Davey – a patient in the 1930s ovarian cyst operation, aged 22 gynaecology ward admitted to the children’s ward with a bad heart condition (she is now 87 years old) “I had two cysts, part of my ovaries removed, “My gynaecologist was Mr Sammy Loxton, appendix out and adhesions and tubes sorted who told me I nearly died. One day his wife “In the round hall downstairs there was a for me to have a family. I was lucky having a came in to see me and said: “Sammy doesn‟t Christmas tree so large it touched the ceiling. daughter then a son.” think much about God, but each night he has Every year I cried if they gave me crayons “I remember the highlight of the day was knelt by the bed and prayed for you”. and the heart doctor I was under always got watching the red mast light go by the “Sister Clayfield – everyone called her Clay – me the Big Doll off the top of the tree.” windows of the ward, morning and night, of was one of those single women who “In the Casualty Department, a sister used to the ship, “Harry Brown”. We used to call out dedicated their lives to being a nurse, almost sit on a stool by a desk and you had to pay a “There goes Harry!” The patients were all like a nun. I was on the ward from September penny for treatment and if you were poor and super; we had great fun.” to March and Clay helped save my life. I kept out of work you had to have a letter from the in touch with her ever since and went to her means test office.” funeral six years ago.” 44 QUALITY 1.2 QUALITY DASHBOARD Green Year To Monthly Totals Quarterly Totals ID Title Threshold Date Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Q1 Q2 Q3 Q4 PS-A1 MRSA Pre-Op Elective Screenings 100% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% PS-A2 MRSA Emergency Screenings 90% 93.3% 91.7% 91.5% 93.3% 92.5% 92.7% 93.1% 93.2% 93.4% 94.1% 93.8% 94.1% 94.4% 92.4% 93.0% 93.8% 94.2% PS-A3 Hand Hygiene Audit Compliance 95% 97.7% 97.3% 97.8% 95.0% 98.3% 99.1% 98.8% 97.3% 97.2% 96.2% 98.5% 98.3% 98.2% 97.0% 98.4% 97.3% 98.3% PS-A4 Antibiotic Compliance 90% 81.9% 76.5% 81.5% 78.4% 84.1% 80.1% 76.3% 76.7% 81.5% 83.3% 82.9% 86.8% 84.2% 81.4% 77.4% 82.7% 85.5% PS-A5 Matron's Checklist 95% 94.4% 93.7% 94.8% 93.1% 93.7% 94.2% 93.8% 94.5% 95.2% 94.9% 95.2% 95.5% 96.4% 93.8% 94.2% 95.1% 95.7% Infection Control PS-A6 Cleanliness Monitoring - Overall Score 95% 95% 95% 96% 96% 95% 95% 96% 95% 96% 94% 96% 95% PS-A7 Cleanliness Monitoring - Very High Risk Areas 95% 97% 97% 97% 97% 97% 96% 97% 97% 96% 95% 96% 96% PS-A8 Cleanliness Monitoring - High Risk Areas 95% 96% 96% 96% 96% 96% 97% 97% 96% 97% 96% 95% 96% PS-A9 Number of GRE Bacteraemias <=2 7 11000310020 1 4 2 0 PS-A10 Infection Control - C.Diff Infections Against National Trajectory Patient Safety Patient Falls PS-C3 Number of Inpatient Falls - Patients Aged 65 And Over 973 132 79 104 88 94 63 78 87 96 92 98 94 271 235 275 192 PS-C4 Number of Inpatient Falls - Patients With Cognitive Impairment 500 73 40 53 45 43 26 44 48 47 51 60 43 138 113 146 103 PS-D1 Total Pressure Ulcer Incidence per 10,000 Bed Days 6.51 14.25 9.87 7.23 14.18 14.87 13.65 12.70 14.00 21.21 15.21 14.09 14.08 15.54 12.08 13.45 16.90 14.79 PS-D2 Percentage of Hospital Acquired Pressure Ulcers Not Graded <5% 0.3% 14.8% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 2.7% 0.0% 0.0% 0.0% 1.4% Pressure Ulcers PS-D3 Number of Hospital Acquired Grade 2 Pressure Ulcers <83 yr 349 19 16 34 31 32 27 29 49 33 32 33 33 81 88 114 66 PS-D4 Number of Hospital Acquired Grade 3 Pressure Ulcers <1 30 322423443123 8985 PS-D5 Number of Hospital Acquired Grade 4 Pressure Ulcers <1 3 100000000111 0012 Venous Thrombo- PS-E1 Adult Inpatients who Received a VTE Risk Assessment 90% 97.3% 91.6% 94.2% 95.1% 97.0% 97.5% 98.0% 97.6% 97.5% 98.0% 98.4% 98.2% 98.4% 95.5% 97.7% 98.0% 98.3% embolism (VTE) PS-E2 Percentage of Adult Inpatients who Received Thrombo-prophylaxis 90% 92.9% 87.5% 93.3% 89.6% 97.5% 89.7% 97.5% 96.0% 92.5% 90.4% 94.4% 94.4% Nutrition PS-F1 Patients who Received Fully Completed Nutritional Screening Within 24 Hours 90% 80.0% 76.1% 66.2% 92.0% 83.0% 66.2% 92.0% 83.0% PS-G1 WHO Surgical Checklist Compliance 98% 95.6% 98.0% 98.6% 92.6% 90.2% 87.3% 96.8% 97.7% 97.0% 97.3% 97.5% 98.7% 98.4% 93.5% 93.9% 97.3% 98.5% Safety PS-G2 Reduction in Medication Errors <2.84% 1.54% 5.93% 2.08% 0.79% 0.85% 0.85% 1.77% 1.05% 2.56% 2.04% 2.22% 1.17% 1.23% 2.30% PS-H1 Number of Executive Director Patient Safety Walk-arounds >=6 82 5 7 11 9 6 5 10 9 5 6 8 6 27 21 20 14 Leadership PS-H4 Percentage of Non-Estates Actions Completed Within 2 Months 80% 89% 67% 100% 100% 77% 95% 75% 91% 100% 86% 83% 100% 100% 89% 88% 86% 100% 45 QUALITY Green Year To Monthly Totals Quarterly Totals ID Title Threshold Date Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Q1 Q2 Q3 Q4 Mortality CE-A1 Hospital Standardised Mortality Ratio (HSMR) <=80 65.5 87 72.9 79.2 90.2 73.6 86.4 CE-C1 Average Length Of Stay - Elective <=3.64 3.50 3.66 4.34 3.40 3.65 3.19 4.01 3.37 3.27 3.42 3.57 3.06 3.31 3.78 3.53 3.41 3.19 Length of Stay CE-C2 Average Length Of Stay - Emergency <=5.07 4.99 5.33 5.31 5.27 4.88 5.01 5.21 4.96 4.78 4.66 4.51 5.25 5.02 5.16 5.06 4.65 5.14 Learning Disability CE-D1 Risk Assessment of Patients with Known Learning Disability within 48 Hours 85% 74.2% 50.0% 37.5% 60.0% 33.3% 42.9% 87.5% 85.7% 81.8% 83.3% 100.0% 100.0% 51.7% 61.1% 83.3% 100.0% Readmissions CE-E1 Emergency Readmissions Within 30 Days <411 mth 3814 415 416 399 375 324 387 410 375 374 339 1230 1086 1159 339 Maternity CE-G1 Percentage of Spontaneous Deliveries Compared to All Births 64.4% 62.99% 65.04% 63.83% 65.01% 63.53% 64.88% 61.22% 57.79% 63.84% 61.97% 62.48% 65.80% 62.63% 64.13% 61.32% 62.77% 64.24% CE-H1 Fracture Neck of Femur Patients Treated Within 36 Hours 55.8% 61.1% 51.9% 58.3% 65.4% 58.3% 53.8% 44.8% 57.7% 54.5% 56.5% 59.2% 52.3% Fracture NoF CE-H2 Fracture Neck of Femur Patients Seeing Orthogeriatrician within 72hours 54.9% 22.2% 11.1% 12.5% 38.5% 66.7% 84.6% 86.2% 61.5% 87.9% 14.5% 63.2% 79.5% CE-H3 Fracture Neck of Femur Patients Achieving Best Practice Tariff 31.3% 11.1% 3.7% 8.3% 30.8% 37.5% 46.2% 41.4% 38.5% 51.5% 7.2% 38.2% 44.3% CE-J1 Stroke Care: Percentage Receiving Brain Imaging Within 1 Hour 50% 30.6% 39.4% 25.7% 23.1% 25.0% 42.9% 28.6% 37.9% 28.6% 24.3% 25.7% 33.3% 46.4% 24.7% 35.9% 26.0% 40.0% Clinical Effectiveness Stroke Care CE-J2 Stroke Care: Percentage Spending 90%+ Time On Stroke Unit 80% 82.1% 80.6% 81.4% 86.5% 82.9% 81.8% 85.4% 97.1% 85.7% 87.8% 81.4% 65.8% 68.3% 83.5% 87.9% 84.9% 67.1% CE-J3 High Risk TIA Patients Starting Treatment Within 24 Hours 60% 63.89% 74.07% 70.00% 75.00% 42.86% 50.00% 63.16% 77.78% 75.00% 64.29% 72.22% 52.63% 59.09% 63.04% 65.31% 70.45% 56.10% Specialist CE-K1 Percentage of Haemophilia Patients Undergoing Pharmocokinetic Study 74% 74% 74% Commissioning CE-K2 Lobectomy Patients - Median Length of Stay <=5 days 5 6 5 6 4 5 4 5.53.5 6 4 4 Single Sex Accom. PE-A1 Same Sex Accommodation Breaches - Number of Patients 0 65 39 5 18 22 3 0 7 10 0 0 0 0 45 10 10 0 PE-B1 Patient Survey - Overall CQUIN Score 74.4 75.5 74 74.6 76.3 74.4 75.3 73.9 76.2 75.9 74.8 74.3 75 75 76 74 PE-B2 Monthly Patient Survey - Noise At Night 81 83 83 81 82 83 80 83 82 82 80 82 82 82 80 Patient Experience PE-B3 Monthly Patient Survey - Help To Eat Meals 76 77 81 80 80 76 76 80 79 84 83 79 77 81 83 PE-B4 Monthly Patient Survey - Patients Who Would Recommend The Trust 92% 96% 96% 96% 97% 96% 96% 95% 97% 96% 96% 96% 96% 96% 96% PE-B5 Monthly Patient Survey - Local Score 83 87 87 89 86 88 86 88 88 88 87 88 87 88 87 PE-C1 Number of Patient Complaints <=120 1360 170 107 114 138 123 151 121 122 126 85 151 122 359 395 333 273 PE-C3 Percentage of Complaints Resolved Within Timeframe (Formal Complaints) 98% 90.8% 98.4% 88.9% 92.2% 89.5% 97.4% 92.7% 92.6% 90.2% 90.9% 84.2% 81.4% 95.2% 90.4% 93.9% 88.7% 89.6% Complaints/Complim Patient Experience Patient ents PE-C4 Number of Complainants Disatisfied with Response 0-5 mth 80 9 3 4 14 10 8 4 7 12 7 6 5 21 22 26 11 PE-C6 Complainants Disatisfied with Response (Not Responded In Full) 7 6 1 0 0 0 7 0 PE-C7 Complainants Disatisfied with Response (Additional Information Requested) 30 1 11 7 6 5 19 11 Please note: 1) An amendment has been made to one of the complaints metrics reported for January, following a further validation of the data. January’s Percentage of Complaints Resolved within Formal Timeframe was previously reported as 76.7% (RED rated), and is now 81.4% (RED rated) following validation. On further review two complaints were found to have been resolved within the appropriate timescale. In one case the complainant had declined an early meeting to discuss the complaint. In the other case an extension to the date for resolution had been agreed, which the corporate team was unaware of. A new process for reviewing breaches of the complaints standards has been agreed and will be implemented next month. 2) The Total Pressure Ulcer Incidence per 10,000 bed days was updated in January 2012. This amendment was made because it was found that there were additional wards (e.g. rehabilitation) that should also contribute to the total count of bed days to make this figure comparable to the national measure of pressure ulcer incidence. This had the effect of lowering the reported pressure ulcer incidence each month. However, all months remain RED rated as previously reported. 46 QUALITY 1.3 SUMMARY The number of red rated metrics decreased from twelve in January to eight in February with improvements noted in the management of complaints and serious incidents. Stroke metrics, whilst improved on last month, remain below the green thresholds and pressure ulcers remain above the green threshold despite continued focus in this area. The relevant exception reports provide further detail. Achieving set threshold (29) Thresholds not met or no change on previous Month (8) - MRSA (Meticillin Resistant Staphylococcus aureus) screening – - Antibiotic prescribing compliance elective - Percentage of hospital acquired pressure ulcers not graded at all - MRSA screening – emergency - Number of hospital acquired grade 4 pressure ulcers - Hand Hygiene Audit - Hospital Standardised Mortality Ratio (HSMR) - Clostridium difficile cases against national trajectory - Patient experience overall CQUIN score - Glycopeptide Resistant Enterococci (GRE) Bacteraemias - Monthly patient survey: noise at night - MSSA (Meticillin Sensitive Staphylococcus aureus) cases against - Total number of complaints trajectory - Percentage of complaints resolved within formal timescale - Matrons checklist (C. difficile dashboard) - Cleanliness monitoring very high risk areas - Cleanliness monitoring overall Trust score - Cleanliness monitoring high risk areas - Serious Incidents reported with 48 hours - Serious incident investigations completed within required timescales - Never Events - WHO surgical checklist compliance - Percentage of adult in-patients who had a Venous Thrombo- Embolism (VTE) risk assessment - Percentage adult in-patients who received thrombo-prophylaxis - Reduction in medication errors - Number of executive director patient safety walk rounds - Percentage of all actions completed with 2 months of patient safety walk round - Risk assessment of patients with known learning disability within 48 hours 47 QUALITY - Lobectomy patients median length of stay - Reduction in average elective length of stay - Reduction in average emergency length of stay overall - 30 day emergency re-admissions - Number of breaches of the same sex accommodation standard - Monthly patient survey: help to eat meals - Monthly patient survey: patients who would recommend the Trust - Monthly patient survey local score - Number of complainants dissatisfied with the response Quality metrics not achieved or requiring attention (8) Quality metrics with thresholds not yet finalised (9) - In-patient falls incidence per 1,000 bed days Quarterly Metrics - Total pressure ulcer incidence per 10,000 bed days - Patients receiving fully completed nutritional screening within 24 hours - Number of hospital acquired grade 2 pressure ulcers Thresholds not yet applicable - Number of hospital acquired grade 3 pressure ulcers - Fractured neck of femur patients treated with 36 hours - Percentage of spontaneous deliveries compared to all births - Fractured neck of femur patients seeing an ortho-geriatrician within 72 - Stroke care: percentage spending 90% + time on a stroke unit hours - Stroke care: percentage receiving brain imaging within 1 hour - Fractured neck of femur patients achieving best practice tariff - High risk TIA (Transient Ischaemic Attack) patients starting Metrics for information treatment with 24 hours - Number of serious incidents - Total number of patient safety incidents reported - Falls in in-patients over 65 - Falls in patients with cognitive impairment - Repeat in-patient falls 48 QUALITY Summary of Performance against Clinical Quality Indicator (CQUIN) Quality Dashboard Metrics Those CQUINS whose baseline measurements are based on in-year calculations are excluded from this list, but will be added in once the baseline is established. Percentage of adult inpatients who had a Venous Thrombo-Embolism (VTE) risk assessment. Performance of 98.4% in February against a monthly target of 90%. Spontaneous vaginal births. Performance of 62.6% in February against a target of 64.4% Patient Experience overall score relating to the discharge survey. Score for January 74.3 against target of 74.4. Patient Experience: reducing noise at night. Score for January 80 against target of 81. Patient Experience: assistance at mealtimes. Score for January 83 against a target of 76. Reduction in medication errors of 15% on 2010/11 outturn of 3.5%. Performance of 2.2 % in December against a target of <2.84%. Reduction in median length of stay for adult patients undergoing a (lung) lobectomy from 6 days to 5 days. Performance of 4 days in February against a target of 5 days. 49 QUALITY 1.4 CHANGES IN THE PERIOD Performance against the following indicators changed significantly compared with the last reported month: Falls per 1,000 bed days up from 4.85 in January to 5.60 in February Spontaneous vaginal births down from 65.8% in January to 62.6% in February. Number of complaints down from 151 in January to 122 in February Percentage of complaints resolved within time frame up from 81.4% in January to 95.2% in February. 1.5 EXCEPTION REPORTS Exception reports are provided for ten (10) indicators in total, eight (8) which are RED rated and a further two* (2) which have been of particular interest to the Board: 1. Antibiotic prescribing compliance* 2. In-patient falls incidence per 1,000 bed days 3. Total pressure ulcer incidence per 10,000 bed days 4. Number of hospital acquired grade 2 pressure ulcers 5. Number of hospital acquired grade 3 pressure ulcers 6. Percentage of spontaneous deliveries compared to all births 7. Stroke care: percentage spending 90% + time on a stroke unit 8. Stroke care: percentage receiving brain imaging within 1 hour 9. High risk TIA (Transient Ischaemic Attack) patients starting treatment with 24 hours 10. Serious incidents* 50 QUALITY Q1. EXCEPTION REPORT: Antibiotic Prescribing Compliance RESPONSIBLE DIRECTOR: Medical Director Description of how the standard is measured: Antibiotic compliance measures the compliance with the three elements of the antibiotic prescribing bundle (i.e. prescription in line with policy, indication stated and course length stated). Performance in the period, including reasons for the exception: The overall percentage compliance decreased from 86.8% in January to 84.2% in February. Compliance decreased in all divisions. Specialised Services (85.3%, a decrease from 87.1% in January) Surgery, Head & Neck (86.8%, a decrease from 87.7% in January) Women‟s & Children‟s (88.0%, a marginal decrease from 88.5% in January) Medicine (80.8%, a decrease from 85.4% in January) ** Division of Medicine has had 2 consecutive months fall in compliance since the result of 89.4% in December. Inclusion of a stop or review date continues to be the main reason for non-compliance of an antibiotic prescription. If we concentrate on this essential prescription parameter alone, the target will be achieved. Sustainability is the key issue with antimicrobial compliance as demonstrated by Division of Medicine results. 51 QUALITY Recovery plan, including expected date performance will be restored: Continue with joint microbiology/pharmacy review rounds Divisional boards to ensure consultant engagement with antimicrobial prescribing compliance and that consultants lead on ensuring all patients on their rounds have their antibiotics prescribed correctly. Request via Divisional Boards that specialties not achieving 80% compliance provide reasons for the low compliance rate. Identify a method to specifically target the inclusion of a stop or review date on the prescription. A teaching session on antibiotic prescribing for the F1 doctors has been delivered. 52 QUALITY Q2. EXCEPTION REPORT: Falls incidence per 1,000 bed days RESPONSIBLE DIRECTOR: Chief Nurse Description of how the standard is measured: The number of inpatient falls per 1,000 bed days compared with national benchmark data from the National Patient Safety Agency of 5.6 falls per 1,000 bed days Performance in the period, including reasons for the exception: Performance of 5.6 falls per 1,000 bed days against the national benchmark of 5.6 which is just over the threshold set of less than 5.6. There were 137 inpatient falls in February, the degree of harm arising from these was: Near miss = 9 falls No harm = 80 falls Minor harm = 41 falls Moderate harm = 7 falls The seven falls reported by staff as having caused moderate harm have yet to all be reviewed by the relevant manager. A corporate review of these seven falls suggests that no harm was sustained in four, minor harm in a further two and there was one case of moderate harm. Recovery plan, including expected date performance will be restored: Falls involving inpatients in hospital have multiple causes, therefore they require multiple solutions. Falls prevention is a key element of the UH Bristol „Being the Best‟ Programme and the South West Quality and Patient Safety Improvement Programme which employ a range of strategies to reduce falls. The evidence base relating to inpatient falls suggests falls strategies need to focus on developing systems and practices that enable staff to repeatedly ask “what will stop this patient from falling?” rather than trying to answer “what will stop all patients falling?” Analysis of the most recent falls investigated as serious incidents showed that the root causes were failure to reassess the falls risk on transfer to a new environment and the disorientation experienced by patients associated with this. Work that is underway to reduce the number of transfers for patients with dementia and to improve the quality of clinical handover at transfers will help with both of these causes. The Transfer Policy has been reviewed to provide a consistent approach and checklist across adult services to improve communication regarding patients who are at risk of falls. Safety briefings on all general wards are due to be implemented by the end of March 2012. The aim of safety briefings is to highlight to all staff key safety issues for specific patients, such as risk of falling 53 QUALITY Q3-Q5 EXCEPTION REPORT: RESPONSIBLE DIRECTOR: Chief Nurse Pressure ulcer incidence per 10,000 bed days Number of hospital acquired grade 2 pressure ulcers Number of hospital acquired grade 3 pressure ulcers Description of how the standard is measured: Pressure Ulcers identified at nursing/medical assessment are categorised 1-4 (Category 1 being red discolouration, Category 2 being a break or partial loss of skin, Category 3 being tissue damage through the superficial layers, Category 4 involving the most serious tissue damage, eroded through to the bone). Pressure Ulcers are reported as patient safety incidents and their reduction remains a CQUIN for 2011/12. Performance in the period, including reasons for the exception: The rate of hospital acquired pressure ulcers grade 2 and above was 15.54 per 10,000 bed days in February 2012. Divisional rates are shown in the table below. Division February 2012 January 2012 December 2011 November 2011 Medicine 19.24 9.57 13.99 20.16 Specialised Services 12.63 16.80 12.50 16.54 Surgery Head & Neck 31.45 37.43 30.33 24.06 Women‟s & Children‟s 1.45 1.44 4.33 1.54 Trust 15.54 14.08 14.09 15.21 There has been a slight increase in the overall rate of hospital acquired pressure ulcers in February 2012. Reductions in rates were seen in Surgery Head & Neck and Specialised Services Divisions, with the Medical Division seeing a marked increase in rate. The following areas are being prioritised for action by the Divisions: Medicine – Ward 7, Ward 17, Ward 26 Surgery Head and Neck – Intensive Care Unit, Ward 4 Specialised Services – Cardiac Intensive Care Unit There were three Category 3 pressure ulcers and one Category 4 pressure ulcer reported in February 2012. Patients were on the following wards when the pressure ulcer was detected: Medicine – Ward 7, Ward 20 54 QUALITY Surgery Head and Neck – Ward 9, Ward 5B For three of these patients, the category 3/4 ulcer has developed from a reported category 2 ulcer or a moisture lesion. The root cause analyses are focusing on how further pressure damage occurred following the identification of early damage. Recovery plan, including expected date performance will be restored: Intentional rounding (care rounds) for all patients has been implemented in adult areas of Women‟s & Children‟s and Specialised Services Division. This is now being rolled out across Surgery Head & Neck and Medicine Divisions. A trial of a prophylactic dressing is underway within Surgery Head & Neck Division. Support is being given to Ward 7 to understand the level of pressure ulcer acquisition in their patient group. 55 QUALITY Q6. EXCEPTION REPORT: Spontaneous vaginal births RESPONSIBLE DIRECTOR: Chief Nurse Description of how the standard is measured: Improvement of 1% in the proportion of spontaneous vaginal deliveries, compared with the number of all births including caesarean sections. The target is 64.4%. This is a Commissioning for Quality Indicator (CQUIN) incentive and is designed to increase the proportion of normal births. The deliveries include patients of all Primary Care Trusts and home births supervised by a UH Bristol employed community midwife. Performance in the period, including reasons for the exception: A spontaneous vaginal birth rate of 62.63% was reported in February. A significant increase in spontaneous vaginal deliveries would therefore be required in March in order to achieve the CQUIN. It should be noted that in February the unit had the delivery of the quadruplets by caesarean section which will affect the compliance as this is classed as four births. Recovery plan, including expected date performance will be restored: Please note previous actions have been removed from this list. All inductions except Term +12 inductions and inductions for prolonged rupture of membranes will be agreed by a Consultant only. Extra senior midwives (including Community Midwives) are being asked to work additional shifts so that they can support the junior midwives and co-ordinator on the delivery suite The service is reviewing all maternity pathways as part of a service review and is putting in an expression of interest as part of next year‟s Operating Plan for more midwives and a capital spend to enable the formation of a triage area and midwifery led unit. This would allow fewer non-labouring women to be on the delivery suite and reduce the risk of intervention for low risk women by having them on a unit away from the main unit. This will promote normality and improve normal birth rates. 56 QUALITY Q7-Q9. EXCEPTION REPORT: Stroke care RESPONSIBLE DIRECTOR: Medical Director percentage receiving brain imaging within an hour percentage of patients spending at least 90% of their stay on a stroke unit High risk TIA (Transient Ischaemic Attack) patients starting treatment with 24 hours Description of how the target is measured: Percentage receiving brain imaging within an hour: The percentage of patients suspected as suffering from a stroke that are scanned within 1 hour of arrival in the hospital. The national standard is for at least 50% of suspected strokes to be scanned within 1 hour. Scanning helps to ensure patients requiring thrombolysis are appropriately identified. This is based upon the finding that around 50% of suspected strokes have clinical indications that a scan is warranted. Percentage of patients spending at least 90% of their stay on a stroke unit: The percentage of stroke patients spending at least 90% of their stay on a designated stroke unit. Stroke patients are identified on the basis of their primary diagnosis being one of stroke. Patients‟ length of stay on a stroke unit is reported in the month of their discharge. The target is for 80% of patients to spend at least 90% of their stay on a designated stroke unit. High risk TIA (Transient Ischaemic Attack) patients starting treatment with 24 hours: The percentage of High Risk TIA (Transient Ischaemic Attack) patients starting treatment with 24 hours of referral. Only those patients treated in an outpatient setting count as a treatment. Monitor measurement period: Monitor is still to confirm which stroke indicators are to be included in its Compliance Framework. Performance during the period, including reasons for exceptions: Percentage receiving brain imaging within an hour (target 50%): Performance against this standard increased from 33.3% to 46.4% in the month, but is still below the national 50% standard. The national standard is based upon the assumption that 50% of stroke patients have symptoms that suggest braining imaging is required to assess their condition. The Trust‟s own figures suggest that the percentage of patients with symptoms that would indicate scanning is well below 50%, and all patients receiving thrombolysis are scanned within an hour of arrival. However, where a scan is required there are two potential areas where delays in the pathway can occur. Firstly a delay in requesting the CT scan, and secondly a delay in processing the request and undertaking the scan. At present any grade of doctor can see an acute stroke patient arriving in the Emergency Department, GP Support Unit or Medical Assessment Unit. This has made it more challenging to ensure everyone has the understanding of the clinical urgency for scans, as well as ensuring there are no delays in the request for a scan being made. 57 QUALITY Percentage of patients spending at least 90% of their stay on a stroke unit (target 80%): Prior to January 2012 the 80% standard has been achieved every month since February 2011. But the performance in January and February have been below the 80% target (January 2012 - 65.8% and February 2012 - 68.3%). Year to date performance against the 90% stay Stroke standard remains above the national standard (82.1% against the 80% standard). During February norovirus resulted in a number of wards being closed. Both the designated Acute Stroke Unit and the ward used as a contingency in the event of an outbreak of norovirus had to be closed. In addition, length of stay (LOS) for care of the elderly medical emergency patients increased significantly between January and February 2012, going from 11.0 to 12.7 days. The previous peak in LOS was in February 2011, when the 80% standard also failed to be achieved. The increase in LOS could be a result of increasing acuity (sickness) of patients, and/or delays in patients being discharged from the hospital when clinically ready to leave. Levels of delayed discharges (i.e. patients fit to leave whose discharge was delayed for other reasons – e.g. awaiting a placement in a residential home) within the Bristol Royal Infirmary (BRI) was particularly high during this period. All of these factors put pressure on beds and meant that it was not easy to re-provide protected stroke beds in the event of the Acute Stroke Unit and the contingency ward being closed due to norovirus. High risk TIA (Transient Ischaemic Attack) patients starting treatment within 24 hours (target 60%): Performance in February was 59.1%, and therefore just below the required standard. Overall performance against this standard remains above the 60% national target year-to-date (63.9% against the 60% standard). The clinic in which the TIA patients are seen is based within the stroke unit. A review of the performance suggests that the failure to achieve the 60% standard was at least partly due to the disruption in the service caused by the closure of the Acute Stroke Unit and contingency stroke wards, but also due to key staff being off sick. Analysis of January‟s breaches has shown that many were outside of the control of the team (e.g. not referred in a timely way, and patients refusing appointments). Performance is expected to above the 60% standard by the end of March. Recovery plan, including expected date performance will be restored: The actions being taken to ensure improved performance are detailed below. Please note: actions completed in previous months have been removed from the following list: Review the specific reasons why stroke beds were not available in January/February (Action complete) Feed-back to admitting teams the importance of being clear about the need for a bed on the stroke ward when making bed requests to the Clinical Site Team (Action complete) Further analysis will be undertaken as to the reasons for not achieving the 60% TIA treatment standard in January/February (Action complete) Different practice has been identified in other trusts around the requesting of CTs by nurses with extended roles; the Stroke Navigator is receiving additional training to enable them to make requests for CTs. This should speed-up the requesting of the tests; the education of junior doctors on the need for prompt scans continues (ongoing); work is also ongoing with Emergency Department nurses to help them recognise the 58 QUALITY symptoms of patients requiring a scan so that these patients can be brought to the attention of doctors (ongoing). Progress against the recovery plan: Despite a deterioration in performance over the last two month, performance remains above the national standard year-to-date, for both the 90% stay and high risk TIA treatment standards. Performance against the one hour scan standard remains below 50%, although ongoing audits carried-out by the Division provide assurance that those patients requiring a scan are receiving it within an hour, as required. The clinical team is continuing to review any additional actions that can be taken to ensure compliance with this standard. 59 QUALITY Q10. EXCEPTION REPORT: Serious Incidents RESPONSIBLE DIRECTORS: Medical Director / Chief Nurse Description of how the standard is measured: There is no threshold for numbers of serious incidents reported as there can be significant variation month on month and all incident reporting is to be encouraged to support an open and transparent safety culture. This sometimes means serious incidents are reported in a month after they occurred. The focus of serious incident investigations is to understand what happened and learn from the event as the causes are often multi-factorial. Performance in the period, including reasons for the exception: In January 2012, sixteen serious incidents were reported. This is an unusually high number and the Board requested further information in this respect. In February the number reported has reduced to seven. A detailed report on the sixteen serious incidents reported in January has been provided to the March 2012 Quality and Outcomes Committee. Five of the sixteen serious incidents reported in January occurred in previous months, but were identified and therefore reported in January. This is appropriate, as the measure used to assess levels of serious incidents is the number of serious incidents reported in the given month. Four of the serious incidents reported in January were inpatient falls and six were hospital acquired grade 3 and 4 pressure ulcers. Of these six pressure ulcers reported as serious incidents in January, two occurred in previous months and one was downgraded as it was subsequently identified as a rare dermatological condition. The remaining six serious incidents reported in January varied in type. The graph to the left shows that there was a peak in both falls and pressure ulcers reported as serious incidents in January 2012. This, in combination with the high number of incidents reported in the month that actually occurred in a previous month, explains why January‟s serious incident figures were above the typical monthly averages. 60 QUALITY 1.6 SUPPORTING INFORMATION 1.6.1 QUALITY ACHEIVEMENTS - Division of Specialised Services Bristol Haematology and Oncology Centre (BHOC) Acute Care The BHOC Acute Care unit opened on 1st February 2012. This is an acute assessment area for patients who are having systemic anti-cancer treatment at BHOC, and aims to prevent patients needing to attend the Emergency Department for urgent care. There is also a new 24-hour Triage Helpline which patients can call for advice, and professionals can also call this helpline to discuss a patient that they are concerned about. This service has already proven to be very successful and there has been fantastic feedback from our patients. The Advanced Nurse Practitioner who is leading this service will be carrying out an audit of the service after the three months, including identifying the number of avoided admissions. Peer Review. Internal validation has been completed for two new Cancer Peer Reviews. The Chemotherapy Service scored 91%, and the Teenage and Young Adult Cancer service scored 71%. Radiotherapy The radiotherapy department have achieved re-accreditation of their Quality Management System by the British Standards Institute. Division wide Quality indicators show consistent achievement of over 99% for VTE (Venous thrombo-embolism) risk assessments, 100% on MRSA (Meticilin Resistant Staphylococcus aureus) elective screening within the Specialised Services Division. Real-time ward monitoring This is where the admission, discharge and transfer of patients is tracked in real time. It ensures all hospital personnel know where our patients are at all times, improves access to our services for patients and allows us to connect relatives to their loved ones quickly and efficiently, thus reducing anxiety. The Division have been working hard to improve accuracy of data capture over recent weeks, culminating in achievement of 100% accuracy in the week preceding 14th March 2012. 61 QUALITY Patient Experience The Division continues to have a strong focus on patient experience, mean quarterly scores for Quarter 3 show that we are doing well in these areas, though we can and will do better. The metrics below reflect the Divisional breakdown of those in the main quality dashboard with the exception of “percentage of patients who said they would definitely or probably recommend us.” Mean Quarterly Divisional Score for Quarter 3 Specialised Services National Patient Experience CQUIN Score 80 Local CQUIN Score: Patients' saying noise at night from staff isn't a problem 88 Local CQUIN Score: Patients' given the help they need to eat meals 85 Percentage of patients who would "definitely" or "probably" recommend us 98 62 QUALITY 1.6.2 EXAMPLES OF LEARNING FROM COMPLAINTS Summary of complaint one On admission on a Saturday, a patient was given no choice of what he would like to eat but was instead given the lunch and dinner that had been ordered by the previous occupant of the bed he was in. The same thing happened the following day. Also, as he was in the last bed in the bay, he often just had to have whatever was left over from the catering trolley. The patient also requested decaffeinated coffee and was not only told this was not available but got the impression this was somehow a rare speciality that no one had ever requested before. Finally, there was no bedside TV available on the ward, despite the Trust website indicating that this service is available on all wards. Investigation The investigation found that: The patient was indeed given the previous occupant‟s menu choice for two and a half days before the situation was remedied. The Ward Sister would have expected Hotel Services‟ staff to ask each patient to complete their own menu choice. Staff were unaware that they could obtain decaffeinated coffee from the Bistro if requested by a patient. The Trust website does indicate that bedside services, including TV, are available on all wards in the Bristol Royal Infirmary. It is unlikely that these services will be extended to include wards where the service is not already available. Organisational Learning The Trust‟s Telecoms Manager has amended the Trust website to reflect the fact that not all wards in the Bristol Royal Infirmary have bedside services/TV. The Ward Sister has asked the Senior Catering Manager to look into whether decaffeinated tea and coffee can be provided routinely on wards. Departmental Learning Ward staff have been reminded that decaffeinated drinks can be obtained from the Bistro if they are requested by patients. An apology was given to the patient for the failure to provide him with his own choice from the menu. The Ward Sister reminded Hotel Services‟ staff of the correct procedure for obtaining menu choices from patients. Summary of complaint two Following an admission to the Bristol Royal Infirmary, a patient was discharged back to her supported sheltered housing, which is not registered to provide nursing care. Staff at the sheltered housing society were assured that the patient was able to walk with the aid of a frame and was able to wash 63 QUALITY and dress herself, but needed a soft diet. However, they found that the patient was doubly incontinent and required a high level of personal care. No drugs or supplements were provided on discharge, no care package was arranged and soiled incontinence pads were found in a bag containing the patient‟s clothing. Investigation The investigation found that: On admission, the patient was noted as using incontinence pads and pants due to urinary urgency and took laxatives for constipation. The patient changed her pad and pants by herself whilst on the ward. There was no change in her normal habits and therefore no necessity to refer her to a continence advisor during her admission. There was no indication of any symptoms of diarrhoea at any time whilst the patient was in hospital. The patient was reviewed more than once by the physiotherapists during her admission and it is noted that she was mobilising independently on the ward with the aid of a four wheel walker (which she stated she preferred to a zimmer frame) prior to discharge. A soiled incontinence pad was inadvertently put into the bag containing the patient‟s clothing. The patient was initially assisted with washing and dressing but progressed to supervision only and was independent with washing and dressing on the day she left the ward. It was therefore not considered that there was a need to refer the patient for a package of care. Nursing staff documented four attempts at contacting the sheltered housing society to check that they were happy for the patient to return. It is documented that there was some discussion with the nursing home to notify them that the patient was being discharged and required a soft diet. Support staff at the sheltered housing society had been informed of the patient‟s need for a soft diet, although the ward staff should have communicated with the sheltered housing society staff what the patient had eaten on the day of discharge and what else she may have needed. No food supplements were prescribed, recommended or required and therefore not recorded on the discharge summary. The medical advice was simply to eat small amounts of food on a regular basis to avoid further swallowing difficulties. Departmental Learning Although patients are not usually discharged with a large supply of incontinence pads when they were already using them prior to admission, apologies were given that we did not communicate more clearly with the patient‟s GP or District Nurse to ensure that sufficient supplies would be available. Ward staff have been advised of this omission in order to avoid a recurrence. Apologies were given that the sheltered housing society staff found a soiled incontinence pad amongst the patient‟s clothes. This is completely unacceptable. We have clear expectations for standards of infection prevention and control practice, which appear not to have been adhered to. All ward nursing staff have been informed of this unacceptable incident and reminded of the practice standards that we expect. The patient was independent before admission with washing and dressing and had assistance with a shower at her sheltered housing. It was assumed that the shower arrangements would be restored when the patient was discharged home. Apologies were given that this assumption was made and ward staff have been asked to check arrangements are in place for patients prior to discharge, even if they are returning to the pre- admission residence. 64 WORKFORCE 2.1 SUMMARY The Trust has selected a range of key workforce indicators. Targets for workforce costs and workforce numbers were achieved in February 2012. The indicators which are below target this month are sickness absence, bank and agency usage and appraisal. Achieving (2) Underachieving (0) - Workforce costs – compared with budget - Workforce numbers – compared with budget Failing (3) Not reported/scored (1) - Sickness absence - compared with target - Turnover (no target) - Bank and agency usage - compared with target - Appraisal compliance - compared with target 65 WORKFORCE 2.2 EXCEPTION REPORTS Exception reports are provided for the red-rated indicators, which in February 2012 were as follows: 1) Sickness absence – red rated against Divisional targets 2) Bank and agency usage - red rated against Divisional targets 3) Appraisal compliance – red rated against 80% Trust-wide target 66 WORKFORCE W1. EXCEPTION REPORT: Sickness compliance RESPONSIBLE DIRECTOR: Director of Workforce and Organisational Development Description of how the standard is measured: Sickness absence figures are shown as percentage of available FTE (full time equivalent) absent Performance in the period, including reasons for the exception: Absence has increased to 4.6% in February compared with 4.5% in the previous month, and a target of 3.6%. Trust Diagnostic Surgery Specialised Women & Services (exc Estates & UH Bristol & Medicine Head & Services Children Estates & Facilities Therapies Neck Facilities) Absence February 2011 4.4% 3.2% 5.2% 4.5% 4.1% 4.2% 4.8% 5.0% Target February 2012 3.6% 3.2% 3.7% 3.9% 2.9% 3.9% 3.6% 4.3% Absence February 2012 4.6% 2.9% 6.2% 4.2% 4.6% 4.0% 3.7% 6.8% Cumulative absence February 4.0% 2.5% 4.9% 3.6% 3.9% 4.2% 3.7% 5.3% 2012 The increase in sickness has been associated with short term rather than long term absence, with the greatest increase being in colds and influenza. Although norovirus has continued to be a problem, with at least 22 members of staff directly affected in Medicine and Women`s and Children`s Divisions alone, overall gastrointestinal related absence has reduced compared with last month. Recovery plan, including expected date performance will be restored: Continued management of long term sickness absence. Employee Services attending regular meetings with service leads to discuss approaches to sickness. The Trust-wide sickness project which is due to start in April 2012 is expected to have a major impact on sickness absence rates in 2012/13. Progress against recovery plan: See above. 67 WORKFORCE W2. EXCEPTION REPORT: Bank and Agency usage RESPONSIBLE DIRECTOR: Director of Workforce and Organisational Development Description of how the standard is measured: Bank and agency usage in Full Time Equivalent (FTE) compared with targets set by Divisions for 2011/12 Performance in the period, including reasons for the exception: Bank and agency usage for February 2012 is 22.7% above target. Usage increased by 52.1 FTE compared to January 2012. However, compared with the same period a year ago, every Division except Estates & Facilities have reduced their bank and agency usage. For Medicine and Women`s & Children`s Division, targets have not been achieved due to high sickness and maternity leave, high vacancy levels and 12 instances of wards closures within the Division of Medicine due to Norovirus in February. Bank and Agency (FTE) UH Bristol Diagnostic & Medicine Specialised Surgery Women‟s & Trust Services Estates & Therapies Services Head & Children‟s (exc Estates & Facilities Neck Facilities) Actual February 2011 444.2 22.6 123.8 51.7 94.6 74.4 53.8 23.3 Actual February 2012 370.6 20.8 109.5 30.5 74.9 67.2 22.4 45.3 Target February 2012 286.3 21.3 87.8 29.6 37.1 55.4 12.2 43.0 Recovery plan, including expected date performance will be restored: For Medicine, Specialised Services and Surgery Divisions, there has been a strategy to hold vacancies for staff displaced as a result of the nurse transformation programme, ward changes and closures. Detailed ward based workforce planning is now underway following the receipt of the preference forms completed by ward nursing staff, and the vacancies will be filled when the nurse transformation changes are implemented in May 2012. An outbreak of Norovirus at Callington Road increased the requirement for RMN (Registered Mental Health Nurse) cover within the Division of Medicine, which should be a short term issue. Bank and Agency Nursing continues to staff the additional capacity on Medical Wards 20 and 21. It is planned that this extra capacity will be closed by mid March and the Division reviews the bed situation daily. Progress against recovery plan: see above 68 WORKFORCE W3. EXCEPTION REPORT: Appraisal compliance RESPONSIBLE DIRECTOR: Director of Workforce and Organisational Development Description of how the standard is measured: Numbers of staff appraised annually – target 80% across the Trust Performance in the period, including reasons for the exception: Appraisal compliance has reduced from 80.3% in January 2012 to 77.5% in February 2012. All Divisions are below monthly target, except Surgery Head & Neck and Trust Services (excluding Estates & Facilities). UH Bristol Diagnostic Medicine Specialised Surgery Women‟s & Trust Services Estates & Appraisal compliance February & Services Head & Children‟s (exc Estates & Facilities 2012 Therapies Neck Facilities) excluding Junior Doctors 77.5% 69.7% 74.3% 77.2% 80.3% 78.1% 87.6% 76.4% Junior Doctors 92.9% 97.8% 95.5% 87.7% 91.8% 92.7% 100.0% n/a Target February 2012 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% The reduced appraisal compliance this month is part of a cyclical pattern reflecting the disproportionate numbers of appraisals which are due during January and February. This cycle is in part due to previous intensive exercises to increase compliance, which have taken place in January 2010 and January 2011. Recovery plan, including expected date performance will be restored: Action taken by Employee Services includes the following: Employee Services continues to send a list of all staff to cost centre managers each month showing when appraisals are due, and a report is provided for Divisions showing managers with consistently low responses Employee Services now has Division-facing staff with specific responsibility for highlighting poor performing areas to the Division and contacting non-compliant managers to offer support. In response to staff and managers requests, the appraisal paperwork has been simplified and made more relevant to staff. Hundreds of mangers have been briefed on using the new paperwork and setting objectives. In addition, all Divisional Business Partners have been asked to submit detailed recovery plans to the Director of Workforce and Organisational Development which detail the measures which will be taken in each Division, and the timescales for recovery. These measures will include meetings with Divisional Manager for those managers not achieving compliance amongst their staff, with particular focus on those managers with consistently 69 WORKFORCE low rates. These measures are expected to achieve 80% compliance in most Divisions by the end of March 2012. These plans are attached as supporting information. 70 WORKFORCE 2.3 SUPPORTING INFORMATION - Appraisal Recovery Action Plans 2.3.1 This section provides additional detail on plans to ensure the 80% appraisal compliance target is achieved. Medicine Division Issue Action Accountable By When All areas with low compliance On a monthly basis Performance and Operations Managers (POMs) and Matrons, Per On going are asked to produce an action matrons will be provided with a list of those areas that are non-compliant and and Ops plan to provide assurance that will be required to meet with the line managers as part of their regular one-to Managers appraisals are booked and take one meetings to discuss why their areas are non-compliant and support them in (POMS) place. This approach has providing an action plan to achieve. Senior worked in some areas; however In the event that compliance is not achieved a meeting will then be arranged Managers there are some areas where there with the relevant manager and Divisional Manager (DM) to discuss the issues HR Business has been little or no and reasons behind the non-compliance. Partners improvement over recent (HRBPS) months. The electronic appraisal This is continually reviewed by the Division and is being reviewed again by all DDMs and 16th March 2012 spreadsheet is not sent to the the senior management team. HON, HRBP correct line manager in all cases. 12 departments have been Any line managers that have consistently failed to achieve appraisal compliance HRBP, DM Invitations to be identified that are consistently are required to meet with the DM to account for their low compliance. sent 19th March under performing on appraisal 2012 compliance. The Sleep Unit‟s compliance has Update and improvements plan to be provided to Medicine Division Senior Nicki Jewell 19th March 2012 remained consistently low and Management Team. HRBP, DM the Department‟s performance across several management indicators has been highlighted as a concern to the Division 71 WORKFORCE Specialised Services Division With the actions identified below, it is anticipated that appraisal performance will be restored by the end of March 2012 Issue Action Accountable By When Accountability of Service Leads to Divisional Manager to send reminder communication to all service leads Divisional 16th March ensure appraisals are conducted on Manager, 2012 an annual basis and records are Service Leads kept of staff appraisal dates Non-compliance of staff in certain Targeted communication from HR Business Partner giving individual HR Business Completed on areas breakdown of areas where compliance is below 80%. Partner 8th March 2012 Non-return of weekly appraisal e- Employee Services team supporting areas that have difficulty completing the HR Business Ongoing forms form to ensure they understand the process. HR Business Partner Partner communicating with serial non-responders to ensure they understand their responsibilities. Clarity around sanctions for Divisional Manager to meet with all service leads whose appraisal Divisional 31st March 2012 continued non-compliance compliance remains below 80% at the end of March 2012. Manager, Service Leads 72 WORKFORCE Diagnostics & Therapies Division Each Head of Service whose compliance is below 80% has been sent the detailed list of non-compliant staff and has been asked to submit an action plan showing when appraisals have been booked for these members of staff. Meetings to discuss the action plans are being arranged with the Divisional Manager and HRBP. We expect to show an improvement next month to 73-75% and reach 80% by the end of April 2012. Details by each Head of Service are provided below. Issue Action Accountable By When Extended stroke discharge Present action plan to Divisional Manager including date that 80% compliance Jayne Weare 30th March compliance 70% will be reached 2012 Physiotherapy compliance Present action plan to Divisional Manager including date that 80% compliance Sarah Brown 30th March 78.57% will be reached 2012 Linda Clarke Cate Mitchell Julie Packman Lab Med compliance 62.5% Separate Infection Control from Lab Med figures Employee Done Services Jo Infection Control to liaise with Employee Services to ensure the correct Davies/ Joe 30th March compliance is being calculated for Infection Control. Bennett 2012 Liaise with Employee Services to ensure the correct compliance is being Liz Worsam/ 30th Apr 2012 calculated for Haematology Joe Bennett Present action plan to Divisional Manager Mark Orrell/ 30th March Liz Worsam 2012 Mark Orrell/ Achieve min 80% compliance 30th Apr 2012 Liz Worsam Radiology compliance 75.6% Present action plan to Divisional Manager Sheena MacDonald Achieve min 80% compliance 73 WORKFORCE Pharmacy compliance 57% Present action plan to Divisional Manager Steve Brown 30th March 12 31 May 2012 Achieve min 80% compliance Division-wide services Action plan to achieve min 80% compliance Lisa Galvani Done compliance 70% Achieve min 80% compliance 30th March 2012 Audiology Compliance 31.25% Present action plan to Divisional Manager including date that 80% compliance Pat Smith 30th March will be reached 2012 Occupational Therapy compliance Present action plan to Divisional Manager including date that 80% compliance Scott Allan 30th March 34.78% will be reached 2012 Neurophysiology compliance Present action plan to Divisional Manager including date that 80% compliance Philip 30th March 22.22% will be reached Blackwell 2012 Radiology compliance 75.6% Present action plan to Divisional Manager Sheena 30th March 12 MacDonald Sheena 30th April 12 Achieve min 80% compliance MacDonald 30th April 12 Paul Davison 74 WORKFORCE Women’s & Children’s Division Issue Action Accountable By When All Wards/Departments with All Wards/Departments failing 80% compliance will be required to meet with Ward/ End of each compliance below 80% to the Divisional Manager to discuss issues and provide assurance that required Department month produce an action plan to provide compliance will be achieved by following month. Managers assurance that appraisals are booked and take place. HR BP to provide information HRBP Midwifery Workforce (very low Divisional Manager meeting with Head of Midwifery to discuss issue and gain Head of 31st March 2012 compliance) assurance that Midwifery will achieve 80% compliance (issue has been Midwifery/ exacerbated by requirement for all midwives to attend a whole day of Medway Matrons Training) by 30th April 2012 NICU (consistently low Divisional Manager to meet with Head of Nursing/Matron to discuss issues Head of 31st March 2012 compliance) and gain assurance that NICU workforce will achieve 80% compliance by 30th Nursing/ April 2012 Matron Administration Services, St Divisional Manager to meet with DDM/Admin Manager to discuss issues and DDM/Admin 31st March 2012 Michael‟s Hospital (consistently gain assurance that workforce will achieve 80% compliance (Admin Manager Manager low compliance) has been on long term sick but is now back) by 30.4.12 75 WORKFORCE Surgery Head & Neck Division Issue Action Accountable By When Continued Non-response and low Highlighted 10 departments required to submit recovery plan within set period Mike Nevin 2 weeks compliance and Sarah Nadin No consistent challenge or Transformational Leadership Programme project of having a set template and Lisa Balmforth End of April accountability in one to ones agenda where workforce areas of accountability are challenged and supported (appraisals/sickness/essential training etc) at monthly one to ones for Band 7s and above Estates & Facilities Division Issue Action Accountable By When Significant reduction in A number of reviews have been diarised in the weeks beginning 19/3 and General End March 2012 compliance rate onwards, and therefore it is anticipated that by 28/3, the compliance rate in Manager Facilities will be 85.7%. Estates has already achieved a compliance rate of Facilities 91%. 76 WORKFORCE 2.3.1 Summary This report provides an outline of the Trust‟s position against key workforce standards for the month of February 2012 and year to date performance for 2011/12. Workforce Costs (£) Workforce Numbers (FTE) £'000 Actual Budgeted Costs (£) Actual Workforce Costs (£) Total Budgeted Posts (FTE) Total in Post inc Agency and Bank FTE £26,000 Total Employed (FTE) 7,500 £25,000 7,300 7,100 £24,000 6,900 £23,000 6,700 £22,000 6,500 Sickness % Appraisal % Target Actual Target 80% across the trust Completed 5.5% 100% 5.0% 95% 90% 4.5% 85% 4.0% 80% 3.5% 75% 3.0% 70% 2.5% 65% 2.0% 60% 77 WORKFORCE 2.3.2 Changes in the period Performance is monitored against workforce costs, workforce numbers, bank and agency usage, turnover, sickness and appraisal numbers. Indicators on a rolling reporting programme are: Statutory and mandatory training (April 2012), European Working Time Directive (EWTD) (June 2012) The following dashboard shows key workforce information indicators RAG (Red, Amber, Green) rated. Red rated indicators are outside tolerance limits and exception reports are provided for these. Indicator RAG Rating1 Commentary Notes Workforce Workforce costs reduced by 0.1%, budgeted workforce costs also reduced by 0.2% in See summary Costs G February 2012. February‟s costs remained static at 0.4% above the budgeted workforce costs, compared with January 2012. Workforce Workforce numbers reduced by 0.5% compared with January 2012, 3.4% below the See summary Numbers G budgeted workforce numbers. This compares with January 2012, when workforce numbers were 2.8% below budget. Turnover Rolling voluntary turnover increased by 0.2% to 9.6%. See summary Sickness Sickness increased by 0.1 percentage points compared with January 2012 across the See exception report and R Trust, 1.0 percentage points above the monthly target for 2011/12. summary Bank/Agency Bank and agency increased by 52.1 fte and the target reduced by 34.7 fte, compared with See exception report R January 2012. Bank and agency was 22.7% above monthly target for 2011/12. Appraisal Appraisal rates reduced by 2.8 percentage points to 77.5% compared with January 2012. See exception report, R summary and supporting information Note: RAG (Red, Amber, Green) rating reflects whether the indicator has achieved the target. The direction of the arrow shows the change from last month. The colour of the arrow reflects whether actual this month is better in relation to the target (green) or further from the target than last month (red). Please note that sickness targets are set by Divisions. 78 WORKFORCE 2.3.3 Monthly forecast and overview Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Feb 12 Measure 11 11 11 11 11 11 11 11 11 11 11 12 12 Planned Budgeted Posts (FTE) 7196.9 7211.5 7090.1 7140.7 7189.1 7374.1 7379.3 7401.1 7378.4 7351.1 7376.8 7365.3 7368.1 7265.9 Total Employed (FTE) 6951.8 6945.2 6895.7 6932.5 6940.7 6993.0 6898.2 6866.1 6944.8 6919.5 6903.1 6845.5 6757.9 6862.0 Sickness Rate (%) 4.4% 4.3% 3.6% 3.7% 3.8% 3.7% 3.7% 3.9% 3.9% 4.5% 4.5% 4.5% 4.6% 3.6% Bank (FTE) Admin & 80.1 89.1 73.6 73.0 77.8 79.2 80.9 78.7 64.4 63.6 52.3 54.4 62.7 65.4 Clerical Bank (FTE) Ancillary Staff 20.6 25.5 20.3 20.5 19.1 17.4 12.8 16.1 11.4 11.7 12.7 12.6 14.3 18.4 Bank (FTE) Nursing & 214.8 232.4 231.5 233.1 230.8 239.7 193.9 220.7 178.7 178.1 175.3 169.6 191.2 137.3 Midwifery Agency (FTE) Admin & 6.8 9.4 7.0 4.3 3.2 2.6 3.4 5.5 3.5 2.9 2.1 3.0 0.2 3.6 Clerical Agency (FTE) Ancillary 32.1 35.2 31.1 34.7 34.3 18.1 34.1 37.7 30.6 33.5 31.0 33.1 31.4 23.5 Staff Agency (FTE) Nursing & 6.9 10.0 17.5 12.3 7.4 8.4 8.2 11.7 13.5 13.8 12.0 21.1 46.5 5.2 Midwifery Overtime 66.0 72.1 62.2 62.2 78.8 61.5 40.4 65.3 62.7 81.1 64.9 72.2 76.6 69.2 Appraisal (%) excluding 81.1% 82.3% 82.6% 80.8% 80.3% 78.8% 80.8% 80.3% 81.8% 83.0% 83.3% 80.3% 77.5% 80.0% Junior Doctors Appraisal (%) Junior Doctors 80.3% 88.3% 93.5% 94.5% 97.4% 94.5% 92.9% 80.0% Rolling Average Turnover 15.3% 15.4% 15.0% 14.9% 15.0% 14.8% 14.4% 15.2% 15.1% 15.3% 15.7% 16.4% 16.0% (%) Rolling Average Voluntary 9.2% 9.3% 9.1% 9.0% 9.0% 8.6% 8.6% 8.8% 8.8% 9.1% 9.3% 9.4% 9.6% Turnover (%) Vacancy Rate (%) 3.4% 3.7% 2.7% 2.9% 3.5% 5.2% 6.5% 7.2% 5.9% 5.9% 6.4% 7.1% 8.3% Notes „Turnover‟ measures the number of leavers expressed as a percentage of the average number of staff in post in the defined period. „Vacancy‟ measures the number of vacant posts as a percentage of the budgeted establishment. The Sickness Rate is expressed as a percentage of total whole time equivalent (FTE) staff in post 79 ACCESS STANDARDS 3.1 SUMMARY The following section provides a summary of the Trust‟s performance against key national access standards at the end of February 2012. It shows those standards not being achieved either in the current quarter (i.e. quarter 4), and/or the year to date. The standards include those used in Monitor‟s Compliance Framework, as well as key standards included within the NHS Operating Framework and NHS Constitution. Achieving (14) Underachieving (0) - 31-day diagnosis to treatment cancer standard - first - 31-day diagnosis to treatment cancer standard – subsequent surgery, drug & radiotherapy - 62-day referral to treatment cancer standard – GP & Screening referred - 2-week wait urgent GP referral cancer standard - Symptomatic breast patients (cancer not initially suspected) 2-week wait - Referral to Treatment Time for admitted patients (95th percentile) - Referral to Treatment Time for non-admitted patients (95th percentile) - Genito-Urinary Medicine (GUM) 48-hour access - A&E Left without being seen rate - A&E Unplanned re-attendance - A&E Time to Treatment - Access to healthcare for patients with learning disabilities Failing (6) Not reported/scored (0) - A&E Maximum waiting time (4-hours) - A&E Time to Initial Assessment (ambulance arrivals) (95th percentile) - Reperfusion times (call to balloon time of 150 minutes) - Infant health – breastfeeding rate - Last-minute cancelled operations - 28-day readmission – a date for re-admission within 28 days of cancellation Please note: the position shown above for the cancer standards includes the draft performance figures for February. Performance for these standards is reported by all trusts in the country two months in arrears. Indicators are shown as being failed where both the year-to-date and quarterly performance is below the required standard. The Rapid Access Chest Pain Clinic standard, and the Infant Health: mothers not smoking, are no longer being reported nationally, and have been removed from the above report. 80 ACCESS STANDARDS 3.2 ACCESS DASHBOARD Access Standards - dashboard Thresholds 2010/11 2011/12 Month Quarterly Performance 2011/12 Target Green Red to date To Date Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Q1 Q2 Q3 Q4 Cancer - Urgent Referrals Seen In Under 2 Weeks 93% 88% 95.4% 95.6% 96.8% 96.9% 96.0% 95.4% 94.6% 95.4% 96.4% 93.4% 94.2% 96.7% 98.1% 93.9% 95.4% 95.1% 97.0% 93.9% Cancer - Symptomatic Breast (cancer not suspected) in Under 2 Weeks 93% 88% 91.9% 98.2% 100.0% 100.0% 100.0% 98.1% 98.6% 97.7% 97.0% 100.0% 93.6% 95.3% 97.7% 100.0% 99.0% 98.1% 96.8% 100.0% Cancer - 31 Day Diagnosis To Treatment (First Treatments) 96% 93% 98.2% 98.0% 97.8% 98.0% 97.3% 96.8% 96.7% 97.2% 99.1% 99.1% 98.1% 97.5% 98.1% 99.0% 97.1% 98.5% 97.9% 99.0% Cancer - 31 Day Diagnosis To Treatment (Subsequent - Drug) 98% 93% 99.8% 99.8% 100.0% 100.0% 99.1% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.2% 99.7% 100.0% 100.0% 99.2% Cancer Cancer - 31 Day Diagnosis To Treatment (Subsequent - Surgery) 94% 89% 95.4% 96.5% 93.0% 98.0% 98.2% 100.0% 96.8% 97.8% 94.0% 98.3% 93.6% 94.5% 100.0% 93.1% 98.2% 96.5% 96.0% 93.1% Not arrears Cancer - 31 Day Diagnosis To Treatment (Subsequent - Radiotherapy) 94% 89% 99.5% 100.0% 99.5% 100.0% 99.4% 100.0% 99.4% 100.0% 98.9% 99.0% 99.5% 100.0% 99.5% 99.8% 99.4% 99.5% 99.5% applicable Cancer 62 Day Referral To Treatment (Urgent GP Referral) 85% 80% 85.5% 87.0% 85.7% 91.2% 88.1% 85.7% 82.7% 85.4% 85.1% 87.7% 88.1% 88.2% 89.3% 90.4% 85.1% 86.2% 88.4% 90.4% Cancer 62 Day Referral To Treatment (Screenings) 90% 85% 93.2% 93.9% 70.8% 87.5% 96.8% 100.0% 95.3% 85.3% 86.1% 95.2% 88.1% 100.0% 100.0% 95.8% 97.1% 89.3% 95.3% 95.8% Not Not Cancer in months standards report two Cancer 62 Day Referral To Treatment (Upgrades) published published 95.5% 94.2% 100.0% 100.0% 100.0% 100.0% 88.9% 92.6% 100.0% 94.9% 94.4% 94.7% 87.0% 91.9% 96.2% 95.2% 91.7% 91.9% Referral To Treatment Admitted Under 18 Weeks 90% 80% 93.2% 91.7% 92.7% 91.5% 93.0% 92.4% 92.7% 91.8% 91.3% 91.9% 91.2% 91.2% 90.6% 91.8% 91.4% 92.7% 91.7% 91.0% 91.6% Referral to Referral To Treatment Non Admitted Under 18 Weeks 95% 85% 98.4% 97.9% 98.0% 98.0% 98.1% 98.7% 98.4% 98.0% 97.6% 97.7% 97.8% 97.2% 98.0% 97.6% 97.6% 98.4% 97.7% 97.6% 97.6% Not Standard not in Treatment Referral to treatment time admitted patients (95th percentile - weeks) 23 23 applicable 22.0 effect 21.3 21.6 20.6 21.7 21.9 21.9 22.6 23.0 22.7 22.1 22.4 21.1 21.9 22.9 22.2 Not Standard not in Referral to treatment time non-admitted patients (95th percentile - weeks) 18.3 18.3 applicable 14.9 effect 13.6 13.7 14.0 15.0 15.1 15.3 15.6 16.3 14.3 16.0 16.0 13.9 15.1 15.4 16.0 A&E Total time in A&E 4 hours - without Walk in Centre attendances 95% 95% 95.1% 96.3% 90.8% 94.2% 97.0% 98.8% 98.4% 97.7% 98.1% 97.1% 95.4% 97.1% 94.5% 94.1% 91.5% 98.0% 97.6% 95.6% 92.8% Not Standard not in A&E A&E Time to initial assessment (95th percentile) - in minutes 15 15 14 85 53 15 15 12 13 14 12 13 12 48 55 13 13 19 applicable effect Clinical Not Standard not in A&E Time to treatment decision (median) - in minutes 60 60 19 24 20 20 18 15 18 19 17 21 19 24 20 17 19 21 Quality applicable effect Not Standard not in Indicators A&E Unplanned reattendance rate (within 7 days) 5% 5% 1.7% 2.1% 1.6% 1.1% 1.1% 1.8% 1.9% 2.0% 1.9% 1.8% 1.8% 1.5% 1.6% 1.6% 1.9% 1.6% applicable effect Not Standard not in A&E Left without being seen 5% 5% 1.0% 1.6% 0.8% 0.8% 0.9% 0.9% 1.1% 1.3% 0.6% 0.9% 0.8% 1.1% 1.1% 1.0% 0.9% 0.9% applicable effect Last Minute Cancelled Operations 0.80% 1.50% 1.27% 0.88% 1.44% 1.69% 0.97% 0.92% 1.01% 1.13% 0.89% 0.31% 0.90% 0.89% 0.85% 0.88% 0.96% 0.97% 0.77% 0.88% 0.92% 28 Day Readmissions 95% 85% 91.8% 93.9% 91.1% 82.9% 94.1% 91.5% 95.8% 93.0% 93.2% 96.1% 100.0% 92.0% 93.9% 95.2% 92.0% 93.9% 94.0% 94.0% 93.5% Other key access GUM Offer Of Appointment Within 48 Hours 98% 95% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% standards Not Primary PCI - 150 Minutes Call To Balloon Time (direct admissions only) 90% 70% 83.7% 75.0% 88.0% 94.1% 80.0% 81.8% 78.4% 85.2% 97.1% 85.7% 77.3% 70.4% 86.1% 85.2% 86.9% 81.4% 86.1% applicable Infant Health - Mothers Initiating Breastfeeding 76.3% 76.3% 76.2% 76.2% 75.1% 77.1% 72.3% 74.7% 78.4% 77.0% 78.1% 73.8% 78.2% 77.1% 76.5% 77.3% 74.7% 75.1% 76.2% 77.3% 76.0% Please note: Where the threshold for achieving the standard has changed between years, the latest threshold for 2011/12 has been applied in the Red, Amber, Green ratings The Rapid Access Chest Pain standard and the Infant Health: mothers not smoking have now been withdrawn from national The standard for Primary PCI 150 Call to Balloon Time now only applies to direct admissions - threshold to be confirmed The Last-minute canccled operations figures for May and June has been amedned, following late corrections to the data. All CANCER STANDARDS are reported nationally two months in arrears. Monthly figures are indicative, until they are finalised at the end of the quarter. 81 ACCESS STANDARDS 3.3 CHANGES IN THE PERIOD Performance against the following national standards changed significantly compared with the last reported period: 31-day Subsequent surgery (down from 100% in December to 93.1% in January) – although achieving for quarter 4 as a whole A&E Maximum wait (4 hours) (down from 94.1% in January to 91.5% in February) A&E Time to Initial Assessment (95th centile) (up from 12 minutes in January to 48 minutes in February) 28-day readmission following a last-minute cancellation (down from 95.2% in January to 92.0% in February) Infant Health – Mothers initiating breast feeding (down from 77.3% in January to 74.7% in February) Please note the above performance figures only show the final reported position and do not include the draft February performance for the cancer standards. 3.4 EXCEPTION REPORTS Exception reports are provided for the six (6) RED rated performance indicators. 1) Last-minute cancelled operations + 28-day readmission 2) Reperfusion times (call to balloon time of 150 minutes) 3) A&E Maximum wait (4 hours) + A&E Time to Initial Assessment 4) Infant Health – Mothers initiating breast feeding 82 ACCESS STANDARDS A1. EXCEPTION REPORT: Last-minute cancelled RESPONSIBLE DIRECTOR: Chief Operating Officer operations / 28-day re-admission Description of how the target is measured: 1) The number of patients whose operation was cancelled at last minute for non clinical reasons, as a percentage of all admissions. 2) The number of patients re-booked within 28 days of a last-minute cancellation, as a percentage of all last-minute cancellations This standard remains part of the NHS Constitution. Monitor measurement period: Not applicable Performance during the period, including reasons for exception: There were 53 last-minute cancellations of surgery in February (0.96% of operations) which is just above the national standard of 0.8%. The main reasons for cancellations in the month were as follows: – 26% of cancellations (14 cancellations) were due to an emergency patient being prioritised on the day – 17% (9 cancellations) were due to no critical care bed being available – 13% (7 cancellations) were due to another clinically complicated patient being in theatre, taking longer than expected Of the 53 cancellations, 10 were day-cases and 43 were inpatients (19% day cases). On average, seventy percent of the Trust admissions in a month are day-cases. The higher rate of inpatient cancellations reflects the high cancellation rate due to emergency patients, the lack of a critical care beds and/or the clinical complexity of other cases in theatre, all of which are more likely to impact inpatient than day-case procedures. Although there was an outbreak of norovirus in the month, the lack of availability of a bed on a ward only accounted for 9% of cancellations during the period. 92.0% of patients were re-admitted within 28 days of the cancellation of surgery at last-minute in February, which was below the 95% national standard. Four patients were not re-booked within 28 days. One was a paediatric cardiac surgery case that needed two particular surgeons to undertake the procedure. The operation could not be re-scheduled within 28 days due to their availability. The three other cases (vascular, paediatric cardiology and gynaecology) could not be operated on within 28 days due to other patients needing to take priority. Recovery plan, including expected date performance will be restored: The following actions continue to be taken to reduce last-minute cancellations and achieve the 0.8% standard (please note: actions completed in previous months have been removed from the following list): Continued focus on making sure theatre lists are appropriately booked, to minimise cancellations due to session over-runs and lack of time to commence operations Weekly reviews of future week‟s operating lists, to ensure the demand for critical care beds is spread as evenly as possible across the week; 83 ACCESS STANDARDS daily reviews of current demand for critical care beds, and flexible critical care bed-usage across Divisions to minimise cancellations The avoidance of last-minute cancellation remains a key priority of the Productive Operating Theatres Programme; Phase 2 of the programme includes actions to improve the scheduling of theatre lists, finalising theatre lists the day before and establishing the process for escalating any theatre list changes Implementation of the Optimising Use of Beds work-steam will continue – with the aim of balancing bed capacity and demand for beds Planning for the closure of beds ahead of the transfer of services to South Bristol Community Hospital (SBCH) (end March) Operational plan for bed/admission management during the transition to the new Patient Administration (PAS) planned for the mid April (recently revised from March); and for the bank holiday periods (end March) Last-minute cancelled operations action plan to be refreshed focusing on the primary causes of last-minute cancellations during the last quarter (end April) Progress against the recovery plan: In August NHS Bristol formally raised concerns regarding the levels of last-minute cancelled operations. The Primary Care Trust (PCT) was provided with the recovery plan. Performance since the start of the implementation of the recovery plan has been within the trajectory agreed with the PCT. Despite the outbreak of norovirus in the month, February‟s performance (at 0.96%) was similar to the 0.97% forecast and significantly better than last year‟s performance in February 2011 of 1.44%. The Trust is currently above the target trajectory agreed with the PCT of meeting the 0.8% national standard in March, but continues to work towards achieving this. 84 ACCESS STANDARDS A2. EXCEPTION REPORT: Reperfusion (call to balloon RESPONSIBLE DIRECTOR: Chief Operating Officer times) within 150 minutes (direct admissions only) Description of how the target is measured: The number of patients receiving primary percutaneous cardiac interventions (PPCI) where the commencement of treatment (balloon inflation) happened within 150 minutes of the call for professional help. The standard is for Call to Balloon times to be within 150 minutes for at least 90% of patients. To support achievement of Call to Balloon times there is also a local target for Door (arrival in hospital) to Balloon times of 50 minutes. The standards apply for direct admissions to the Bristol Heart Institute only. Monitor measurement period: Not applicable Performance during the period, including reasons for exception: During January 86.1% of patients had a Call to Balloon time of less than 150 minutes, with the standard not being met in 5 cases. This represents a significant improvement on the previous month when 70.4% of patients were treated within 150 minutes. Year to date performance is 83.7% against the 90% standard. There have been 59 breaches of the Call to Balloon 150 minute standard for the year to date, of these: 41 (69%) happened overnight or at weekends (i.e. out-of-hours) 51 had a Door to Balloon times of over 50 minutes (30 were also over the 90 minute national standard) Analysis carried-out at the end of December showed that the specific reasons for the failure to carry-out the procedure within the 150 minutes were as follows: 42% resulted from delays due to another patient already being in the lab and having the procedure 16% were due to the ambulance ECG (Electrocardiograph) not being diagnostic, and this having to be repeated 16% having a long ambulance conveyance 13% due to the patient having a cardiac arrest and the procedure not being able to be carried-out for clinical reasons 9% clinically complex case 4% other reasons This detailed analysis suggests that the primary reason for a delay in the procedure being carried-out is that another patient is already being treated in the Catheter Laboratory (42% of breaches). Clinical exceptions (cardiac arrest and/or clinical complexity) account for a further 22% of breaches, and were therefore outside of the control of the service. 85 ACCESS STANDARDS Recovery plan, including expected date performance will be restored The following actions are being taken to improve Call to Balloon times (please note: actions completed in previous months have been removed from the following list): A review is going to be undertaken to assess whether a second on-call team is needed to enable the 150 minute standard to be consistently met. The review will consider the latest figures on the reasons patients are not treated within 150 minutes, how the Bristol Heart Institute‟s on-call rota can be maintained whilst meeting the 150 minute standard, what impact the service has on the Coronary Care Unit and general Intensive Therapy Unit (ITU) and following a recent meeting with Great Western Ambulance Service (GWAS), what improvements can be made by working more closely with the ambulance service on care protocols. The review will be discussed with the Executive Team at the quarterly review in April. Benchmarking data will be sourced from the national audit data-set, to identify high performing trusts and how UH Bristol performs relative to the national picture Clinical team will meet with Great Western Ambulance Service (GWAS) to discuss ambulance ECG issues and conveyance times, with a view to understanding what further contribution the Bristol Heart Institute (BHI) can make to Call to Balloon performance (Action complete) Further analysis will be undertaken to review the timings for patients who are delayed due to another patient being in the lab. This will help to identify whether there are significant benefits associated with having a second on-call team, and what alternative options exist for reducing delays for this category of patients (Action complete). Progress against recovery plan: Performance in January (86.1%) was the highest it‟s been since September 2011. The Trust is currently achieving 83.7% against the 90% standard year to date. 86 ACCESS STANDARDS A3. EXCEPTION REPORT: A&E maximum wait 4 hours + RESPONSIBLE DIRECTOR: Chief Operating Officer A&E Time to Initial Assessment – 15 minutes (95th centile) Description of how the target is measured: A&E maximum wait 4 hours The number of patients admitted, discharged or transferred within 4 hours of arrival in the Trust‟s Bristol Royal Infirmary (BRI), Bristol Children‟s Hospital and Bristol Eye Hospitals, as a percentage of all patients seen. The local Walk in Centre attendances are no longer included in the performance figures. Monitor measurement period: Quarterly A&E Time to Initial Assessment – 15 minutes (95th centile) The time of arrival in the department through to initial assessment of the patient‟s condition. The assessment will involve both pain scoring and other physiological assessments. The 15 minute target for initial assessments only applies to ambulance arrivals. Monitor measurement period: Not applicable – this is a quality standards trusts are working to achieve Performance during the period, including reasons for exceptions: Performance in February was 91.5%, and well below 95%. Unlike January it was below the expected trajectory for the quarter. The primary cause of breaches of the 4-hour standard remained the wait for a bed. Although overall, the emergency length of stay for the total spell in the Trust has fallen, the length of stays for emergency medical patients in the BRI has gone up. As reported last month, the length of stay for medical patients in the BRI increased from 5.2 days in December to 6.4 days in January (this figure excludes zero lengths of stay). Length of stay increased again in February to 7.2 days. The increase in length of stay remains most evident in patients with stays of over 3 weeks. But the number of short stays also decreased significantly, as many patients had to bypass the Medical Assessment Unit and go straight into inpatient beds. This further compromised length of stay. Overall, the lengthening stays accounted for an additional 700 bed-days in February, relative to January. Despite significant efforts to eliminate delays to discharge for the more complex patients, delayed discharges increased during January and remained high in February (i.e. medically fit patients whose discharge is delayed due to other reasons, such as awaiting a place in a residential home). Analysis recently undertaken shows that the percentage of patients attending the BRI Emergency Department (ED) that needed to be admitted, was much higher than previous months. Patients attending the BRI ED during December and January also had significantly more tests requested than in any previous month in the past three years. This could be due to patients spending more time in the ED, due to beds not being available, and hence tests that would have been carried-out on the Medical Assessment Unit were instead requested by the ED team. But it also supports the suggestion that a sicker group of patients being admitted during December/January, resulting in longer stays and a worsening of bed availability. The backlog of patients being cared for in the BRI Emergency Department had a direct impact on the ability to receive ambulance arrivals and maintain timely initial 87 ACCESS STANDARDS assessments. Performance against the 4-hour standard improved towards the end of February, when wards previously closed due to norovirus were re-opened following a deep clean. However a further outbreak of norovirus occurred resulting in additional wards being closed. Recovery plan, including expected date performance will be restored: The following actions continue to be taken to ensure continued achievement of the 4-hour standard in quarter 4 (please note: actions completed in previous months have been removed from the following list): Four Medical Assessment Unit (MAU) and four Surgical and Trauma Assessment Unit (STAU) beds will aim to be made available by 10:00 each weekday (three at the weekends) to improve the flow of patients out of the ED early in the day and prevent a build-up of patients needing admissions (Action complete) – the process to support this of sending trolleys to wards as pre-emptive transfer has been piloted and learning from this is currently being implemented (Action complete) A fortnightly Professional Standards group will be established and chaired by the Head of Division for Medicine, to review examples of good and poor compliance with the previously agreed standards for specialist opinion in the BRI Emergency Department – professional standards drafted to be discussed at Strategic Trust Management Executive (TME) group at end of February (Action complete) Continued daily focus on the list of patients that are fit for discharge, whose discharge has been delayed for other reasons (e.g. waiting for placement in a residential home) - ongoing Consultant-led team established to focus on the management of outlying patients on a daily basis (those patients not on the correct specialty ward) (Action complete); this is a temporary team which varies each day, and is made-up of staff transferred from other responsibilities. An operational plan is being developed for the bank holiday and half-term in quarter 1, which will include ward staffing levels and other key resources for managing patient flow. Further analysis is being undertaken to understand the reasons why 4-hour performance in February was well below the expected trajectory. The output from this will be an operational planning tool that will model the impact of the size of the BRI bed-base, length of stay, and changes in levels of patient acuity. Along with this planning tool a monitoring report will be developed. This will alert the Divisions to potential changes in patient acuity and other key factors that put pressure on the BRI bed-base, to allow operational teams to manage potential changes in demand in a more pro-active way, especially during the winter. The above actions were reviewed and endorsed by both the Service Delivery Group and Trust Management Executive (TME) Group in January (Action complete), and were reviewed again by TME in February and March, to ensure whole-Trust buy-in to the plans (Action complete); further review by the TME to take place in April, in time for the Q1 prospective review and the annual assessment of risk for the Monitor Annual Plan. 88 ACCESS STANDARDS Progress against the recovery plan: The national 95% standard was achieved in quarter 3, despite the dip in performance in December. Quarter 4 has historically been the most challenging quarter for achievement of the national A&E 4-hour standard. The expected trajectory for quarter 4 2011/12 was based upon December‟s performance relative to that of previous years, and the pattern performance typically follows across this quarter. Although January‟s performance was above the expected trajectory for the quarter, performance in February has been well below the forecast trajectory. It is however clear that the improvements in performance seen in December 2011 have continued, with both January and February‟s performance being above the same period last year (January 2011 – 89.5%; January 2012 - 94.1%; February 2011 - 90.8%; February 2012 – 91.5%). Greater control over patient flow has also been exerted, with few medical outliers, cancellations of surgery and no unplanned use of the Queen‟s Day Unit (for inpatients), despite a smaller bed-base. Recent performance against the 4-hour standard has improved, and actions continue to be taken to try to achieve the 95% standard for March as a whole. This will also help to ensure the Trust is in the best possible position going into the first quarter of next year. The BRI‟s Time to Initial Assessment, which is directly related to how busy the Emergency Department is, is expected to improve along with the improvement in achievement of the 4-hour standard and bed-related patient flow. The analysis which is being undertaken to help us understand the reasons for the failure to achieve the 95% standard in quarter 4 will also help the operational planning for the winter of 2012/13. 89 ACCESS STANDARDS A4. EXCEPTION REPORT: Infant health: breast feeding rates RESPONSIBLE DIRECTOR: Chief Nurse Description of how the target is measured: The number of mothers breast feeding as a percentage of the total number of mothers that gave birth during the period. Home births are excluded in the figures. Monitor measurement period: Not applicable Performance during the period, including reasons for exception: Breastfeeding rates are just below last year‟s overall performance for the year to date, for reasons not well understood. The percentage of mothers breastfeeding has not improved over the last two years, and remains below the local stretch target set by the Primary Care Trust of 80%. However, it has been acknowledged that achievement of this standard largely relates to patients choice and so the Trust‟s ability to influence breast feeding rates is to a certain extent limited. Recovery plan, including expected date performance will be restored: Breast feeding rates continue to be reported to St Michael‟s staff each month to raise profile of breastfeeding rates and the importance of encouraging mothers to initiate breastfeeding wherever possible. Progress against recovery plan: The 76.3% standard was achieved in quarter 3 and in January 2012. Variation in monthly performance will continue to be monitored. 90 Cover Sheet for a Report for the Public Trust Board Meeting, to be held on 27 March 2012 at 10:30 in the Conference Room, Trust Headquarters, Marlborough Street, Bristol, BS1 3NU Item 06 – Histopathology Action Plan Update Purpose To brief the Board on progress in implementing the Trust’s Histopathology Action Plan. Abstract V25 of the Trust’s action plan in response to the Independent Inquiry into our Histopathology Services (December 2010) shows the most up to date progress in implementing actions. The vast majority of actions have been completed and the few that remain are aligned to the outcome of the Bristol Pathology Services Review and the development of an integrated Pathology Service for Bristol. Recommendations The Trust Board is asked to note the report. Executive Report Sponsor or Other Author Sponsor – The Chief Nurse, Alison Moon Author – Anne Reader, Assistant Director of Governance and Risk Management. Appendices • Appendix A – Histopathology Action Plan v25 91 Recommendations from Histopathology Inquiry – Action Plan Actions not yet fully complete Ref No Actions Timescale Responsible Progress Complete Evidence person Section 1 Overarching recommendation A: A single Histopathology Service should be established for Bristol with the potential to be one of the leading service and Section academic centres. Lead: Rob Pitcher 1.2 Develop Service Structure and Proposition for Rob Pitcher These issues are being considered as part of the Pending integrated cellular pathology service Pathology Services Review being led by NHS progress Bristol. Clinical Lead for Cellular Pathology is of the feeding into the review accordingly. Meanwhile, Patholog a governance structure has been put in place. y Services Revised Agreed sub-milestones: Review management structure/Job Integration of the management tier 31 Jan Rob Pitcher Partial integration has taken place as far as Complete Descriptions. beneath Clinical Lead 2012 possible pending the progress of the Pathology pending Services Review. The Head Biomedical Scientists progress have common Job Descriptions which are being of the agreed and single governance and decision Patholog making process has been agreed. y Services Review Common reporting template for each 31 Dec Rob Pitcher Minimum data set reporting has been agreed and Reporting speciality 2011 audit of this will be included in the 2012/13 template. Clinical Audit plan. V25 27/02/2012 1 92 Ref No Actions Timescale Responsible Progress Complete Evidence person Specialist and Agreement of specialist and team 31 Dec Rob Pitcher Specialist and team role profiles have been team role roles & profiles 2011 agreed with existing pathologists. profiles. Common KPI suite and associated 31 March Rob Pitcher The Royal College of Pathologists have put Not yet KPI suite. metrics agreed and in place 2012 together a set of KPI’s. Work is in progress to due. identify how to measure these. A number of lean projects are underway across both Trusts working NHS with NHS Improvement using turnaround times Improvement as one aspect of measurement. Report V25 27/02/2012 2 93 Completed Actions Ref No Actions Timescale Responsible Progress Complete Evidence person Section 1 Overarching recommendation A: A single Histopathology Service should be established for Bristol with the potential to be one of the leading service and Section academic centres. Lead: Rob Pitcher 1.1 Appoint Clinical Lead for Cellular Pathology 30 Jun 11 Jane Luker/ Complete. Job Chris Burton Clinical Lead in post as of 3 May 11. Description and staff in post. 1.3 Short term 31 Mar 11 Jane Luker/ Agreed and implemented where appropriate. Letter of Consultants should work across both sites Chris Burton expectation when necessary to provide the optimum Cross site working in place for haemato- sent to service to patients. malignancy, Head and Neck, Lung and Her 2 pathologists Breast pathology. by Acting Medical Further work underway to develop greater cross Director. site working in line with planned service reconfiguration. Honorary contracts in place. In pathologists’ HR files. V25 27/02/2012 3 94 Ref No Actions Timescale Responsible Progress Complete Evidence person 1.4 Put in place honorary contracts for cellular 31 Mar 11 Philippa Honorary contracts issued to pathologists to be Honorary pathologists with reciprocal trust. Finch/ Tracy signed and returned by 17 Jun 11. contracts in Smallwood place. In UH Bristol and NBT pathologists have all signed pathologists’ their honorary contracts. HR files. Letter from Acting Medical Director to pathologists March 2011. 1.5 All new cellular pathology appointments to be 31 Dec 10 Jane Luker/ Agreed. Appointment joint Chris Burton process March 11: Two new adult pathologists appointed documentatio on 50:50 contracts n i.e. Job Description and advert. Contracts for new staff. In pathologists’ HR files. 1.6 Clarify roles and responsibilities of Heads of 31 Dec 10 Robert Complete. Communications to relevant staff and Letters from Division, Lead Doctor and Specialty Lead Woolley revised job descriptions completed. This is CEO to Heads evidenced through Job Planning and appraisal. of Division. Lead Doctor Job Descriptions. V25 27/02/2012 4 95 Ref No Actions Timescale Responsible Progress Complete Evidence person Written confirmation from divisions. 1.7 Review consultant staffing levels in Review Rob Pitcher The review is complete. A paper has been Review paper. accordance with the Royal College of 31 Aug produced to include recommending an in depth Pathologists' "Guidelines on staffing and 11. Job Planning and skill mix exercise. workload for histopathology and cytopathology departments" (2nd edition) June 2005, and, if necessary, adjust to ensure they are sufficient for a safe, timely and reliable service. Further milestones: Complete comprehensive Job 30 Nov Rob Pitcher Complete. Process in place and job planning is Agreed Planning process for all Consultants 2011 completed. process. working in Cellular Pathology across both UHB and NBT. Complete skill mix exercise to 30 Nov Rob Pitcher Skill mix exercise is completed. Skill mix determine what work currently 2011 exercise performed by Consultants could be outcome. carried out by other staff. V25 27/02/2012 5 96 Ref No Actions Timescale Responsible Progress Complete Evidence person As above. Review outcome of the Job Planning 29 Feb Sean O’Kelly/ Review completed. Two additional and skill mix exercises and, if 2012 Chris Burton. Histopathology Consultant posts have been necessary, adjust staffing approved for the joint service (one by UH Bristol configuration to ensure sufficient and one by NBT). support for a safe, timely and reliable service. 1.8 Identify areas of urgent staffing need and 31 May Rob Pitcher Complete. Necessary measures in place to Specialist produce action plan 11 manage current workload, including outsourcing. working overview. 1.9 Identify short term and longer term location 31 Oct 11 Rob Pitcher The Inquiry recommended that the service plan for department. should for the time being remain on two sites. The longer term plan is subject to the outcome of Linked to the Pathology Services Review. 1.2. See actions for 1.2. 1.10 Develop process to ensure service changes are 31 Oct 11 Rob Pitcher The Bristol Cellular Pathology Forum described is Minutes of fully supported by Histopathology part of developing the wider team ethos and will meetings. include discussions with clinical teams on issues such as service reconfiguration, standards etc. Section 2 The MDTs in both Trusts should be reviewed to promote collaboration. Section Lead: Mark Callaway V25 27/02/2012 6 97 Ref No Actions Timescale Responsible Progress Complete Evidence person 2.1 Complete MDT reviews 31 May Mark UH Bristol MDT review for pathology completed. MDT review 11 Callaway/ report and Chris NBT review has been completed and a report meeting Burton/Rob received by their Board in June 2011. minutes. Pitcher 2.2 Agree a plan for on-going development of 31 July 11 Mark A joint UH Bristol and NBT meeting took place on Joint Report. joint MDT Callaway/ 16th June to agree a joint approach for MDT Chris development going forward. A joint report was Minutes of Burton/Rob produced by the end of July 2011. meetings SDG Pitcher 25/07/2011. Minutes of Cancer Board. 2.3 Ensure slides are available at MDTs. 30 Mar 11 Lis Kutt Complete. The MDT outcome records indicate June 2011 where a patient referred in from another Trust is spot check deferred to the next meeting if their slides are slide audit not yet available from the referring trust. report. MDT audit results. On-going results presented to SDG. V25 27/02/2012 7 98 Ref No Actions Timescale Responsible Progress Complete Evidence person 2.4 Agree and implement process to ensure 30 May Teresa Levy/ Cross Trust leaflet finalised and pilot completed Patient patients are aware that a diagnosis given pre 11 Dany Wells September 2011. Revised leaflet in place. Information MDT may be refined at the MDT meeting. Leaflet. Evaluation of pilot. Section 3 Quality Assurance Section Lead: Rob For information: The Royal College of Pathologists has published a set of Key Performance Indicators for pathology. Pitcher 3.1 Agree audit programme 2011/12 for 30 April Lis Kutt Complete and shared with NBT UH Bristol Histopathology 11 Clinical Audit 5 audits are planned, of which 3 are underway: Forward Plan 2011/12. An audit of the double reporting protocol (started January 2012) An audit of reporting systems (comprising turnaround time) to be reported at the end of March 2012. V25 27/02/2012 8 99 Ref No Actions Timescale Responsible Progress Complete Evidence person Review of supplementary reports after Joint multi-disciplinary team meeting Histopatholog (presented at department Clinical Audit y Audit meeting 23rd February 2012, to be Programme completed by end of March 2012) High grade serous carcinoma of endometrium-network audit (started August 2011, due to be completed by end of March 2012) Correlation of breast tumour grading between core biopsies and resection specimens in a screened population (started July 2011, due to be completed by end of March 2012) 3.2 Develop joint audit plan across both Trusts 30 June Rob Pitcher Complete. Joint 11 Histopatholog y Audit Plan. 3.3 Ensure current involvement in all appropriate 31 Mar 11 Lis Kutt UHB EQA involvement identified. All specialist EQA Matrix. EQAs and CPD to develop specialisation pathologists have an appropriate EQA programme. Relevant UH Bristol pathologists are registered for the regional lung EQA. V25 27/02/2012 9 100 Ref No Actions Timescale Responsible Progress Complete Evidence person 3.4 Develop full joint EQA and CPD programmes 31 Aug 11 Rob Pitcher The interviews with consultants demonstrated Updated EQA the current position on EQA. This information is Matrix. held within the consultants' appraisal folders and reviewed annually as part of their appraisal. The Bristol Cellular Pathology Service in its policy statement on the recognition of specialist roles in cellular pathology recognises the need for pathologists to partake in appropriate EQA schemes. This will be monitored on an annual basis Section 4 Upgrade Histopathology Department Section Lead: Lis Kutt 4.1 Upgrade work to be completed 31 Jul 11 Sven Complete. Site visit Howkins Works Project Plan. Section 5 Double Reporting Section Lead: Rob For information: There is a current Royal College of Pathologists document in existence about double-reporting. The College Histopathology Specialist Pitcher Advisory Committee is meeting in June 11 and will be asked to comment on whether further work is required. 5.1 Agree and implement a revised joint double 31 May Rob Pitcher Complete. Protocol has been finalised and Double reporting protocol 11 disseminated. Reporting Protocol. V25 27/02/2012 10 101 Ref No Actions Timescale Responsible Progress Complete Evidence person Section 6 Overarching Recommendation E: Raising Concerns about diagnostics Section Any concerns about the standard of pathology reporting should be thoroughly, rapidly and, where appropriate, independently investigated and the Lead: Rob results made available to all those involved. Pitcher Concerns should be dealt with at the lowest possible level and not escalated unnecessarily. The pathologist(s) involved should be consulted directly. 6.1 Agree and implement a revised raising 31 May Rob Pitcher Complete. Protocol has been finalised and Raising concerns protocol 11 disseminated. Concerns Protocol. Section 7. Overarching recommendation F: Whistleblowing Section The Department of Health should review advice on whistleblowing to ensure that local policies include clear guidance on raising concerns about the Lead work of a pathologist or any other clinician who works for a different Trust from the Trust employing the person raising the concern. Sarah Pinch 7.1 Strengthen UHB Whistleblowing policy 31 May Sarah Pinch Complete. Policy agreed and confidential staff Revised 11 helpline in place. policy. Evidence of advertising this to staff Robert Business rule for Executive Action Regarding Letter to Woolley Serious Concerns in place. Executive Directors V25 27/02/2012 11 102 Ref No Actions Timescale Responsible Progress Complete Evidence person Section 8 Overarching recommendation G: Media Relationships. Section Lead: Relationships with the media should be proactive with an emphasis on openness, honesty and the involvement of senior managers and clinicians Sarah Relationships with the media should reinforce positive relationships with patients. Service change should be explained including the Chief Executive Pinch 8.1 The Trust Board will approve the revised 30 June Sarah Pinch The Communications Strategy was approved by Revised communications strategy and plan in light of 11 the Board on 28 June 2011. Communicatio the report’s recommendations ns Strategy. Evidence in June 2011 Board papers and minutes. 8.2 The Trust’s media protocols will be revised in 31 Mar 11 Sarah Pinch Complete. Revised media protocols approved 13 Revised Media light of the report’s recommendations and will April 11. Protocols. include consultation with relevant staff Evidence in groups. The revised protocol will then be TEG papers reissued to all staff. The protocol will be and minutes included in the revised communications 13 April 2011. strategy. 8.3 The Trust’s website is currently being 30 June Sarah Pinch The new website was launched on 1st July 2011. New website. redeveloped and will deliver a more 11 responsive, interactive up-to-date tool for Trust communications, direct to patients, staff, FT members and the media. Section 9 Overarching recommendation H: Paediatric and Perinatal Pathology UHB Paediatric and perinatal pathology should be valued and supported by managers, pathologists and other clinicians. Section Lead: Lis The minimum level of staffing should be one paediatric pathologist, one perinatal pathologist and one pathologist trained in both paediatric and Kutt perinatal pathology. V25 27/02/2012 12 103 Ref No Actions Timescale Responsible Progress Complete Evidence person 9.1 Recruit and permanently appoint to proposed 31 Jul 11 Lis Kutt/ Rob Interviews held Feb 2011. No appointment made. Staff in post. staffing levels demonstrating full commitment Pitcher Further interviews were held 23 June 11 and an to the service offer has been made subject to references and Recruitment employment checks. Anticipated start date end update in of September. November 2011 minutes Interim outsourcing provision in place. of Bristol Cellular Pathology Forum 9.2 CEO to write to Southampton and Oxford to 31 Dec 10 Robert Complete. Letters seek opportunities for joint working in Woolley Positive responses received from Southampton between principle CEO and Oxford MD. Trusts. 9.3 Establish joint working arrangement 31 Jul 11 Sean O’Kelly UH Bristol Medical Director has met with the Operational Medical Directors from Southampton and Oxford Specification. to explore networking opportunities for paediatric pathologists. Agreement in made in principle, an operational specification is being drawn up. The first meeting took place in January 2012. Minutes of first network meeting. V25 27/02/2012 13 104 Ref No Actions Timescale Responsible Progress Complete Evidence person Section Overarching recommendation I: Patients and Histopathology 10 Section For information: The Royal College of Pathologists has an active programme to inform the public about histopathology. Next year is designated National Lead: Pathology Year. Alison Moon 10.1 Implement PPI strategy – Year 1 (Inpatient 31 Mar 11 Alison Moon Complete. Inpatient feedback mechanisms in Minutes and feedback systems) place and providing timely information on the papers of quality of patients’ experiences, the results of Patient which are being acted upon within the Trust. Experience Group and its predecessor. Six monthly PPI strategy update to the Board October 2011. In Board papers and minutes. 10.2 Implement PPI strategy – Year 2 31 Mar 12 Alison Moon Year 2 funding obtained. Minutes and (Expansion of Year 1 approach into papers of Outpatients – pending identification of Two major internal surveys of outpatients to Patient funding) complement the National Outpatients Survey are Experience taking place in 2011/12. Group and its predecessor. Comments Cards are being implemented in V25 27/02/2012 14 105 Ref No Actions Timescale Responsible Progress Complete Evidence person Outpatients Departments and plans for surveys Six monthly using hand held devices are currently under PPI strategy discussion. update to the Board October 2011. In addition, we have added questions about tests Outcome and results to our monthly in-patient survey, Reports of outpatient survey and bi-monthly ward based Surveys. surveys. The outcomes of which provide both assurances about our services and areas for patient led service improvements. 10.3 Devise and delivery four UH Bristol patient 30 Apr 11 Tony Watkin Complete. The report from the focus groups has Focus Group focus groups to explore current awareness \ Lis Kutt been finalised and has been shared with the Outcome and future involvement in the on-going Pathology Services Review. report. development of histopathology at UH Bristol 10.4 Develop proactive and constructive working DH Tony Watkin Bristol LINk is a national pathfinder for On-going Notes of relations with new ‘Local HealthWatch’, expects HealthWatch status and attended the Trust’s meeting. including its proposed responsibilities for HW to be Patient Experience Group in November 2011 to patient advocacy (detail has yet to be “up and present its plans. announced by the DH). running Minutes of by 2012” UH Bristol representation on Bristol LINks Acute LINks Acute Hospital Group to facilitate operational activity. Hospital A review of the 2011 work plan and planning Group session for the 2012 work plan took place with V25 27/02/2012 15 106 Ref No Actions Timescale Responsible Progress Complete Evidence person Bristol LINk on 2 February 2012. Third party comments UH Bristol workshop with Bristol and South from LINks on Gloucester LINks has taken place to inform UHB Quality 2010/11 Quality Account. Account. Robert Woolley has met with Chair of Bristol LINk to provide assurance of positive working relations. UH Bristol workshop with Bristol and South Agendas/ Gloucester LINks will take place to inform Flyers and 2011/12 Quality Account on May 9th 2012. meetings. UH Bristol participation in Bristol City Council Healthwatch planning meeting 6 February 2012 UH Bristol hosted LINKs/Healthwatch stakeholder event on 5 December 2012 UH Bristol participation in Bristol LINk scoping event for south Bristol NHS Community Hospital 16 January 2012 There are two new pieces of Patient and Public Survey Involvement work relating to histopathology: outcomes. 1. Interviewing patients in named UH Bristol V25 27/02/2012 16 107 Ref No Actions Timescale Responsible Progress Complete Evidence person outpatient clinics about their experiences of “What having tests and receiving results. This will Patients commence in Spring 2012. Want” document. In 2. Supporting NHS Bristol in broadening electronic participation of parents and carers of young evidence files. people in the “What Patients Want” document which identifies four key themes which matter to patients regarding histopathology services: quality, timeliness, convenience of access and communication. Two participants who attended the Trust’s “Tell us about your care” Focus Groups in April 2011 are attending the Independent Inquiry Panel’s Review February 2012 10.5 Agree process to promptly inform patients of 31 Jan 11 Jane Luker Complete. Current policy. diagnostic errors Staff Support and Being Open Policy 2009 is on DMS. already in place. Interim update has made the Updated link to diagnostic errors more explicit. policy. 10.6 Explore options for providing service users 31 Mar 11 Teresa Levy Cross Trust leaflet finalised and pilot completed Patient with information about the purpose of role September 2011. Revised leaflet in place. Information and multi-disciplinary cancer teams and team Leaflet. meetings. V25 27/02/2012 17 108 Ref No Actions Timescale Responsible Progress Complete Evidence person 10.7 Where a patient‘s care is going to be discussed at a The Trusts have agreed that implementing this recommendation N/A N/A multidisciplinary team meeting, patients should not be could lead to a delay in patients being given information given information contained in histopathology reports until concerning their diagnosis and could put clinicians in the position the reports have been considered by the multidisciplinary of having to withhold important information from patients. The team. Trusts’ ability to run one-stop clinics would also be compromised. Instead the Trusts propose that patients should be given information appropriate to their care, with an explanation of the diagnostic and treatment decision process by the Multidisciplinary Team. Section Training 11 Section Lead: Rob Pitcher 11.1 Trainees should have supervised involvement Nov 10 Lis Kutt Complete. Trainees are supervised by individual Annual report in the full range of specimens, including the consultants as befits their experience and to Severn most complex cases, in accordance with their seniority. The number of educational supervisors Deanery. seniority has been increased from 1 to 4 to further improve monitoring of progress with subsequent adjustments to individual learning plans as required. V25 27/02/2012 18 109 Ref No Actions Timescale Responsible Progress Complete Evidence person 11.2 Training plans to be adjusted to provide 30 Nov 10 Lis Kutt Complete. access to all levels of case Training plans for the trainees have been revised by Dr Mohammed Sohail. Training Plan A written training plan has been in use since the January 2011 which advises on the type of case mix trainees should expect to see to ensure that they have opportunities to work with a broad range of specimens of varying complexity. Section Overarching recommendation L: The histopathologists should be given whatever support they need to face the aftermath of this Inquiry including 12 skilled facilitation. Section Lead: Steve Aumayer 12.1 Develop detailed organisational development 31 Aug 11 Steve Integrated Cellular Pathology Service: Training plan to support the move towards an Aumayer/ resources, integrated cellular pathology service Rob Pitcher Joint Trust Monthly formal business meetings attendance in place (Latest 20th February 2012) records and Joint Trust workshop programme enabling notes of discussion on key issues and development of meetings. policy e.g. o Policy on . The recognition of specialist roles in cellular pathology . Definitions of Lead Roles in Cellular Pathology . Policy on the content of the V25 27/02/2012 19 110 Ref No Actions Timescale Responsible Progress Complete Evidence person reports from the Bristol Cellular Pathology Service . Policy on the management of discrepancies o Discussions on . Quality in cellular pathology . Approach to diagnoses outside ones field of expertise . Push v pull systems for allocating work . The working of the specialist teams A series of workshops at specialist team level has taken place as part of the wider pathology review in Bristol to determine what cellular pathology service is required on which site to support the clinical service Educational activities were originally intended to be part of this programme but there has not been time to include these and other options for this are being considered Working with NHS Improvement Again as part of a wider piece of work under NHS the aegis of the Pathology review cellular Improvement Report pathology is working with NHS I to embed a culture of continuous improvement into the service (LEAN approach). Whilst NHS Improvement is working with individual V25 27/02/2012 20 111 Ref No Actions Timescale Responsible Progress Complete Evidence person Trusts we have ensured a coordinated approach in cellular pathology. Good progress has been made with a second Bristol wide event on the 14th March. 12.2 Provide Counselling and Occupational Health 31 Dec 10 Steve Complete. Letter from support to affected staff Aumayer Acting Some staff have accessed this Medical Director to pathologists March 2011 12.3 Provide facilitation and mediation As Lis Kutt Facilitation and mediation are available to staff Letter from required should this be required. Head of Division to Externally facilitated event took place in Jan 11 pathologists with NBT and meetings of the Bristol Cellular Jan 2011. Pathology Forum continue. Agenda, minutes and papers of Bristol Cellular Pathology Forum. 12.4 Support to assist in development of single On-going. Lis Kutt/ Rob As for completed action 12.1 and on-going. On-going service Pitcher V25 27/02/2012 21 112 Ref No Actions Timescale Responsible Progress Complete Evidence person Section 13 Section Lead: Rob Pitcher 13.1 The Royal College of Pathologists should For RC RC Path Rob Pitcher has met informally with the President review its guidance on specialist Path to of the Royal College of Pathologists. histopathology with the intention of making it determin more explicit where possible. e There is a current Royal College of Pathologists To be To be advised document in existence on specialist reporting. advised by Royal by Royal College. The College Specialist Advisory Committee on College. Histopathology has discussed this. Guidance on double reporting is in preparation 13.2 There should be at least two specialist Depende Rob Pitcher Linked to action 1.2. histopathologists in each subspecialist area to nt on the Business Case. allow proper review and to provide cover for outcome The staffing review recommended pursuing a meetings and periods of leave. of 1.2 second oral and maxillofacial pathologist. A business case has been produced which has been agreed. For small specialities network arrangements with other centres are part of the solution. V25 27/02/2012 22 113 Ref No Actions Timescale Responsible Progress Complete Evidence person Section Pathology reports 14 Section Lead: Rob Pitcher 14.1 Review style of reporting and implement any To be Rob Pitcher The Bristol Cellular Pathology Forum has topics Reporting changes if deemed appropriate agreed already identified to be built into its work policy. programme. These topics for discussion, debate and development into policy and procedure include pathology reporting. Revised reporting template in place as described in action 1.2. V25 27/02/2012 23 114 Cover Sheet for a Report for a Public Trust Board Meeting, to be held on 27 March 2012 at 10:30 in the Conference Room, Trust Headquarters, Marlborough Street, Bristol, BS1 3NU Item 07 – Infection Control Annual Programme 2012/13 Purpose To brief the Board on the proposed programme for infection prevention and control 2012/13. Abstract For compliance with the Hygiene Code, Board approval of the annual infection prevention and control programme is required. The programme for 2012/13 The programme reflects regulatory developmental requirements. Divisional input to the proposed programme has been through the designated Matrons. The Infection Control Group and Clinical Quality Group have approved the programme. Recommendations The Board is recommended Approve the Programme as set-out. Executive Report Sponsor or Other Author • Sponsor – The Chief Nurse, Alison Moon • Author – The Director of Infection Prevention and Control, Christine Perry Previous Meetings Trust Other Finance Finance Executive Outcomes Committee Committee Qualityand Management Executive Team Audit Committee Clinical Quality Group 115 Proposed Infection Control Programme 2012/13 The Infection Control Annual Programme is a requirement for compliance with the Code of Practice on the Prevention and Control of Infections and Related Guidance and Care Quality Commission Outcome 8. The programme contents reflect these regulatory requirements and also include developmental requirements. Divisional input to the proposed programme has been through the designated Matrons. The Infection Control Group and Clinical Quality Group have approved the programme. Implementation of the programme will be monitored through the Infection Control Group and Clinical Quality Group. Number Objective Responsibility Timescale 1. Ensure there are systems to manage and monitor the prevention and control of infection 1.1 Ensure Board to Ward reporting Director Infection Prevention and Ongoing Control 1.2 Ensure appropriate use and monitoring of risk register Director Infection Prevention and Ongoing Control 1.3 Ensure appropriate use and monitoring of infection control Director Infection Prevention and Ongoing assurance framework Control 1.4 Implement a prevalence survey to provide assurance of Senior Infection Control Nurse February 2012 infection rates across the Trust 2. Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infection 2.1 Matrons report on cleanliness and environmental issues to the Designated Matron Lead Ongoing Board regularly 2.2 Policies for the infection control related to the environment are Director of Estates and Facilities Ongoing in place and adhered to 2.3 Suitable arrangements and monitoring for cleaning services are Facilities General Manager Ongoing in place. Ensure monitoring and delivery of contracted Facilities General Manager Ongoing cleanliness service at South Bristol Community Hospital is in line with Trust standard Facilitate the annual PEAT programme Facilities General Manager March 2012 116 Review the escalation process for Ward Sisters and Facilities General Manager September 2012 matrons raising concerns regarding facilities and estates performance 2.4 A programme to ensure decontamination across the Trust Decontamination Lead Ongoing meets required standards is in place and implementation monitored. 3. Provide suitable and accurate information on infections to service users and their visitors 3.1 Identify key information leaflets and ensure all wards have a Senior Infection Control Nurse December 2013 process for maintaining up to date ward stock. 4. Provide suitable and accurate information on infections to any person concerned with providing further support or nursing/medical care in a timely fashion 4.1 Implementation of actions following audit of discharge Senior Infection Control Nurse January 2013 information for MRSA, C diff etc. in 2011/12 and re-audit of discharge information 5. Ensure that people who have or develop an infection are identified promptly and receive the appropriate treatment and care 5.1 Maintain processes for reporting, investigation, analysis and Senior Infection Control Nurse Ongoing learning for relevant healthcare associated infections 5.2 Audit of completion of infection control risk assessment Matrons Ongoing through quality in care tool 5.3 Review RCA process for MRSA, C diff, MSSA and E coli and Senior Infection Control Nurse August 2011 revise reporting policy 6. Ensure that all staff are fully involved in the process of preventing and controlling infection 6.1 Divisions will have in place appropriate structures to support Heads of Nursing/Midwifery Ongoing engagement of staff in infection prevention 6.2 Infection control will be included in the induction of all staff Senior Infection Control Nurse Ongoing 6.3 Induction and update training packs will have content reviewed Senior Infection Control Nurse Ongoing and updated quarterly 6.4 Review link nurse system in view of proposed Supervisory Senior Infection Control Nurse/Heads of December 2012 Ward Sister role Nursing/Midwifery 6.5 Undertake awareness raising activities as part of international Senior Infection Control Nurse October 2012 infection prevention week 14-20/10/2012. 117 7. Provide adequate isolation facilities 7.1 Isolation facilities will be appropriately planned into all Director of Estates and refurbishments or new developments Facilities/Director of Strategic Development/Senior Infection Control Nurse 7.2 Upgrade of isolation room Ward 54 to specialist isolation Director of Estates and Facilities/ Head Ongoing facilities and implement appropriate policies of Nursing Medicine/Senior Infection Control Nurse 8. Secure adequate access to laboratory facilities 8.1 Implement and monitor contract with Health Protection Divisional Manager Diagnostics and Ongoing Agency for microbiology and infection control services Therapy Division 9. Have and adhere to policies that will prevent and control infections 9.1 Review and update relevant infection control policies Senior Infection Control Nurse March 2013 9.2 Review and update management packs Senior Infection Control Nurse March 2013 9.3 Review and update hand hygiene policy to meet NHSLA level Senior Infection Control Nurse May 2012 3 requirements 9.4 Review and update inoculation incident policy to meet Senior Occupational Health Nurse May 2012 NHSLA level 3 requirements Advisor 9.5 Audit infection control practice through Quality in Care tool Matrons Ongoing 9.6 Audit of sharps management Senior Infection Control Nurse September 2012 9.7 Audit of Linen policy Senior Infection Control Nurse September 2012 9.8 Audit of Tuberculosis policy Senior Infection Control Nurse January 2013 9.9 Audit of Waste Policy Senior Infection Control Nurse January 2013 9.10 Audit of Legionella prevention actions at ward level Heads of Nursing/Midwifery September 2012 9.11 Audit of environment and equipment (ICNA audit tools) Senior Infection Control Nurse December 2012 10. Ensure that healthcare workers are free of and protected from exposure to infections and ensure that all staff are suitably education in the prevention and control of infection 10.1 Implement a system for maintenance of records of staff Human Resources Team September 2012 immunisation and audit compliance 10.2 Maintain compliance to infection control training requirements Director Infection Prevention and Ongoing at 95% to attain NHSLA level 3 Control/Heads of Nursing/Midwifery 118 11. National Requirements 11.1 Report and investigate cases of healthcare associated infection Director Infection Prevention and Ongoing as mandated Control 11.2 Reduce further the incidence of MRSA blood stream infections Director Infection Prevention and March 2013 (national target = 2) Control 11.3 Reduce further the incidence of Clostridium difficile infections Director Infection Prevention and March 2013 (national target = 54). Control 11.4 Reduce the incidence of MSSA1 blood stream infections Director Infection Prevention and March 2013 (locally agreed target). Control 12. Developmental Objectives 12.1 Establish in-house infection prevention and control masterclass Senior Infection Control Nurse September 2012 training programme 12.4 Implement a programme for sharps injury prevention to meet Senior Infection Control October 2012 requirements of Directive 2010/32/EU - prevention from sharp Nurse/Occupational Health Advisor injuries in the hospital and healthcare sector 1 Meticillin sensitive Staphylococcus aureus 119 Cover Sheet for a Report for a Public Trust Board Meeting, to be held on 27 March 2012 at 10:30 in the Conference Room, Trust Headquarters, Marlborough Street, Bristol, BS1 3NU Item 08 – Outpatient Feedback, including Results of the 2011 National Outpatient Survey Purpose To report to the Board key themes arising from patient feedback about outpatient services, including the findings of the 2011 National Outpatient Survey. Abstract Eliciting feedback from outpatients about their experience at the Trust has been a key focus of the second year of the Trust’s current Patient and Public Involvement Strategy (2010-2012). A number of initiatives have taken place or are in progress, including: - Comments cards being introduced to outpatient areas - A comprehensive survey of 2,250 outpatients - Participation in the 2011 National Outpatient Survey - Establishing links between the Trust’s Patient and Public Involvement function, Patient Experience Group and the Productive Outpatient programme. A report is attached which summarises key themes arising from a range of patient feedback sources and explains what actions the Trust will be taking to improve outpatient experience in the future. The report includes a summary of the Trust’s 2011 National Outpatient Survey results. The headline message from the Care Quality Commission’s public dashboard for the national survey is that the Trust’s score on all survey questions was classed as “the same as other Trusts” (which can be broadly interpreted as in line with the “national average”). Recommendations The Board is recommended to Note the report. Executive Report Sponsor or Other Author • Sponsor – The Chief Nurse, Alison Moon • Author – The Patient Involvement Co-ordinator, Paul Lewis Appendices • Appendix A – Outpatient Experience at University Hospitals Bristol NHS Foundation Trust Previous Meetings Trust Other Finance Finance Executive Outcomes Committee Committee Qualityand Management Executive Team Audit Committee 120 Page 2 of 2 of a Cover Sheet for a Report for a Public Trust Board Meeting, to be held on 27 March 2012 at 10:30 in the Conference Room, Trust Headquarters, Bristol, BS1 3NU 14 March 26 March Patient 2012 2012 Experience Group 121 `` Outpatient Experience at University Hospitals Bristol NHS Foundation Trust Background Measuring outpatient experience at UH Bristol is difficult due to the large volume of patients and the diversity of the specialties / clinics that are provided at the Trust. This magnifies the imperfections of any one data source, but bringing together patient feedback from a range of channels does yield relatively clear messages. This report reviews the following sources of patient experience data: The 2011 National Outpatient Survey (NOPS): a postal survey that was sent to 850 people who attended an outpatient appointment at UH Bristol during May 2011. 488 responses were received. The UH Bristol Outpatient Survey: a postal survey that was sent to 4,250 people who attended an appointment during July 2011. The survey sampling took place at a Divisional-level (approximately 850 people were selected per Division). 2,125 1 responses were received. Complaints data: provided by the Trust’s Patient Support & Complaints team. Patient comments on the NHS Choices website: the public are able to rate Trust services and leave comments about their experience on www.nhschoices.nhs.uk Further information about these data sources is provided in the Appendices to this report. Two reports accompany this document to show the Trust’s 2011 NOPS results in detail: 1. The Public Dashboard: this is the Care Quality Commission’s (CQC) flagship national outpatient survey report, aimed at providing members of the public with a simple presentation of each Trust’s survey results. This will be housed on the CQC website 2. The Benchmark Report: a technical report that in previous years was the CQC’s main vehicle for presenting Trust-level national survey results. This report is difficult to interpret and will therefore now only be available to the public via the National Survey Co-ordination Centre’s website.2 1 The national survey employs a Trust-level random sample and so is skewed by a small number of very high volume clinics (e.g. Audiology, Ophthalmology). The Trust’s own outpatient survey aimed to correct these and other effects by taking a sample of 850 people per Division (with steps taken to account for the influence of very large volume clinics). The Trust survey also included people aged 15 and under (or the parents of 0-11 year olds): an age group not covered in the national survey. 2 The Benchmark report attempts to classify Trusts as being in the mid-range, upper or lower quintile on each survey question relative to other Trusts. However, the inherent margin of error in the data (represented by error bars in the report) makes this difficult because the score often overlaps the quintile thresholds (e.g. a score might itself be in the best 20%, but cannot be interpreted as such because the margin of error around it crosses into the mid-range). The public dashboard uses a different statistical method to compare Trusts. 122 National Outpatient Survey Overview In the Care Quality Commission’s Public Dashboard, all of UH Bristol’s scores in the 2011 NOPS are classed as being “about the same” as other acute Trusts in England. The Benchmark report shows that patients gave UH Bristol an overall score of 84 out of 100 (or 8.4/ 10 in the Public Dashboard) for the care they received as an outpatient. This is in line with peer3 and neighbouring4 Trusts. The best Trust nationally scored 94/100. Previous national outpatient surveys have been carried out in 2004 and 2008. Most of UH Bristol’s scores have not changed significantly since 2004. The exceptions are improvements in the following scores: o Patients receiving copies of letters sent between the hospital doctor and their GP (15/100 in 2004; 44/100 in 2011) o Whether the patient was given a choice of appointment time (62; 77) o How long the patient waited between referral and their first appointment (74; 83) The only significant improvements for UH Bristol between the 2008 and 2011 surveys were on the first two of these scores (copies of letters and choice of appointments, with a 12 and 10 point increase respectively) Analysis of the CQC’s Benchmark reports shows that between 2004 and 2011, the only significant change in the threshold required for a Trust to be classed in the top quintile came in the “letters sent between GP” and “waiting time from referral” questions. This suggests that, in general, other Trusts had a similar pattern of change over this period to 5 UH Bristol. The Trust’s best scores in the 2011 national outpatient survey were in the sections on “seeing the doctor” and “overall impressions of the outpatient department” (both 8.75 out of 10). The Trust’s lowest scores were in the “waiting in the hospital” section. This section includes two questions: delays experienced whilst in the clinic and whether the patient was kept informed about these delays (the latter being the lowest Trust score by some distance at 2.52 out of 10) Please note that the Trust has not been provided with a report that compares UH Bristol and national results in percentage terms. 3 The mean score across twenty peer Trusts is 84/100 (the same as UH Bristol), with a range of 79-87 (which can be accounted for by the margin of error in the survey). 4 A mean score of 84/100, with a range of 83-85. See Appendices for the list of Trusts used in this analysis. 5 Although improvements in national survey results tend to feature in CQC press releases, this tends to be based on all of the 72,000+ responses received nationally, where virtually any change is statistically significant. 123 Outpatient experience at UH Bristol: key issues Service improvement opportunities can be identified by looking at national survey scores that are outliers (i.e. scores that are low in absolute and relative terms). However, given the size and complexity of outpatient services at UH Bristol it is also important to look across several feedback channels to determine the issues that matter most to patients. Table 1 shows that the most frequent outpatient complaints received by the Trust are around delayed / cancelled appointments, failure to respond to patient queries, and waiting times in clinic. This is corroborated by the Trust’s survey (Chart 1), where the most frequent service improvement needs cited by outpatients were around waiting times in clinic and “administration” (a broad category covering issues such as delayed appointments, failure to answer queries, and problems contacting the Trust). Chart 1 also places these issues in context: by far the most common type of feedback was praise for Trust staff. Table 1: Outpatient Complaints by category Frequency (2010/11) Delayed Appointment 102 Cancelled appointment(s) 95 Failure to answer telephone / respond to letters etc 44 Waiting time in clinic 25 Source: Patient Support & Complaints Team 2010/11 Annual Complaints Report. The categories “cancelled appointment” (30) and “cancelled appointment - multiple” (65) have been combined; as have “failure to answer telephone” (29) and “failure to respond” (to correspondence / messages) (15) Chart 1: most frequent free-text comments (UH Bristol Outpatient Survey) Waiting in clinic Administration Other (average per Staff (positive) (negative) (negative) category) Series1 45% 10% 6% 1% Source: UH Bristol Outpatient Survey (% is out of the 950 patient free-text comments received in response to the question: Any other comments e.g. things we did well or need to improve) 124 Table 2 summarises the key patient experience improvement opportunities that have arisen from an analysis of the NOPS, Complaints, the Trust’s Outpatient Survey, and NHS Choices. The main issues raised by patients are around delays in clinic and the efficiency of the outpatient experience. While patients are generally very positive about the Trust’s clinical staff, a cluster of questions emerge around conveying certain types of information during the appointment (potential medication side effects, danger signals to look out for regarding the patient’s treatment / condition, and who to contact if the patient is concerned about their condition).6 Table 2: Key issues across patient feedback channels Issue Source Low scores in NOPS; issue raised by patients in Delays in clinic UH Bristol’s survey; Complaints; NHS Choices comments In clinic In Keeping patients informed about delays in Lowest score in NOPS and UH Bristol Outpatient clinic Survey Raised by patients via UH Bristol survey Contacting the Trust comments, Complaints, and NHS Choices Raised by patients via UH Bristol survey Cancelled appointments comments, Complaints, and NHS Choices Among scores furthest from the best Trust Providing a choice of appointments nationally in NOPS; Issue raised via comments in UH Bristol survey Providing patients with letters sent between NOPS: among lowest scores and among furthest Efficiency & EfficiencyAdministration & their hospital doctor and GP from best Trust nationally NOPS: among lowest scores and among furthest Telling patients about potential medication from best Trust nationally; Among lowest scores side effects in UH Bristol OP Survey Staff Telling patients about danger signals to NOPS: among five lowest Trust scores watch for regarding their illness / treatment Clinical Clinical Ensuring the patient is told who to contact if NOPS: among furthest scores from best Trust communication they are concerned about their condition or nationally. Among lowest scores in UH Bristol’s treatment outpatient survey 6 It is interesting to note that three out of five of the Trust’s best scores in the CQC’s Public Dashboard were also around communication: telling the patient the purpose of any new medications, how to take these medications, and the reasons for changing them. The two other top five scores were around treating the patient with respect and dignity. 125 Improving outpatient experience at UH Bristol Outpatient experience has been a focus of Year 2 of the Trust’s 2010-12 Patient & Public Involvement (PPI) Strategy. A key aim of this Strategy is to ensure that systems are in place for patients to provide feedback about their experience and that the Trust can learn from this. Initiatives carried out or underway in respect of the PPI Strategy include: Via the Trust’s Outpatient Survey and the NOPS: obtaining feedback about UH Bristol outpatient experience from more than 2,500 people. These surveys also provide robust patient experience metrics against which to benchmark improvements. Introducing a comments cards system and “you said/we did” notice boards in outpatient areas of the Trust, to be implemented via the Productive Outpatients programme. Carrying out qualitative activities (e.g. interviews and focus groups) to understand patient experience issues in more depth. The issues identified in Table 2 will become Trust-wide outpatient experience improvement objectives (any new issues identified as we accumulate feedback will be added to this list). The Trust’s Productive Outpatient improvement programme, which has a strong emphasis on improving patient experience, will be the primary means through which these service improvement issues are addressed. An action plan is provided in Appendix A. A progress update on this action plan will be provided to the Trust’s Patient Experience Group (which includes the Patient Experience Lead for the Productive Outpatient Programme) on a quarterly basis. To ensure that patient-reported experience is a key measure of service improvement, a bi- annual outpatient survey will be introduced from 2012/13. This will support a performance dashboard (Table 3, over) that has an ambitious, staggered target leading to the best Trust score nationally by 2014 (this is the year when the next NOPS is due and so the service improvements should also be reflected in those results).7 This dashboard will become a key evaluation tool for the Patient Experience Group and Productive Outpatient Steering Group, and the results will be shared with staff across the Trust. 7 The full Productive Outpatient evaluation dashboard will contain additional data, such as an objective monthly measure of appointment cancellations. 126 Table 3: Patient Experience Survey Dashboard Interim tracking scores (UH Bristol outpatient survey - precise programme to be confirmed) Baseline July 2012 February August Target: (2011 UH July 2013 UH February 2013 UH August February February March 2014 National Bristol 2012 Bristol 2013 Bristol 2013 2014 2014 National OP OP survey Interim survey Interim survey Interim survey Interim Survey (best Measures Survey) result Target result Target result Target result Target Trust score) Reducing delays in clinic 66 68 71 73 75 75 Communicate length of delay to patients 25 31 37 43 49 49 Reduce cancelled appointments 91 92 94 95 96 96 Improve ease of telephone contact with the Trust 80 84 88 91 95 95 Explain medication side effects 50 57 63 70 76 76 Tell patient who to contact if worried 67 72 76 81 85 85 Tell patient about potential danger signals to watch out for in relation to treatment / condition 56 60 64 67 71 71 Ensure patients receive a copy of letters between hospital doctors and GP 44 57 69 82 94 94 Patient given a choice of appointment time 77 82 86 91 95 95 127 Appendix A: Action Plan Theme Action When Accountable Lead(s) 1.1 Productive Outpatient Scheduling and Booking Project (Phase 1): currently working with clinics / specialties / From July 2011 booking teams to develop "realistic scheduling" of patient (ongoing) appointments (e.g. understanding flow of patients through the clinic, factoring in time for tests etc) Divisional / Hospital 1.2 Scheduling and Booking Project (Phase 2): focus on in- Productive OP Leads + 1. Reducing delays in clinic clinic processes to speed up clinic times (e.g. having a Cat McElvaney Starting April 2012 named nurse specifically responsible for the clinic list each (Productive Outpatient day) Lead) 1.3 Clinics starting on time campaign: this element of the Productive Outpatient project will identify common Starting April 2012 reasons for late clinic running and develop / implement solutions within specialties / clinics 2.1 Phase 2 Productive Outpatient Project: each clinic will have a status board showing the anticipated waiting time (red = 1 hour or more delay; amber = 30-60 minutes delay; Status Boards in Cat McElvaney + Nicky green less than 30 minutes delay). The board will also outpatient clinics by Brooks display the reasons for any delay. (An electronic solution End April 2012 2. Communicate length of to communicating this information will also be delay to patients in clinic investigated / trialled during 2012/13.) Heads of Nursing for 2.2 Divisions (via Heads of Nursing) will communicate the March 2012 (and outpatient areas / importance of this issue to clinic staff with a view to ongoing) Dawn Wilson (D&T ensuring a verbal update is also provided to patients Lead for PPI) 128 Theme Action When Accountable Lead(s) 3. Reduce cancelled 3.1 Review the Choose and Book system / policies (e.g. appointments capacity, current ability of patients to book appointments Starting February over 11 weeks in advance). This element of the Productive Cat McElvaney / Michal 2012 (Reviewed in Outpatient project will start at the Eye Hospital and Kus / Sophie Fox May 2012) learnings from this will provide the basis of a Trust-wide roll-out 3.2 Review staff leave / on-call booking procedures and systems with a view to aligning them with appointment May-12 booking (i.e. to reduce the problem of cancelling appointments due to staff leave etc) Divisional / Hospital Productive OP Leads + 3.3 Investigate the potential of an electronic leave booking Cat McElvaney May-12 system in order to achieve action 3.2 (Productive Outpatient 3.4 Review booking processes to understand demand for Lead) appointment types at a Speciality-level. This will enable July 2010 onwards clinics to better meet "regular demand" and to provide more appropriate scheduling of appointments 4.1 A new call-centre will provide patients with a single point of contact with the Trust. Phase 1 will provide a Dec-12 service for 50% of booked appointments Cat McElvaney / Michal Kus 4.2 The call centre service will be expanded to cover 100% 4. Improve ease of telephone Dec-13 of booked appointments contact with the Trust 4.3 Expected reduction in outpatient queries due to the Cat McElvaney other intiatives put in place via the Productive Outpatient Ongoing (Productive Outpatient project (e.g. reduced cancellations, better appointment Lead) scheduling etc) 129 Theme Action When Accountable Lead(s) 5. Conveying 5.1 Notify Divisional Patient Safety Leads of survey results so that they can be important clinical Mar-12 Paul Lewis shared amongst clinicians and other relevant staff information to patients (medication 5.2 Share results with the Patient Safety Team so that they can seek Feb-12 Paul Lewis side effects, who to opportunities to raise the profile of these issues as part of their work contact if concerned, 5.3 In conjunction with the Patient's Association: carry out patient interviews Helen Mogan / Tony potential danger and a focus group to determine the type and format of medication side effects Mar-12 Watkin signals) information that patients require Heads of Nursing for 5.4 Divisions to share the results with clinical, nursing and Allied Health outpatient areas / Dawn Mar-12 Professional staff Wilson (D&T Lead for PPI) 5.5 Patient Information Team to incorporate a prompt in their leaflet guidance for leaflets to include information about who patients should contact with any Mar-12 Graham Slee concerns 5.6 Explore how to incorporate these issues as key themes within Phase 2 of the from April Cat McElvaney / Paul Productive Outpatient project 2012 Lewis 6.1 Raise query with IM&T to assess whether this is deliverable via the Medway 6. Ensure patients Feb-12 Paul Lewis receive a copy of system letters between 6.2 If action 5.1 is deliverable: produce an options paper for consideration by By July hospital doctors and Cat McElvaney the Service Delivery Group (as this will have a cost implication) 2012 GP Heads of Nursing for 7. Patient given a 7.1 Patients should already be given a choice of appointments, therefore this outpatient areas / Dawn choice of Mar-12 will be re-issued as a priority from Divisions to booking staff Wilson / Paul Lewis / appointment time Michal Kus 130 Appendix B: UH Bristol Survey Scores: distance from the best Trust nationally (All UH Bristol scores are in line with the national average) UH Bristol Best Trust 2011 in 2011 Difference The patient received copies of letters sent between hospital doctors and their GP 44 94 -50 The patient was told about medication side effects to watch for 50 76 -26 Patients experiencing a delay were told how long it would be 25 49 -24 Patient was given a choice of appointment times 77 95 -18 The patient was told who to contact if they were worried about their condition or treatment 67 85 -18 The patient was asked what they felt was important in managing their condition or illness 62 79 -17 A member of staff explained the risks and / or benefits of the treatment in an understandable way 78 93 -15 The patient was told about danger signals to watch for 56 71 -15 The patient was told how they would find out their test results 80 93 -13 Patient knew what would happen during their appointment 67 79 -12 A member of staff clearly explained why the patient needed the tests 82 94 -12 The staff treating and examining the patient introduced themselves 81 93 -12 The main reason the patient went to the Outpatients Department was dealt with to their satisfaction 84 96 -12 From the time you were first told you needed an appointment, how long did you wait for your appointment? 83 94 -11 Perceived cleanliness of the toilets at the outpatient department 85 96 -11 The appointment helped the patient feel they could better manage their condition or illness 66 77 -11 A member of staff clearly explained the test results to the patient 72 82 -10 If the patient saw another health professional, they got understandable answers to their questions 83 93 -10 The patient had confidence and trust in the other medical professional they saw 87 97 -10 Overall rating of care during outpatient appointment 84 94 -10 How long the patient had to wait after their scheduled appointment time 66 75 -9 Perceived cleanliness of the outpatient department 88 97 -9 131 UH Bristol Best Trust 2011 in 2011 Difference If the patient asked the doctor important questions then they got answers that they could understand 84 93 -9 A member of staff explained to the patient what would happen during their treatment 86 94 -8 The doctor seemed aware of patient's medical history 89 97 -8 The doctor clearly explained the reasons for any treatment or action 86 94 -8 The patient felt sufficiently involved in care and treatment decisions 82 90 -8 The patient had confidence and trust in the doctor 89 96 -7 The patient was given enough privacy when discussing their condition / treatment 90 97 -7 A member of staff said one thing and another said something else 90 97 -7 The patient felt they had enough time with the doctor 88 94 -6 The doctor listened to what the patient had to say 90 96 -6 Did the doctors / other staff talk in front of the patient as if they weren't there 92 98 -6 The patient was given the "right amount" of information about their condition or treatment 88 94 -6 The patient was told how to take any new medications 91 97 -6 Patient's appointment changed to a later date by the hospital 91 96 -5 The patient felt they were treated with dignity and respect during the appointment 94 99 -5 The patient was told the purpose of medications they were taking home 91 95 -4 The reason for changing the patients medication was clearly explained 91 95 -4 132 Appendix C: Patient Feedback Sources and Comparative Trusts 2011 National Outpatient Survey: 163 Acute Trusts in England took part in this survey. The Trust’s survey contractor, Quality Health Ltd, sent a questionnaire to 846 people who had attended an outpatient appointment at UH Bristol during May 2011. 488 people responded to the survey: a response rate of 58%. This survey is important both as a benchmark against other Trusts and because it has a relatively high profile. It is however a relatively small survey at Trust-level which this makes it difficult to carry out detailed analysis of the results (e.g. by hospital or division). In addition, the use of a Trust-level random sample means that the sample is skewed towards a small number of very high volume clinics (primarily Ophthalmology and Audiology). This survey is now conducted every three years, with the next one scheduled for 2014. 2011 UH Bristol Outpatient Survey: A sample of approximately 850 patients was drawn from each Division (4,250 patients in total), and where necessary quotas were applied to limit the effect of very large volume clinics (statistical weighting at the analysis stage was employed to correct this, although in the final publication this was removed as it did not significantly affect the Divisional results). 2250 people responded to the survey: enough to carry out analysis by Division, Hospital, and the larger specialties. It is anticipated that this survey will be repeated regularly by the Trust, but with lower numbers, in order to monitor progress against the Trust’s outpatient experience objectives. The data from the 2011 survey can be found on the following Workspace (accessible via the Trust’s Intranet): http://workspaces/sites/Committees/PatientExperienceGroup/PPI%20Data%20and%20repo rts/Forms/AllItems.aspx Complaints: the Patient Support & Complaints Team provided a breakdown of complaint categories for 2010/11 and identified the issues that relate primarily to outpatient services. NHS Choices: the public can leave comments on this website about their patient experience. At the time of writing, 138 comments had been posted on this site about UH Bristol’s services. Peer Trusts used in comparative analysis: Barts & The London NHS, Cambridge University NHS FT, Central Manchester NHS FT, Chelsea & Westminster NHS FT, Guy's & St Thomas NHS FT, Imperial College NHS, Kings College NHS FT, Leeds Teaching NHS, Nottingham NHS, Oxford Radcliffe NHS, Royal Free NHS, Royal Liverpool NHS, Salford NHS FT, Sheffield Teaching NHS FT, Southampton University NHS, St George NHS, UCL NHS FT, UH Birmingham NHS FT, UH Leicester NHS, UH South Manchester NHS FT. Local Trusts used in comparative analysis: North Bristol NHS Trust, Royal United Hospital Bath, Weston Area Health NHS Trust, Great Western Hospitals NHS Foundation Trust, Gloucestershire Hospitals NHS Foundation Trust. 133 Appendix D: Timetable of data publication The CQC National Outpatient Survey reports and the Trust’s Outpatient Experience Report were released on the following timetable: The two Care Quality Commission (CQC) data reports (i.e. public 19th January dashboard and benchmark report) released to the Trust under embargo Email from the Trust's Patient & Public Involvement (PPI) Team to the Trust's Executives to provide the two CQC reports and to highlight the 23rd January 2012 key messages from the results 14th February 2012 CQC reports released publicly The PPI Team's review of outpatient experience and the associated action plan (i.e. this report) presented to the Trust's Patient Experience 23rd February Group, alongside the CQC survey reports Service Delivery Group review the PPI Team / CQC reports and action 5th March plan Clinical Quality Group receive the outpatient experience improvement 8th March dashboard Trust Management Executive review the PPI Team / CQC reports and 14th March action plan Quality & Outcomes Committee review the PPI Team / CQC reports and 26th March action plan 27th March Trust Board review the PPI Team / CQC reports and action plan 134 Cover Sheet for a Report for a Public Trust Board Meeting, to be held on 27 March 2012 at 10:30 in the Conference Room, Trust Headquarters, Marlborough Street, Bristol, BS1 3NU Item 09 – Patient Experience and Involvement Strategy Purpose To brief the Board on the development of a Patient Experience and Involvement Strategy. Abstract The University Hospitals Bristol NHS Foundation Trust is committed to providing high quality, patient-focused healthcare that meets the needs of a diverse population. We are also committed as an organisation to learning from experience: for the purposes of this strategy, this means the experiences of the people who use our services and those who care for them. In early 2010, we set out our ambitions for improving patient experience in a document called Involving People - Influencing Change: A Patient and Public Involvement Strategy for 2010-12. The implementation of this strategy has added significantly to our understanding of what people think about our services and has introduced real-time feedback into wards and clinics, enabling our staff to respond better to individual patient needs. The latest strategy builds on our learning from the last two years and sets out our planned focus for the next three. Our ambitions for patient involvement and experience are set out in the strategy and can be summarised as follows: Refining and developing how we measure the patient experience Sharing what patients have told us and using this to drive change Not just measuring, but involving Embedding patient involvement and experience activities at all levels of the Trust Recommendations The Board is recommended to approve the strategy. Executive Report Sponsor or Other Author • Sponsor – The Chief Nurse, Alison Moon • Author – The Assistant Director for Audit and Assurance, Chris Swonnell Appendices • Appendix A – Patient Experience and Involvement Strategy 135 Page 2 of 2 of a Cover Sheet for a Report for a Public Trust Board Meeting, to be held on 27 March 2012 at 10:30 in the Conference Room, Trust Headquarters, Bristol, BS1 3NU Previous Meetings Trust Other Finance Finance Executive Outcomes Committee Committee Qualityand Management Executive Team Audit Committee 14 March 26 March Patient 2012 2012 Experience Group, Clinical Quality Group 136 Patient Experience and Involvement Strategy 2012-2015 1. Statement of strategic intent The Trust Board of Directors is committed to ensuring that University Hospitals Bristol NHS Foundation Trust is an ‘organisation with a memory’: that we learn from our experiences and those of the people who use our services. The Board expects the Trust to fulfil its ‘duty to involve’ and to ensure that systems are in place to enable the Board to monitor and act upon the views of patients and the people who care for them, and of the communities the Trust serves. The Board’s ambitions for developing and improving patient experience and involvement are set out in this document. The Trust Board of Directors monitors the achievement of its objectives, and associated risks through the annual cycle of Board reporting set out in the Board forward planner, including the Board assurance framework and risk register. 2. Introduction University Hospitals Bristol NHS Foundation Trust is committed to providing high quality, patient-focused healthcare that meets the needs of a diverse population. We are also committed as an organisation to learning from experience: for the purposes of this strategy, this means the experiences of the people who use our services and those who care for them. In early 2010, we set out our ambitions for improving patient experience in a document called Involving People - Influencing Change: A Patient and Public Involvement Strategy for 2010-12. The implementation of this strategy has added significantly to our understanding of what people think about our services and has introduced real-time feedback into wards and clinics, enabling our staff to respond better to individual patient needs. This document represents a natural development of our strategy, building on our learning from the last two years and setting out our planned focus for the next three. Our ambitions for patient involvement and experience can be summarised as follows: Patient Experience and Involvement Strategy 2012-2015 137 Refining and developing how we measure the patient experience Sharing what patients have told us and using this to drive change Not just measuring, but involving Embedding patient involvement and experience activities at all levels of the Trust Our plans for each of these areas are explained in more detail later in this document. 3. Why a ‘patient experience and involvement’ strategy? Since our first strategy was written the term ‘patient experience’ has become a shared currency in the NHS, describing one of the three core aspects of quality as defined by Lord Darzi in the NHS Next Stage Review: “Quality of care includes quality of caring. This means how personal care is – the compassion, dignity and respect with which patients are treated. It can only be improved by analysing and understanding patient satisfaction with theirown experiences.”1 Through our strategy, Involving People - Influencing Change, we have put in place systems that allow the Trust to understand and monitor patient experience, and to use this knowledge to improve services. This new strategy sets out our aspiration to build on these strong foundations to create a culture of genuine patient and public involvement within our hospitals. The NHS Constitution states: “You have the right to be involved, directly or through representatives, in the planning of healthcare services, the development and consideration of proposals for changes in the way those services are provided, and in decisions to be made affecting the operation of those services.” We can already point to very good examples of how patient and public involvement has been used to improve patient experience at the Trust2: our vision is now to see this embedded as standard practice at all levels of the organisation. 1 High Quality Care for All: NHS Next Stage Review Final Report, June 2008, p47 2 Here are some recent examples: Feedback from patients and carers has shaped the way we provide patient information on our wards: a new “Welcome Guide” reflects the information patients and carers told us they wanted to see. Feedback we received from carers of patients with Dementia has been instrumental in the Trust purchasing ward based “reminiscence pods”. An ophthalmology paediatric service project involved parents and children/young people in a review of the surgical service, informing the development and design of the new paediatric outpatient department. Young people were involved in the development of the Bristol, North Somerset and South Gloucestershire (BNSSG) self-assessment framework for the transition of patients with long term conditions from paediatric to adult services. Patient feedback about the level of noise at night on the wards has resulted in a plan to install quiet closing bins on all wards. Patient Experience and Involvement Strategy 2012-2015 138 4. Scope of this strategy The Trust’s Quality Strategy 2011-2014 includes a number of strands of activity which will enable the Trust to better understand and improve the patient experience. The patient experience and involvement strategy adds detail to these aspirations and outlines the legislative context and key drivers. Our strategy has been tested through consultation (see Appendix A for details). We would like to thank everyone who has taken the time to help us shape our plans. The strategy supports the Trust’s core business of providing high quality services and is relevant to a number of other key Trust strategies and initiatives including: the productive ward and productive outpatient programmes (part of our transformation activities); the equality delivery scheme; Trust strategies for communications, volunteering, membership development, and teaching and learning; research and innovation; and the anticipated Policy of Candour. The strategy also directly reflects the Trust’s core values, namely: Respecting Everyone Working Together Embracing Change Recognising Success We are also committed as an organisation to learning from experiences. When patients and carers tell us that we’ve got something wrong, firstly we want to put it right (if we can) for those people, but secondly we also want to learn wider lessons so that we get it right for patients we see in the future. 5. Context Our patient experience and involvement activities are driven by the desire to make things better for patients, their families and carers. We also need to consider local and national expectations, trends and developments. Examples include: Section 242 of the NHS Act 2006 which states that NHS Trusts must involve service users in planning, developing, and delivering health services; develop robust involvement practices; and ensure that involvement outcomes inform decision making. Lord Darzi’s ‘NHS Next Stage Review’ which includes an expectation that local NHS providers will involve their patients, their carers, the public and other key partners. The Darzi Report describes patient experience as one of three elements of quality (the others being patient safety and clinical effectiveness). Patient Experience and Involvement Strategy 2012-2015 139 The emerging ‘Localism’ agenda (i.e. the transfer of power and resources from central government to the local level so that local people set priorities and become involved in decisions about the places where they live). The coalition government’s white paper: Equity and Excellence: Liberating the NHS, a core aim of which is to put patients at the heart of everything that the NHS does. The white paper includes proposals for the transition from Local Involvement Networks to ‘Healthwatch’; it also includes proposals for GP commissioning which in due course will redefine the Trust’s patient and public involvement (PPI) relationship with service commissioners. Reporting requirements for Quality Accounts and Quality Reports. The NHS Constitution, which states that patients will be involved in planning and developing services. The publications Healthy Lives, Brighter Futures and You’re Welcome which address the involvement of children and young people in services. NHS 2010-2015: From Good to Great which outlines plans to expand the measurement of patient experience, and link patient experience to 10% of hospital funding. NHS Bristol’s Patient Experience Ambitions which outlines local intentions for the commissioning of high quality patient experience, plans for regular experience evaluation, and the use of CQUIN (Commissioning for Quality and Innovation payments). Care Quality Commission Registration Standards which require the Trust to be able to evidence the sorts of outcomes experienced by our patients. Foundation Trust status also requires us to ensure members and Governors have the chance to participate in involvement activities. NHSLA standards for ‘analysis’ and ‘improvement’ (about how we learn as an organisation from patient complaints/feedback and incidents). The opening of the new South Bristol Community Hospital in April 2012, for which the Trust will be the lead provider of services. The NHS Equality Delivery System which is to be operational from April 2012 and will rely upon rigorous engagement with patients and carers. 6. Where we are now (March 2012) and what have we learned? In Involving People - Influencing Change we wrote: At present [March 2010], the Trust’s ‘intelligence’ about patient experience is significantly reliant upon the findings of National Patient Surveys, plus a range of largely ad hoc local patient surveys. National Patient Survey data is robust, however findings are released too late (usually nine months after the event) to make this a viable self- improvement tool. Over the last two years, we have established a core feedback programme across the Trust, consisting of: Patient Experience and Involvement Strategy 2012-2015 140 a statistically robust monthly post-discharge postal survey for inpatients a large-scale annual survey of outpatients’ experience comments cards on wards and in clinics, and a bi-monthly interview programme Through our monthly postal surveys alone, we have heard the views of well over 20,000 patients and have used this to improve services. Table 1 summarises our progress against the objectives we set ourselves in the 2010-12 strategy. Table 1: Involving People - Influencing Change (PPI Strategy 2010-12) achievements 2010-12 Strategy objective Achievement Comments / Learning To collect robust patient experience Fully met Initially, some of our staff were apprehensive about metrics via a regular postal survey of a significant influx of new data about patient discharged inpatients. There will be experience, but as the process and data became three strands to the survey: Adult more familiar, the focus turned naturally to service inpatients, Maternity patients, improvement. Patient experience targets linked to Parents of children aged 0-15 years CQUIN incentive payments have seen the largest improvements. The survey data will support monthly Fully met Collaborative working has been the key to delivering quality reports to Trust and Divisional this objective. We need to continue to engage all Boards; be reported at ward level on a staff in patient experience and involvement as we quarterly basis; inform the Trust’s move forward. annual Quality Account; detect shifts in patient experience resulting from improvement activities; support the Productive Ward programme To develop a proactive programme of Fully met Recruiting, training and retaining volunteers to Trust survey activities using electronic deliver this survey has been resource-intensive. The hand-held survey devices. hand-held devices received mixed reviews and we now offer volunteers the option to use a paper questionnaire if they prefer. To give patients, their relatives, Fully met This has worked well because ownership is at ward visitors and carers the opportunity to level. Completed comments cards are also displayed comment on their inpatient at all meetings of the Trust Board and Membership experience via comments cards Council. available on each ward. To explore new and innovative ways Partially met In the event, it was agreed that the focus should be of allowing patients and the public to on the implementation of our core methodologies give us feedback about our services (post discharge surveys, ‘deep dive’ surveys and (£5k funding from Above and Beyond comment cards). to deliver a specific project of our However, in Quarter 4 of 2012/13 we are choosing) introducing a purpose-designed comment card to enable people with learning disabilities to tell us about their experience. Our action plan for 2012/2015 includes a commitment to develop innovative ways of engaging ‘seldom heard’ groups. The funding assigned by Above and Beyond has been used to support our core methodologies in Year 2 of our current strategy. Patient Experience and Involvement Strategy 2012-2015 141 To continue to engage our local Met / ongoing We continue to engage with relevant stakeholders, communities about matters which including our Local Involvement Networks, as they affect them and the Trust. approach a period of transition to HealthWatch. We will continue to welcome and act on the “listening exercises” our LINks undertake with seldom heard and vulnerable communities of interest and where appropriate, actively participate in these. Systematic measurement of patient In progress In Year 2 of the current strategy, we undertook a experience in Outpatient Clinics and will be comprehensive outpatient survey. We gave over met by 31st 4,000 people the opportunity to comment in detail March 2012 on their experience of being an outpatient at our hospitals. The feedback we received is being used to develop action plans which will be delivered through the Trust’s transformation activities. Comments cards and boxes will be in all outpatient settings by 31st March 2012. Integrated reporting using different Partially met During 2010-2012 we have moved to a point where forms of patient feedback, including patient feedback and complaints data are reviewed PALS and Complaints to give us a “360 alongside each other at the board and at corporate degree” view of patient and public and divisional quality meetings. There is more work involvement to do to integrate thematic learning from different sources of feedback and this ambition is reflected in our new strategy. 7. How will our new strategy differ from the previous one? Our strategy for 2010-12 focused on measuring patient experience and learning from this. The Trust had previously been reliant upon National Patient Surveys and various ad hoc local patient surveys, in addition to complaints, as sources of intelligence about what patients thought about our services. Thanks to the willingness of patients to share the things that matter to them, the financial support of our charitable trustees, the skills of our central patient experience team working in partnership with divisional leads, and the commitment of our staff, we are now in a very different place. The challenge is to take patient experience to ‘the next level’. In order to do this we need to: 1. Continue to refine our core patient experience tools; extending their use, prominence and influence 2. Develop a systematic approach to our qualitative patient and public engagement methods, such as focus groups and interviews 3. Use these qualitative methods as a springboard to developing a culture of collaboration with patients and the public in service delivery 8. Our objectives for patient experience and involvement We aspire to provide patients with an experience of hospital care that is second to none. We can only do this by working in partnership with people who use our services, their families and carers. This is particularly important in an environment Patient Experience and Involvement Strategy 2012-2015 142 where the Trust is required to make challenging decisions based on financial realities. There are a number of specific pieces of work that we plan to take forward during the course of the next three years to achieve this: a) Refining and developing how we measure the patient experience: Rationale: We need to ensure that the Trust’s core feedback channels are appropriate for the new strategy and that they continue to give people a voice. At the same time, we need to refine our approach in recognition of current financial constraints. We propose to continue a monthly post-discharge survey of inpatients, but to reduce the volume of this survey. This will reduce the cost of the survey, whilst retaining monthly board-level reporting (albeit with a slightly wider statistical margin for error in the data produced). For our wards, clinics and other departments, we will therefore place a renewed focus on the use of comment cards to drive real-time improvements at the point of service. We will carry out at least one major survey of outpatients each year, however we will seek to scale-back the overall volume of questionnaires we send out. We will continue to outsource our core patient surveys to guarantee a flow of reliable patient experience data into the organisation. We will seek to measure patient experience along specific agreed pathways of care and where possible we will do this in conjunction with commissioners and stakeholders. We propose to expand the volunteer base for the bi-monthly interview programme and also promote this as a learning opportunity for our own staff. We would like to develop a partnership understanding with our governors, who have been at forefront of measuring and understanding patient experience in outpatient areas, to develop an integrated model of working. We will develop a framework which enables the triangulation of a range of sources of patient feedback, including complaints. Our aim is to be able to present a single, joined-up view of patient experience that brings in feedback from a range of sources. We will develop our techniques for ‘drilling down’ into feedback data to identify demographic trends, e.g. ethnicity. Processes for supporting and quality assuring staff-led surveys will be reviewed as part of a ‘Lean’ review during 2012. We will embrace new developments in patient experience monitoring which emerge through the NHS Outcomes Framework (e.g. understanding and responding to the experience of bereaved relatives) and the anticipated NICE Patient Experience Quality Standard. Patient Experience and Involvement Strategy 2012-2015 143 b) Sharing what patients have told us and using this to drive change: Rationale: In order to maximise the positive influence of patient feedback, we need to share this information, and our learning from it, with a wider audience Working in partnership with the Trust’s communications team, we will develop a new and prominent facility for people to give feedback via the Trust’s internet site: we will also develop new patient experience web pages to enable us to share outcomes and actions with the public in accordance with a policy of candour. We will develop and increase our use of information boards around the Trust to display information about patient feedback. We will publish an annual patient experience report expanding on the summary information published in the Trust’s Quality Report (Account). As this report evolves, we will use it to provide a holistic view of patient experience from our full range of feedback channels. The Trust’s PPI team will work through Heads of Nursing to ensure ward staff have a shared understanding of the survey data displayed on the Trust’s productive ward information boards. We will continue to expect our Divisions to set challenging inpatient targets within their respective patient experience action plans, with an increased focus on shared learning between Divisions. Outpatient patient experience objectives will be identified based on feedback from patients via our surveys and other sources. Strong links will be in place with the productive outpatient project to ensure that patient experience measures are a core part of their evaluation process. We will establish clear lines of working between the Trust Patient Experience Group and Service Delivery Group to facilitate the implementation of change. The Trust’s PPI Team will develop closer links with the Innovation arm of the Trust’s Research and Innovation team, in order to maximise the impact of PPI activities. c) Not just measuring, but involving: Rationale: The Trust has listened and responded to feedback from patients and the public, but we want to involve them more in planning, developing, and delivering our services. We will develop and expand our organisational capacity to use qualitative patient experience methods such as focus groups. Our patient and public involvement activities will be extended to the new South Bristol Community Hospital. Working in partnership with the City Council, LINks and other partners we will develop new approaches to engaging and involving the local community in health related issues. Patient Experience and Involvement Strategy 2012-2015 144 We will continue to build constructive partnership working with external stakeholders, including LINks and new local HealthWatch, and the Patients’ Association. Working in partnership with the Trust’s equality and diversity manager and local health partners, we will conduct a stakeholder analysis to identify any particular groups or sections of our community who are not reached effectively by our current programme of feedback activities and involvement events. A structured programme will be put in place to address this. We will seek opportunities to facilitate patient-staff partnership in developing services, for example using methodologies such as experience-based co- design and service improvements3. d) Embedding patient involvement and experience activities at all levels of the Trust: Rationale: Patient and public involvement should become standard practice for staff working at all levels of the organisation and across all hospital services. We will provide staff with the necessary tools and training to enable them to carry out effective patient experience and involvement activities with minimal support from the corporate team. We will develop an evidence base of experience and involvement activities throughout the organisation (developing the existing ‘PPI log’). We want to develop a culture where patient experience considerations are at the heart of any key service changes or developments, embedding the philosophy of ‘nothing about me without me’: a culture where board papers routinely address the question ‘what do our patients think about this?’ and are challenged if they do not. The Trust’s PPI team will support the Trust’s research and innovation function to develop feedback from people involved in clinical trials and other research activities. The PPI team will also work with colleagues within the Trust, for example the patient support and complaints team and the equality and diversity manager, to maximise the positive impact of patient feedback on the organisation. 9. Accountability, responsibility and enablers Accountability for the strategy at Board level rests with the Chief Nurse on behalf of the Chief Executive. Responsibility for delivery of the strategy is shared by: The lead senior manager for patient experience – the Assistant Director for Audit and Assurance The lead clinician – the Deputy Chief Nurse 3 Methodologies used by the Trust in previous PPI activities with McKinsey and Company Patient Experience and Involvement Strategy 2012-2015 145 Nominated divisional leads (in the bed-holding divisions, these are the Heads of Nursing) The Trust’s corporate Patient and Public Involvement Team in conjunction with the Young Persons Involvement Facilitator at the Bristol Royal Hospital for Children Essential enablers, without which the strategy will not be deliverable include: Commitment from staff at all levels of the organisation Funding4 10. Evaluation: how we will assess whether this strategy has worked The success of our strategy will be measured by our patients telling us they have had positive experiences whilst in our care. The Trust’s overall objectives for patient experience as set out in our Quality Strategy 2011-2014 are to improve our performance, relative to other NHS providers, in the various NHS National Patient Surveys (inpatients, outpatients, A&E, maternity and cancer). In this way, our intention is to use the national surveys not so much as a driver for change (data from these surveys is published far too late and is of insufficient depth and reliability to enable it to be used effectively for improvement purposes) but rather as a barometer of whether our local patient experience initiatives are bearing fruit. Evaluation will therefore include: - achievement of overarching patient experience objectives as set out in the Trust’s quality strategy above - achievement of specific patient experience objectives for inpatients and outpatients which will be identified by our divisions on an annual basis for each year of the lifetime of this strategy, the majority of which will be measured through our systematic and robust postal surveys - achievement of any agreed CQUINs5 - reductions in reported complaints - evidence of how patient and public involvement has helped to shape our services - delivery of the action plan associated with this strategy document Progress will be monitored by the Patient Experience Group, Clinical Quality Group, the Quality and Outcomes Committee of the Board, and the Board itself. 4 The Trust will need to determine how the Patient Experience and Involvement Strategy will be funded. Activities associated with the previous strategy have been funded courtesy of the Trust’s charitable trustees, ‘Above and Beyond’. 5 Annual quality and innovation targets agreed with our commissioners Patient Experience and Involvement Strategy 2012-2015 146 11. Equality and diversity Patient and public involvement is about giving a voice to people to enable them to influence and shape the quality and direction of local healthcare services. We recognise that listening to people is essential to the future development of our hospitals and services. This means engaging with, and listening to, people of all backgrounds, from all social groups and all sections of the communities we serve. Our commitment to removing potential barriers to involvement forms part of the plans outlined in this strategy. An Equality Impact Assessment for this strategy is also available upon request. Patient Experience and Involvement Strategy 2012-2015 147 Appendix A This strategy was developed by the following people at UH Bristol: Chris Swonnell, Assistant Director for Audit and Assurance Joan Bayliss, Governor (Partnership Community Group constituency) Cathy Gane, Young Persons’ Involvement Worker Paul Lewis, Patient Involvement Co-ordinator Helen Morgan, Assistant Chief Nurse Tony Watkin, Public Involvement Project Lead The following key services, partners and individuals were invited to comment during the consultation phase of developing and testing this strategy: University Hospitals Bristol Heads of Nursing and Midwifery Jane Buswell, Nurse Consultant Care of Older People Chris Davies, Head of Spiritual and Pastoral Care Michele Doubtfire, Carers Development Project Elinor Griffiths, Research Facilitation and Grants Manager Lorna Hayle, Learning Disabilities Specialist Nurse Karen Hurley, Patient Support and Complaints Manager Andrew May, Equality and Diversity Manager Paul May, Non-Executive Director and Chair of the Board Quality and Outcomes Committee Sarah Pinch, Head of Communications Sue Silvey, Governor (Public constituency, Bristol) Partners Bristol City Council Neighbourhood Partnerships Bristol Community Health Bristol Equalities Health Partnership Bristol Local Involvement Network (LINk) Bristol Multi Faith Forum The Carers Support Centre NHS Bristol North Bristol NHS Trust South Gloucestershire Local Involvement Network (LINk) Other stakeholders and individuals John Plumb, Lay representative Andrew Howard, Lay representative John Langley, Chair of Bristol Local Involvement Network (LINk) Patient Experience and Involvement Strategy 2012-2015 148 Appendix B – Action Plan A. Improving structures, processes and outcomes Objective Action Lead Timescale Measure of success 1. Refine and 1.1 Complete survey tender process Paul Lewis 30th April 2012 Contracts in place for 2012/13. develop the 1.2 Consolidate and expand volunteer base for Tony Watkin Ongoing Continued ability to deliver the bi-monthly Trust's bi-monthly interview survey6 survey. patient st 1.3 Develop link between PPI team and Paul Lewis 31 May 2012 Process in place for clinics to use data experience governor outpatient survey programme collected by governor's in their outpatient measures constituency meetings. st 1.4 Review Patient Involvement Co-ordinator Chris Swonnell 31 July 2012 Job role refined and positioned to enable role as part of ‘Lean’ exercise in Trust’s delivery of 2012-15 strategy. Governance Team 1.5 Explore potential for integration of patient Paul Lewis / A recommendation Work plan in place for developing survey and complaints data Karen Hurley will be made to the integrated working from 2013 onwards. Patient Experience Group in the third quarter of 2012/13 (i.e. by 31st December 2012) 1.6 Operational development of an approach to Tony Watkin Throughout By 31st March 2013, processes will be patient experience and involvement at the new 2012/13 embedded through which the Trust South Bristol Community Hospital (SBCH) engages and involves the public and service users at SBCH. 6 In this context ‘volunteers’ could be members of staff, governors, or actual volunteers (note that expanding this role is one of the objectives of the Trust’s Volunteering Strategy) Patient Experience and Involvement Strategy 2012-2015 149 Objective Action Lead Timescale Measure of success 1.8 Develop divisional programme of focus Tony Watkin 31st March 2013 A paper will be presented to the Trust’s groups exploring identified themes (also see 1.9 Patient Experience Group in June 2012, below) with a view to commencing a co-ordinated programme in the third quarter of 2012/13. 1.9 In order to expand capacity, a group of Tony Watkin 31st December Suitable candidates will be identified and approximately 5-8 staff, governors or members 2013 trained in facilitation techniques. A will be identified to support focus group programme of work will commence in facilitation. 2014. 1.10 Monitor new / relevant patient experience Tony Watkin, Ongoing The relevant Trust staff will be aware of guidance and determine its implications for the Cathy Gane, and enabled to act upon the implications of Trust e.g. NICE Quality Standard, NHS Outcomes Paul Lewis, important new patient experience Framework Chris Swonnell guidance. 1.11 Begin to develop real-time measurement Heads of By 2015 This is an aspirational objective to begin to of patient experience along defined pathways of Nursing, Tony track the experience of patients in real- care. Watkin, Paul time at different points along agreed Lewis pathways of care, not just as a one-off measure or as retrospective feedback. Specific goals will be agreed for the third year of our strategy. 2. Share 2.1 Develop patient experience and Tony Watkin 31st August 2012 A more prominent feedback facility will be feedback and involvement pages on the Trust's external available on the home page of the Trust’s using this to internet web site; patient experience and drive change involvement pages will be more accessible and informative; key survey data will be updated monthly. Patient Experience and Involvement Strategy 2012-2015 150 Objective Action Lead Timescale Measure of success 2.2 Develop a record log that will include PPI Tony Watkin / 1st September 2012 The Trust will have an up to date record of activities conducted by the Research and Paul Lewis PPI activities that includes PPI work Innovation team undertaken by the Research and Innovation team. 2.3 Publish an annual patient experience and Paul Lewis / 30th August 2013 Using a variety of data (including involvement report (to include a child and Cathy Gane complaints), a comprehensive report will young people friendly version) be produced that gives people a view of how patients and the public view services at the Trust. 2.4 Develop stronger operational links between Chris Swonnell Developing Evidence of SDG ownership of patient the Trust’s Patient Experience Group and / James through the experience ambitions. Service Delivery Group to: Rimmer lifetime of this - facilitate the implementation of change strategy where operational issues arise from patient feedback - to ensure SDG becomes a point of challenge to ensure the patient perspective is integral to operational plans 2.5 Increase the prominence of PPI activities Tony Watkin / 30th April 2012 Noticeboard updates in place. using noticeboards around the Trust Stephanie Feldwicke Patient Experience and Involvement Strategy 2012-2015 151 Objective Action Lead Timescale Measure of success 3. Not just 3.1 Continue to build constructive partnership Tony Watkin / Ongoing Evidence of constructive, ongoing joint measuring working with external stakeholders, in particular Cathy Gane / working with key stakeholders. but involving LINks / Healthwatch Paul Lewis 3.2 Working in conjunction with the Trust's Tony Watkin / 31st August 2012 Relevant seldom-heard groups identified equality and diversity manager, we will conduct Andrew May a stakeholder analysis to identify any groups or sections of the community who are unlikely to be engaged by our existing core feedback channels. (see action 3.3 for next steps) 3.3 Tony Watkin / 1) completed by We will have a structured approach to 1) Carry out a pilot study to develop an Andrew May / 31st March 2013; engaging seldom-heard and vulnerable engagement approach with a selected ‘seldom Paul Lewis 2) Paper to Patient groups heard’ and vulnerable groups. Experience Group 2) Use learning from this to develop a by September structured approach to engaging wider seldom 2013; heard groups during 2013/14. 3) Programme 3) Carry this work forward as a structured commences April programme in 2014/15. 2014 3.4 We will develop an approach to service co- Tony Watkin, April 2014 onwards At least one Trust service will have been design with patients and the public, and identify Cathy Gane, through a programme of patient based co- a suitable service in which to carry this out Paul Lewis design by March 2015 Patient Experience and Involvement Strategy 2012-2015 152 Objective Action Lead Timescale Measure of success 4. Embed 4.1 Expand advice/guidance about PPI activities Paul Lewis 30th June 2012 New intranet / internet pages in place patient and on the Trust intranet. Set up a replica page on public the external net for university staff to access involvement at all levels of 4.2 Develop a culture where TME / Board Executive Developing PPI is seen as an indispensable aspect of the papers routinely address the question "what do Directors throughout the strategic decision making at the Trust. organisation our patients think about this?" and are lifetime of this challenged if they do not strategy 4.3 The corporate PPI Team will work with the Paul Lewis / Ongoing Ward staff will understand the productive Heads of Nursing to ensure that ward staff Heads of ward survey scores and be motivated to understand the nature and purpose of patient Nursing seek improvements. experience data displayed on productive ward boards 4.4 We will develop links between the corporate Debbie Cross-links Evidence of effective collaboration in the PPI team and the Research and Innovation (R&I) Posthelwaite / between the PPI development of the areas described here. team. This will include: Elinor Griffiths and research - links across respective webpages / Paul Lewis / websites put in - where appropriate, corporate PPI Tony Watkin place by contribution to the R&I team's new PPI September 2012; strategy / guides A formal PPI strategy for research will be developed by the R&I Team by April 2013; The R&I Team will produce a guide to PPI in research by December 2012 Patient Experience and Involvement Strategy 2012-2015 153 B. Specific areas where we want to improve patient experience In the Trust’s Quality Strategy 2011-2014, we made the following commitments to improving patient experience: In 2012/13: We will place a particular focus on the experience of children, patients in End of Life care (reflecting NHS Outcomes Framework priorities), and A&E patients (corresponding with the year in which the National A&E Patient Survey takes place). In 2013/14: We will place a particular focus on the experience of patients who use our maternity services (corresponding with the year in which the National Maternity Survey takes place). For each year of the lifetime of this strategy, our clinical divisions will identify specific and measurable ambitions to improve patient experience. Objectives will take into consideration: The commitments we have made in our Quality Strategy; The approach described in this Patient Experience and Involvement Strategy; The development of Department of Health ambitions for patient experience as expressed in the annual NHS Outcomes Framework; and most critically, Themes arising from what our patients tell us about our services. In addition, at the outset of the period of this strategy, we are also making a specific commitment to support and improve the experience of the following groups of ‘seldom heard and vulnerable’ people: i. Patients with Learning Difficulties A trial of easy-read Comments Card will be launched ahead of 1st April 2012 and will be reviewed over a three month period by our Learning Difficulties Specialist Nurses. The LD nurse team is committed to continuing to develop models of engagement appropriate to patients. A specific objective is to train the Trust’s volunteer interview team in communication skills to engage effectively with this patient group. Patient Experience and Involvement Strategy 2012-2015 154 ii. Frail elderly patients generally, and specifically patients with Dementia and the people who care for them It was agreed in 2011/12 that our existing reference group for patients with and carers of patients who have dementia was not an effective model of engagement. The group has therefore been merged with the wider Carers Reference Group. We have however developed stronger working links with the Alzheimer’s Society: outcomes from the Alzheimer’s Society/LINks listening exercises “Living with Dementia” will be available in 2012 and will inform the reference group’s action plan. At the time of writing (March 2012), additional reminiscence pods are being purchased for wards as a result of a grant from the WRVS. During the lifetime of this strategy and in line with current national learning, we will also focus on improving the experience of frail elderly patients in general. iii. Carers We will continue to work through the Carers Reference Group to develop our understanding of what it’s like to be a carer of a patient at UH Bristol and to improve carers’ experience of our services. In March 2012, our Patient Experience Group will receive a retrospective analysis of feedback received from carers during 2010 and 2011 - we anticipate that this will result in the agreement of specific objectives for improving carer-reported experience in 2012/13 and beyond. Patient Experience and Involvement Strategy 2012-2015 155 Cover Sheet for a Public Meeting of the Trust Board of Directors to be held on 27 March 2012 at 10:30am in the Conference Room, Trust Headquarters, Marlborough Street, Bristol, BS1 3NU Committee Reports - Item 10a – Finance Report Purpose To report to the Board on the Trust’s financial position and on related financial matters that require the Board’s attention. Abstract The summary income and expenditure statement shows a surplus of £6.566m for the eleven months to 29th February 2012. The operating surplus (EBITDA) at £32.72m is £2.248m (or 7.4%) greater than Plan for the period. The Trust’s Financial Risk Rating is 4 (actual = 3.65). The forecast outturn for the year has been increased to £8.5m in light of the requirement to meet a number of technical accounting changes in the Annual Accounts of the Trust for the year ending 31st March 2012. Recommendations To note the financial position at 29th February 2012. Report Sponsor Director of Finance, Paul Mapson. Other Author Head of Finance, Paul Tanner Appendices Appendix 1 – Summary Income and Expenditure Statement Appendix 2 – Divisional Income and Expenditure Statement Appendix 3 – Analysis of pay expenditure Appendix 4 – Executive Summary Appendix 5 – Financial Risk Matrix • Appendix 6 – Financial Risk Ratings Previous Meetings Trust Quality and Executive Finance Audit Management Outcomes Other Team Committee Committee Executive Committee 22/03/12 156 Trust Board 27th March 2012 Agenda Item 10a REPORT OF THE FINANCE DIRECTOR 1. Overview The summary income and expenditure statement shows a surplus of £6.566m for the eleven months to 29th February 2012. This is better than the Annual Plan projection for this period. The operating surplus (EBITDA1) at £32.720m is £2.248m (or 7.4%) greater than Plan for the period. The Financial Risk Rating is unchanged at 4 (actual 3.65), further information on this is given in section 5 below. It has recently been confirmed, through attendance by Finance staff at Annual Accounts workshops and discussions with the Trust’s External Auditor, that a number of technical changes are required to be included in the Trust’s Annual Accounts for 2011/12. None of these has a cash impact on the Trust’s position. The overall impact of these changes is that the forecast outturn has been increased from £7m to £8.5m. A summary of the changes is given in the table below. Position to Projected 29th February Outturn £’000 £’000 Reported / Projected Position 6,566 7,000 Reversal of asset impairment – Impact of District Valuer 976 assessment of asset indexation greater than the 2% assumed for financial planning purposes Prior Period Adjustment – reversal of impairment charged 644 to income and expenditure in 2010/11 Less notional Donated Assets depreciation income (1,250) Add Donated Assets Income 1,130 Revised Forecast Outturn 2011/12 8,500 The financial performance reported for the 11 months to 29th February is broadly in line with earlier projections towards a surplus of £7m for the year. The planning assumption to date has been that buildings would increase in value by 2% over the year to 31st March 2012. The projected gain arising from the reversal of the impairment charge (£1.154m to date) as a result of the indexation of the Trust’s buildings has been included in financial performance reports. For this month’s report the gain from the impairment reversal has been recorded as Operating Income (and therefore within EBITDA). Information has recently been received from the District Valuer to advise that the projected increase in the Trust’s buildings for the year will be 3.7%. This will increase the gain on the reversal of asset impairment charges by a further £0.976m in 2011/12. The recurring impact for 2012/13 onwards for depreciation charges and Trust Debt Remuneration dividend payments will be addressed as part of the budget setting process. The forecast outturn also now includes an adjustment for a transaction which took place in 2010/11. For that year an impairment charge of £644k was posted to the income and expenditure account. Following discussions with the Trust’s External Auditor it has been determined that this should be corrected in 2011/12 by moving the charge to the Revaluation Reserve with a corresponding credit 1 Earnings Before Interest Depreciation Taxation and Amortisation 157 to the Trust’s Income and Expenditure account. The effect of this transaction is to increase the reported surplus for 2011/12. Prior to 2011/12 the funding of Donated Assets was accounted for through the Donated Asset Reserve within Taxpayers’ Equity. From April 2011 Donated Assets are accounted for under the same standard as Government Grants (IAS 20). Donated income in relation to assets must now be recognised within income, unless the donor imposes a condition (i.e. if the asset is not used it is to be returned to the donor). Consequently the Donated Asset Reserve at the 31 March 2011 has been ‘unwound’ with the balance transferring to the Income and Expenditure Account and Revaluation Reserve. The funding for Donated Assets is now credited to Operating Income in the year of acquisition with the depreciation charged to Operating Expenditure over the life of the asset. The impact of this change is that the historical convention of introducing notional donated asset income to match donated asset depreciation is removed – the Trust’s financial plan assumed notional donated assets depreciation income of £1.25m this year. The projected donation income of £1.13m is to be brought into account in 2011/12. The achievement of cash releasing efficiency savings headline message is that February has seen delivery of CRES savings of £2.241m. This equates to 88% of the Plan for the month. The February report reflects an adverse variance of £5.295m year to date on the CRES programme. Actual savings of £19.122m represents slippage of £4.742m when compared with phased planned savings for the first eleven months of £23.864m. The adjustment to bring CRES plans on to a 1/12ths basis adds a further £0.553m to the reported non achieved CRES in the February report. The latest CRES forecast is that savings of £21.234m, a further improvement on last month’s forecast, will be achieved this year of which the non-recurring element is £4.547m (January = £3.996m). This represents an under achievement of £5.402m when compared with the Plan for the year of £26.636m. The full year effect of the 2011/12 CRES programme is estimated to be £20.082m. The Finance Committee will receive a more detailed report on CRES as a separate item on this month’s agenda. The table below shows that the in-month movement on the Trust’s income and expenditure position. The table sets out the variances on the four main income and expenditure categories together with a note on the impact of CRES slippage to date, on a 1/12ths basis. The overspending against divisional budgets totalled £0.463m in February. Detailed information and commentary for each Division is to be considered by the Finance Committee (report included under agenda item 5.3 below). Memorandum Variance to Variance this Variance to CRES 31st January month 29th February Variance Fav/(Adv) Fav/(Adv) Fav/(Adv) Fav/(Adv) £’000 £’000 £’000 £’000 Pay (936) (97) (1,033) (2,280) Non Pay (4,428) (847) (5,275) (3,083) Operating Income 587 190 777 71 Income from Activities (557) 291 (266) (3) Totals (5,334) (463) (5,797) (5,295) It can be seen that the non achievement of savings within the CRES programme is still a feature on the expenditure lines shown in the table above to the extent that had the savings been achieved then a surplus would be reported on the pay heading and the overspend on non pay budgets would be greatly reduced. 158 Pay budgets have overspent in February by £0.097m bringing the cumulative overspending to £1.033m. Significant overspendings are recorded this month against the Women’s and Children’s Services (£96k), Medicine (£75k) and Specialised Services (£130k). Further information is given on these adverse movements in the Divisional commentary below with more detail provided in Divisional financial commentaries for the Finance Committee. Continued maintenance on the control of pay budgets is an essential element in providing a solid platform for 2012/13. Non pay budgets show a further overspending in February of £0.847m to a cumulative adverse variance of £5.275m. Slippage on non-pay CRES schemes of £0.158m in the month, cumulative slippage £3.083m, is embedded within this position. Significant overspendings are reported this month against Diagnostic and Therapies (£244k) Medicine (£122k), Specialised Services (£187k) and Surgery, Head and Neck (£267k). Operating Income budgets show a cumulative favourable variance of £0.777m with a favourable movement of £0.190m recorded in February. The principal areas of favourable performance are reported in the Divisions of Medicine and Women’s & Children’s services together with Trust HQ. Income from Activities shows an over performance of £0.291m for February (January activity reported a month in arrears). 2. The main Divisional Budget changes in February include the following:- £’000 Capital to Revenue transfer 296 Clinical Systems Implementation Programme 162 European Working Time Directive 112 Energy Inflation 52 3. Income For the year to date, contract income is £2.68m greater than plan. This position includes £0.81m related to 2010/11 activity; therefore 2011/12 contract income is £0.61m ahead of Plan. Further information on principal commissioner Service Level Agreement variances is given below. Clinical Income by Worktype Plan Actual Variance £’m £’m £’m Accident & Emergency 9.00 9.25 0.25 Emergency Inpatients 60.58 61.34 0.76 Day Cases 28.26 29.60 1.34 Elective Inpatients 40.05 38.62 (1.43) Non-Elective Inpatients 24.78 25.62 0.84 Excess Bed days 7.39 6.28 (1.11) Outpatients 54.35 54.01 (0.34) Bone Marrow Transplants 7.47 6.62 (0.85) Critical Care Bed days 28.54 28.96 0.42 PbR Exclusions / NICE 31.29 29.40 (1.89) Contract Penalties / Rewards (5.73) (5.45) 0.28 Other 38.88 42.48 3.60 Sub-Totals 324.86 326.73 1.87 2010/11 Estimate v Actual - 0.81 0.81 Totals 324.86 327.54 2.68 159 This month’s income position also reflects the following assessment of contract penalties / rewards. Month 10 Current Month 11 (Penalties) / Rewards Year to Date Month Year to Date £m £m £m CQUINS(Variance against Plan) 1.73 0.12 1.85 Emergency Readmissions (Variance against Plan) (0.29) - (0.29) Emergency Marginal Tariff (Variance against Plan) (0.06) 0.15 0.09 First to Follow Up OP Ratio (Variance against Plan) 0.67 0.08 0.75 Others (0.14) (0.12) (0.26) Totals 1.091- 0.23 2.14 The contract penalties associated with emergency admissions following an elective or emergency spell total £3.32m for the first 10 months of 2011/12. There are also a number of significant SLA risks from potential fines and limiters including cancelled operations, 18 week referral to treatment, INNF (interventions not normally funded) cases subject to prior approval etc. The income over-performance position can be summarised as follows: SLA Variances - £m South West Other BNSSG2 Specialist Totals Commissioners Commissioning Over/(under) performance as at Month 10 10.51 (1.70) (6.95) 1.86 QIPP (8.83) - 8.83 - A&E / Emergencies 0.14 0.05 (0.42) (0.24) Residual Over / (Under) performance 1.82 (1.65) 1.46 1.62 This demonstrates that, for example, of the £10.51m over-performance to date for BNSSG £8.69m is due to QIPP and A&E / Emergency activity. In total there is, therefore, a net residual over performance of £1.82m. 4. Expenditure In total, Divisions are shown as overspent by £5.797m for the eleven month period to 29th February. The position for each Division, together with comparable results with CRES accounted for on the Divisional Phased Plan basis, is summarised below: CRES on 1/12ths profiling CRES on Phased Plan Variance to Memorandum Variance to Memorandum Division 29th February CRES Variance 29th February CRES Favourable / to 29th Favourable / Variance to (Adverse) February (Adverse) 29th February £’000 £’000 £’000 £’000 Diagnostic and Therapies 43 (66) 71 (38) Medicine (1,186) (645) (1,080) (539) Specialised Services (1,978) (973) (1,922) (917) Surgery, Head and Neck (1,608) (2,283) (1,327) (2,002) Women’s and Children’s (1,398) (1,141) (1,333) (1,076) Facilities and Estates 5 (40) 19 (26) Trust Services 176 49 179 52 Other Services 149 (196) 149 (196) Totals (5,797) (5,295) (5,244) (4,742) 2 Bristol, North Somerset and South Gloucestershire Commissioner 160 The Diagnostic and Therapies Division reports a cumulative underspending of £43k – an underspending of £99k in the month. Pay budgets have underspent this month by £81k bringing the cumulative position to £302k favourable. The favourable performance reflects the continued holding of vacancies in Radiology and Laboratory Medicine, Medical Physics and Physiotherapy. Non pay budgets show an overspending of £224k in the month to give a cumulative adverse variance of £725k. Further work undertaken since the closedown of the ledger for the month indicates that the position is better than reported at this stage. The investigations into timing and transactions within the new Pharmacy system will be completed shortly and the favourable adjustments will be reflected in the March report. Income from Activities shows a favourable movement this month of £287k reflecting SLA over-performance by the Division and a share of other services provided by the Trust together with CQUINs income. Operating Income has under achieved by £25k in the month. The Division of Medicine reports an adverse variance of £1,186k for the eleven months to 29th February. The headline figure of a Divisional overspend of £99k for the month is made up of an Emergency Marginal Tariff adjustment with Specialised Services which adversely affects the Division of Medicine by £205k and a favourable performance on the Division’s operational budgets of £106k for February. To date pay budgets are overspent by £438k, a deterioration of £75k in February. Non pay budgets show a cumulative overspending of £1,245k (January £1,123k adverse). This is a continuation of the previously reported trend relating to slippage on CRES and overspendings on other headings. The Division reports that expenditure in February was £86k lower than January. Operating income budgets continue to perform well with the in month underspending of £73k increasing the cumulative favourable position to £381k. Income from Activities shows a favourable movement this month of £25k and a cumulative favourable variance of £116k to date. The non achievement of CRES at £0.645m continues to be a significant factor in the Division’s reported position. The Division of Specialised Services reports an adverse variance on its income and expenditure position of £1,978k, a reported net overspending of £390k in February. The February performance is after a favourable adjustment in respect of EMT3 (and see Division of Medicine) to a value of £205k. Pay budgets are reported as having a cumulative overspending of £1,150k, an overspending of £130k in the month. This follows the continuing use of higher than budgeted staff through agency to cover, for example, gaps in the cardiac surgery junior doctor rota. Non pay budgets have overspent by £187k in the month resulting in a cumulative overspending of £513k. The results for February include an underspending on blood products (£15k) offset by higher than planned expenditure on clinical supplies, slippage on CRES and other structural funding issues. CRES slippage of £444k to date is clearly a significant factor in non pay budgets being overspent to date. This month has seen an under performance on Operating Income budgets of £7k thereby reducing the cumulative favourable variance to £192k. Income from Activities shows an adverse variance of £66k in the month. This is net of the favourable adjustment for EMT and results in a cumulative adverse position of £507k. The Division has an agreed control total of £2m adverse (to be revised downwards for the EMT adjustment) and given the results to 29th February is significantly off trajectory to meet this target. The Surgery, Head and Neck Division reports a cumulative adverse variance on its income and expenditure position of £1,608k, an overspending of £122k in February. Pay budgets have a cumulative underspending of £228k, an overspending in the month of £108k. The February overspending includes the cost of covering junior general surgery posts with agency and locum staff and sickness cover in ITU and Anaesthesia provided by the payment of additional sessions. Non pay budgets are overspent by £1,675k to date, an increase of £267k in the month. The Division was given non-recurring funding of £2m at the start of the year so as to provide some time to bring its operations into recurring financial balance for quarter 4. The funding was profiled into the 3 Emergency Marginal Tariff 161 Division’s budgets over the period April – December i.e. £222k each month. February is the second month in which the Division’s financial performance is reported without the benefit of the non-recurring support. As the Division has yet to secure recurring financial balance this month’s results reflect a proportion of the underlying deficit. The Division reports higher than planned expenditure in theatres on the BRI and St Michael’s sites which is understood to be partially linked to increased activity. Slippage on the delivery of the CRES programme at £1.410k is also a significant factor in the Division’s performance on non pay budgets. Income from Activities shows a favourable variance of £24k this month to bring the cumulative position to £401k adverse. Operating Income budgets have a favourable variance of £13k in February thereby increasing the cumulative over achievement to £240k. The Division of Women’s and Children’s Services reports an adverse variance on its income and expenditure position of £1,398k – a net underspending of £101k in February. Pay budgets are overspent by £916k – an adverse movement of £96k in the month. Slippage on CRES accounts for £40k of the overspending. The remainder of the variance relates to nursing staff costs linked to higher than planned levels of 1:1 and 1:2 nursing on medical wards, high winter occupancy rates in PICU and continuing agency premium costs where bank shifts are difficult to fill. Non pay budgets show a cumulative overspending of £234k – an underspending of £104k in February. Income from Activities budgets have overachieved in the month with a favourable variance of £53k, cumulative adverse variance of £317k. Slippage to date on the CRES programme of £1.141m is a significant factor in the Division’s reported financial position. The Facilities and Estates Division reports a cumulative underspending to date of £5k, an improvement of £14k in the month. Trust Services report an in-month underspending of £20k thereby increasing the cumulative underspending to date to £176k. 5. Financial Risk Rating The Trust’s overall financial risk rating, based on results to 29th February is 4. The actual financial risk rating is 3.65 (January = 3.65) which rounds up to 4. The actual value for each of the 5 metrics is given in the table below together with the bandings for each metric. 29th February 2012 Metric Metric Weighted Metric Result Score Average Weighting Rating categories Score % 5 4 3 2 1 EBITDA Margin 7.1% 3 0.75 25 11 9 5 1 <1 Plan achieved 107.4% 5 0.50 10 100 85 70 50 <50 Return on Capital 5.5% 4 0.80 20 6 5 3 -2 <-2 Employed I&E surplus margin 1.9% 3 0.60 20 3 2 1 -2 <-2 Liquidity ratio (days) 28.6 days 4 1.00 25 60 25 15 10 <10 3.65 Overall Financial Risk Rating 4 The technical accounting changes referred to earlier in this report will lead to a favourable impact on the Trust’s performance within each metric but is not likely to result in any upward revision to 162 any metric scores. For example, this month’s EBITDA Margin is shown as 7.1% (January 6.85%). The principal reason for the change is the accounting of the gain from the asset revaluation as operating income (£1.154m to February). It has recently been confirmed (attendance at Annual Accounts workshops and discussions with the Trust’s External Auditor) that a number of items such as certain recharges of pay costs and the treatment of bad debts will need to be accounted for on a ‘gross’ basis for 2011/12 and subsequent years. This is a minor change in some cases where income has been netted off against expenditure. There will be no change to the Trust’s overall income and expenditure outturn but total income and expenditure values will be correspondingly higher, by around £5m. A consequence of having a higher turnover value is that there will be a marginal dilution in the performance against the EBITDA Margin, Income and Expenditure Surplus Margin and Liquidity Ratio metrics. The Trust is operating well within the 4 metrics specified in the Prudential Borrowing Limit. Further information is given at Appendix 6. Capital Programme A summary of income and expenditure for the eleven months to 29th February is given in the table below. Expenditure for the period of £34.941m is £1.331m less than the current Plan. 11 Months Ended 29th February 2012 Plan for Variance Year Plan Actual Favourable / (Adverse) £’000 £’000 £’000 £’000 Sources of Funding 1,156 Donations - - - 16,833 Retained Depreciation 15,559 15,497 (62) 1,808 Sale of Property 1,808 1,987 179 600 Grant - University of Bristol 600 600 - 31,073 Cash balances 18,305 16,857 (1,448) 51,470 Total Funding 36,272 34,941 (1,331) Expenditure (27,321) Strategic Schemes (21,616) (21,661) (45) (5,225) Medical Equipment (1,104) (754) 350 (5,497) Information Technology (4,008) (4,124) (116) (2,165) Roll Over Schemes (1,614) (1,583) 31 (4,076) Refurbishments (2,818) (2,592) 226 (10,407) Operational / Other (5,112) (4,227) 885 3,221 Anticipated Slippage - - - (51,470) Total Expenditure (36,272) (34,941) 1,331 Expenditure for the year is projected to be £42.034m.This reflects anticipated slippage on medical equipment, operational capital, refurbishments and contingency funds which are not expected to be required in 2011/12. 163 6. Statement of Financial Position (Balance Sheet) and Cashflow Cash - The Trust held a cash balance of £45.104m as at 29th February. The graph, shown below, sets out the current forecast for month end cash balances to March 2012. Debtors - The total value of invoiced debtors has decreased by £2.972m during February to a closing balance of £15.241m. The principal change relates to the payment of invoices by NHS Bristol where the debtor balance has reduced this month by £3.319m. The total amount owing is equivalent to 12.6 debtor days. 164 Accounts Payable Payments - The Trust aims to pay at least 90% of undisputed invoices within 30 days. In February the Trust achieved 85% and 94% compliance against the Better Payment Practice Code for NHS and Non NHS creditors. Accounts Payable Performance 2011/12 Attachments Appendix 1 – Summary Income and Expenditure Statement Appendix 2 – Divisional Income and Expenditure Statement Appendix 3 – Monthly analysis of pay expenditure 2011/12 Appendix 4 – Executive Summary Appendix 5 – Financial Risk Matrix Appendix 6 – Financial Risk Rating 165 Appendix 1 UNIVERSITY HOSPITALS BRISTOL NHS FOUNDATION TRUST Finance Report February 2012- Summary Income & Expenditure Statement Approved Position as at 29th Feb Actual to 31st Forecast Budget / Plan Heading Variance Plan Actual Jan Outturn 2011/12 Fav / (Adv) £'000 £'000 £'000 £'000 £'000 £'000 Income (as per Table I and E 2) 394,568 From Activities 362,155 362,470 315 329,814 396,256 108,809 Other Operating Income 95,779 96,568 789 88,283 106,578 503,377 Sub totals income 457,934 459,038 1,104 418,097 502,834 Expenditure (310,833) Staffing (284,767) (285,801) (1,034) (259,275) (310,015) (150,200) Supplies and services (134,879) (140,517) (5,638) (130,198) (156,988) (461,032) Sub totals expenditure (419,646) (426,318) (6,672) (389,473) (467,003) (7,558) Reserves Reserves (7,816) - 7,816 - - (7,558) Sub Total Reserves (7,816) - 7,816 - - 34,786 EBITDA 30,472 32,720 2,248 28,624 35,831 6.91 EBITDA Margin - % 7.13 6.85 7.13 (1,356) Fixed asset impairments (1,356) (1,356) - (216) (207) (5) Profit/ loss on sale of asset (5) 176 181 190 190 (18,204) Depreciation & Amortisation (16,696) (16,644) 52 (15,165) (18,204) 357 Interest Receivable 327 347 20 323 350 (411) Interest payable on loans & leases (377) (377) - (342) (411) (9,162) PDC Dividend (8,398) (8,300) 98 (7,551) (9,049) 6,006 NET SURPLUS / (DEFICIT) 3,967 6,566 2,599 5,863 8,500 1.19 Net margin - % 1.43 1.40 1.7 166 Appendix 2 UNIVERSITY HOSPITALS BRISTOL NHS FOUNDATION TRUST Finance Report February 2012- Divisional Income & Expenditure Statement Position as at 29th Feb [Favourable / (Adverse)] Approved Total Net Memorandum Cumulative Forecast Budget / Plan Expenditure / Operating Income from Total Variance CRES Variance Variance to Outturn Division Pay Non Pay 2011/12 Income to Date Income Activities to date to Date 31st Jan Variance £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Service Agreements 388,931 Service Agreements 355,516 ------(3,030) Overheads (2,449) - - - 581 581 - 515 500 40,517 NHSE Income 37,139 ------426,418 Sub Total Service Agreements 390,206 - - - 581 581 - 515 500 Clinical Divisions (42,402) Diagnostic & Therapies (38,467) 302 (725) (468) 934 43 (66) (56) 100 (56,998) Medicine (53,445) (438) (1,245) 381 116 (1,186) (645) (1,087) (1,220) (65,680) Specialised Services (60,977) (1,150) (513) 192 (507) (1,978) (973) (1,588) (1,776) (87,481) Surgery Head & Neck (81,303) 228 (1,675) 240 (401) (1,608) (2,283) (1,486) (1,883) (86,114) Women's & Children's (80,090) (916) (234) 69 (317) (1,398) (1,141) (1,499) (1,150) (338,675) Sub Totals (1) (314,282) (1,974) (4,392) 414 (175) (6,127) (5,108) (5,716) (5,929) Corporate Services (52) Community (22) - 26 - - 26 (3) 23 27 (6,891) Trust HQ (6,222) 99 (252) 183 - 30 (1) 29 - (5,243) Human Resources (4,637) 208 (188) 30 - 50 3 31 40 (6,143) Information Technology (5,534) 196 (133) (13) - 50 - 47 50 (5,136) Finance (4,656) 133 (11) (76) - 46 47 49 50 (26,396) Facilities & Estates (23,902) 238 (275) 75 (33) 5 (40) (9) - (7,238) Misc Support Services (7,374) 122 (214) 41 (58) (109) (193) 28 - 9,197 Research and Development 6,989 (55) 14 114 - 73 - 66 81 (26,336) Capital Charges (23,999) - 150 9 - 159 - 118 - (74,238) Sub Totals (2) (69,357) 941 (883) 363 (91) 330 (187) 382 248 (412,913) Sub Totals (1) and (2) (383,639) (1,033) (5,275) 777 (266) (5,797) (5,295) (5,334) (5,681) - Skills for Health (1) (1) (12) 12 - (1) - 6 - (412,913) Totals I & E (383,640) (1,034) (5,287) 789 (266) (5,798) (5,295) (5,328) (5,681) Reserves (7,499) General - - 7,816 - - 7,816 - 6,243 7,681 (7,499) Sub Total Reserves - - 7,816 - - 7,816 - 6,243 7,681 6,006 TRUST TOTALS 6,566 (1,034) 2,529 789 315 2,599 (5,295) 1,430 2,500 167 Item 10a - Appendix 3 Analysis of pay spend 2010/11 and 2011/12 Division 2010/11 2011/12 2010/11 Mthly Mthly Total April May June Q1 July August Sept Q2 Oct Nov Dec Q3 Jan Feb YTD Total Average Average £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Women's and Pay budget 65,891 5,560 5,526 5,552 16,638 5,535 5,617 5,564 16,716 5,639 5,690 5,573 16,901 5,759 5,751 61,765 5,615 5,491 Children's Bank 2,076 119 165 212 496 169 165 189 524 184 203 134 521 142 192 1,875 170 173 Agency 654 39 88 55 182 40 59 29 128 62 35 65 162 70 111 652 59 55 Waiting List initiative 304 26 25 22 73 16 24 2 42 10 1 5 16 7 9 147 13 25 Overtime 91 4 5 5 14 5 3 3 11 2 2 3 7 5 3 41 4 8 Other pay 62,798 5,401 5,447 5,371 16,219 5,372 5,577 5,325 16,274 5,401 5,582 5,350 16,333 5,611 5,514 59,951 5,450 5,233 Total Pay expenditure 65,923 5,589 5,730 5,665 16,984 5,602 5,828 5,548 16,979 5,660 5,823 5,556 17,039 5,835 5,829 62,666 5,697 5,494 Variance Fav / (Adverse) (32) (29) (204) (113) (346) (67) (211) 16 (263) (21) (134) 17 (138) (76) (78) (901) (82) (3) Medicine (incl Pay budget 41,745 3,548 3,791 3,695 11,034 3,644 3,599 3,657 10,900 3,692 3,631 3,616 10,938 3,660 3,654 40,187 3,653 3,479 Central Services for 2011/12) Bank 3,434 236 270 339 845 227 276 255 758 243 271 175 689 212 281 2,785 253 286 Agency 559 30 62 65 157 59 21 61 141 34 25 54 113 21 74 506 46 47 Waiting List initiative 315 9 10 11 30 3 0 1 4 21 (12) 17 26 23 15 98 9 26 Overtime 69 5 7 13 25 5 5 5 15 4 5 7 16 6 4 65 6 6 Other pay 38,883 3,413 3,405 3,500 10,318 3,378 3,367 3,349 10,094 3,373 3,438 3,231 10,041 3,388 3,355 37,197 3,382 3,240 Total Pay expenditure 43,260 3,693 3,754 3,928 11,375 3,672 3,669 3,670 11,012 3,676 3,726 3,483 10,884 3,651 3,729 40,651 3,696 3,605 Variance Fav / (Adverse) (1,515) (145) 37 (233) (341) (28) (70) (13) (111) 16 (95) 132 54 10 (75) (464) (42) (126) Surgery Head and Pay budget 66,148 5,541 5,245 5,630 16,416 5,607 5,605 5,735 16,947 5,652 5,686 5,706 17,045 5,711 5,904 62,023 5,638 5,512 Neck Bank 2,100 119 127 204 450 183 152 191 525 166 190 141 497 160 164 1,796 163 175 Agency 1,206 41 69 11 121 (2) 53 44 95 67 68 40 175 19 33 443 40 101 Waiting List initiative 1,209 98 127 79 304 16 27 7 50 59 96 65 220 77 34 685 62 101 Overtime 152 7 7 8 22 15 8 12 35 12 14 13 40 16 17 129 12 13 Other pay 61,071 5,143 5,327 5,314 15,784 5,337 5,352 5,406 16,096 5,383 5,229 5,309 15,921 5,477 5,549 58,826 5,348 5,089 Total Pay expenditure 65,738 5,408 5,657 5,616 16,681 5,549 5,592 5,660 16,801 5,688 5,597 5,568 16,853 5,749 5,797 61,880 5,625 5,478 Variance Fav / (Adverse) 410 133 (412) 14 (265) 58 13 75 146 (35) 90 138 192 (37) 107 143 13 34 Specialised Pay budget 33,790 2,669 3,066 2,900 8,635 2,829 2,865 2,919 8,613 2,858 2,933 2,850 8,641 3,144 2,956 31,989 2,908 2,816 Services Bank 1,049 61 74 95 230 87 93 85 265 81 102 58 241 63 69 869 79 87 Agency 654 (69) 230 82 243 116 104 73 293 75 93 77 245 114 96 991 90 55 Note : January budget and Waiting List initiative 537 51 42 45 138 34 29 23 86 38 72 17 127 25 14 390 35 45 expenditure includes Overtime 20 2 0 1 3 1 1 2 4 1 5 1 6 6 5 24 2 2 reclassification of Other pay 32,290 2,684 2,813 2,786 8,283 2,857 2,765 2,741 8,362 2,749 2,737 2,732 8,219 3,111 2,901 30,877 2,807 2,691 peripheral clinic staff Total Pay expenditure 34,550 2,729 3,159 3,009 8,897 3,095 2,992 2,924 9,011 2,944 3,009 2,886 8,839 3,319 3,085 33,151 3,014 2,879 recharges. Variance Fav / (Adverse) (760) (60) (93) (109) (262) (266) (127) (6) (398) (85) (76) (37) (198) (175) (129) (1,162) (106) (63) 168 Item 10a - Appendix 3 Analysis of pay spend 2010/11 and 2011/12 Division 2010/11 2011/12 2010/11 Mthly Mthly Total April May June Q1 July August Sept Q2 Oct Nov Dec Q3 Jan Feb YTD Total Average Average £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 DiagnosticWomen's and & Pay budget 36,929 3,045 2,998 3,078 9,121 3,089 3,126 3,066 9,280 3,120 3,041 3,210 9,371 3,239 3,161 34,172 3,107 3,077 TherapiesChildren's Bank 544 46 50 48 144 35 43 29 108 35 52 42 129 41 41 462 42 45 Agency 389 24 32 17 73 13 29 4 46 9 18 36 63 39 27 249 23 32 Waiting List initiative 156 14 15 8 37 15 6 6 27 17 6 5 28 9 8 109 10 13 Overtime 264 22 20 26 68 17 19 13 49 21 19 28 67 27 25 236 21 22 Other pay 35,515 2,937 2,961 3,017 8,915 3,025 3,015 2,989 9,029 3,068 3,007 2,891 8,965 3,054 2,997 32,960 2,996 2,960 Total Pay expenditure 36,868 3,043 3,078 3,116 9,237 3,105 3,112 3,041 9,258 3,150 3,102 3,001 9,253 3,170 3,098 34,016 3,092 3,072 Variance Fav / (Adverse) 61 2 (80) (38) (116) (16) 13 24 22 (30) (61) 209 119 69 63 156 14 5 Facilities & Pay budget 18,706 1,398 1,532 1,727 4,657 1,567 1,647 1,593 4,807 1,515 1,611 1,528 4,655 1,565 1,632 17,316 1,574 1,559 Estates Bank 483 29 29 35 93 26 22 27 75 25 19 28 72 27 27 293 27 40 Agency 1,300 128 105 118 351 148 99 133 380 100 87 126 312 89 141 1,273 116 108 Waiting List initiative 7 1 1 0 2 0 0 0 0 0 0 0 0 0 0 2 0 1 Overtime 1,160 79 95 112 286 97 53 100 250 98 123 87 308 83 95 1,022 93 97 Other pay 15,591 1,164 1,300 1,448 3,912 1,281 1,435 1,305 4,021 1,306 1,300 1,300 3,906 1,337 1,315 14,491 1,317 1,299 Total Pay expenditure 18,541 1,401 1,530 1,713 4,644 1,552 1,609 1,565 4,726 1,529 1,529 1,541 4,598 1,535 1,578 17,082 1,553 1,545 Variance Fav / (Adverse) 165 (3) 2 14 13 15 37 28 80 (14) 83 (12) 57 30 54 234 21 14 Trust Services Pay budget 26,763 4,034 316 2,019 6,369 2,073 1,962 3,212 7,248 2,344 2,286 2,497 7,127 2,111 2,092 24,947 2,268 2,230 Bank 609 38 24 53 115 47 68 42 157 (9) (6) 4 (11) (7) 3 258 23 51 Agency 209 13 (4) 0 9 21 5 27 53 29 38 16 83 23 33 200 18 17 Waiting List initiative 7 1 1 (3) (1) 0 0 0 0 0 0 0 0 0 0 (1) (0) 1 Overtime 108 7 5 4 16 3 4 10 17 5 8 9 23 7 23 86 8 9 Other pay 26,087 4,093 365 2,074 6,532 1,774 1,920 3,137 6,832 2,117 1,971 2,528 6,617 1,998 2,072 24,051 2,186 2,174 Total Pay expenditure 27,020 4,152 391 2,128 6,671 1,845 1,997 3,216 7,059 2,143 2,011 2,557 6,711 2,022 2,131 24,594 2,236 2,252 Variance Fav / (Adverse) (257) (118) (75) (109) (302) 228 (35) (4) 189 201 274 (60) 416 89 (39) 353 32 (21) Trust Total (excl Pay budget 289,972 25,795 22,474 24,601 72,870 24,344 24,421 25,745 74,510 24,820 24,877 24,981 74,678 25,190 25,150 272,398 24,763 24,164 Skills for Health) Bank 10,295 648 739 986 2,373 774 820 819 2,413 725 830 582 2,137 638 777 8,338 758 858 Agency 4,971 206 582 348 1,136 395 370 371 1,136 377 363 414 1,154 374 515 4,315 392 414 Waiting List initiative 2,535 200 221 162 583 84 86 39 209 145 163 109 417 141 80 1,430 130 211 Overtime 1,864 126 139 169 434 143 93 144 380 143 176 147 466 150 172 1,603 146 155 Other pay 286,411 24,835 21,618 23,510 69,963 23,024 23,432 24,252 70,708 23,398 23,264 23,341 70,003 23,977 23,703 258,353 23,487 23,868 Total Pay expenditure 291,900 26,015 23,299 25,175 74,489 24,420 24,800 25,625 74,845 24,788 24,795 24,593 74,177 25,281 25,247 274,039 24,913 24,325 Variance Fav / (Adverse) (1,928) (220) (825) (574) (1,619) (76) (379) 120 (335) 32 82 388 502 (91) (97) (1,641) (149) (161) 169 Trust Board – March 2012 Agenda Item 10a - Appendix 4 Key Issue RAG Executive Summary Table Service For the year to date contract income is £2.67m greater than plan. This is net of the over performance adjustment INC 1 Level G of £0.81m which relates to 2010/11. The reported position includes the impact of the emergency marginal tariff Agreement reduction which is valued at £0.09m favourable (last month £0.06m adverse) and SLA Contract Penalties / Income and Rewards at a net reward of £2.05m (January net reward £1.97m). Activity A&E Attendances at 95,230 are 1,634 higher than planned. The average number of daily attendances is 311. Emergency activity at 31,489 is 0.8% or 253 spells lower than planned. Non Elective activity at 13,098 is 2.1% or 271 spells higher than planned. Elective activity at 11,961 is 5.4% or 685 spells lower than planned. Day case activity at 40,967 is 4.9% or 1,925 spells higher than planned. Outpatient Procedure activity at 21,973 is 10.4% or 2,070 spells higher than planned. New Outpatients activity at 111,506 is 1.3% or 1,416 attendances lower than planned. Follow up Outpatient activity at 257,626 is 3.6% or 9,733 attendances lower than planned. An income analysis by commissioner is shown at Table INC 2. Information on clinical activity by Division, specialty and patient type is provided in table INC 3. Income and The reported surplus for the eleven months to 29th February is £6.566m. I&E 1 Expenditure G The EBITDA surplus of £32.720m equates to 107% of the Annual Plan target for the period. I&E 2 Total income to date £459.038m is £1.104m greater than Plan. This includes £0.810m of residual over I&E 3a performance relating to 2010/11. I&E 3b Expenditure at £426.318m is greater than Plan by £6.672m, this reflects higher than planned expenditure in a number of areas and slippage to date on CRES plans. Financing costs are lower than plan by £351k. 170 Key Issue RAG Executive Summary Table Cash The 2011/12 CRES programme totals £26.636m. Actual savings achieved for the eleven months to 29th I&E Releasing R February total £19.122m compared with a target for the period of £23.864m, a shortfall of £4.742m (January 4a – 4b Efficiency cumulative shortfall £4.428m). The forecast savings for the year is £21.234m (January £21.101m). Savings Statement of The cash balance on 29th February was £45.104m. The forecast cash balance for 31st March 2012 at £40.3m is BS 1 Financial G higher than the Annual Plan forecast of £30.312m as a result of an increase in projected Skills for Health BS 2 Position income and a reduction on net capital expenditure. BS 3 & The balance on Invoiced Debtors has decreased by £2.972m in the month to £15.241m. The invoiced debtor BS 4 Treasury balance equates to 12.6 debtor days. Management Creditors and accrual account balances total £69.724m although £13.815m relates to deferred income. Invoiced Creditors - payment performance for the eleven months to 29th February Non NHS invoices and NHS invoices within 30 days was 92% and 87% respectively. Capital Expenditure for the eleven months to 29th February totals £34.941m - this is £1.331m less than profiled for the G period. Expenditure for the year is projected to be £42.034m. The principal areas of slippage to date are recorded against Operational capital schemes (£0.885m), medical equipment (£0.350m) and Refurbishments (£0.226m). Financial The Trust's overall financial risk rating using the results for the eleven months to 29th February 2012 has been Risk Rating G calculated to be 4 (actual score 3.65). The Trust’s ratings under the Prudential Borrowing Code are satisfactory with all ratios well within the Monitor thresholds. Private Private patient income for the period is £2.366m or 0.65% of total patient related income. This is well below G Patient Cap the Trust’s Private Patient Cap of 1.1%. 171 Item 10a - Appendix 5 UNIVERSITY HOSPITALS BRISTOL NHS FOUNDATION TRUST Finance Report February 2012 - Risk Matrix Corporate Risk if no action taken Residual Risk Risk Register Description of Risk Financial Action to be taken to mitigate risk Lead Financial Progress / Completion Risk Score Risk Score Ref. Value Value £'m £'m Programme Steering Group established. Monthly Divisional Mitigated by Trust Reserves to ensure 741 CRES Targets High 12.0 reviews to ensure targets are met. JR Low 5.5 financial plan delivered. Benefits tracked and all schemes risk assessed. Infection Control plan implemented. SLA Performance Fines Medium 3.0 DL Low 1.0 Regular review of performance. 1240 Maintain reviews of data, minmise PCT Income challenges Medium 4.0 PM Medium 2.0 Position being managed. risk of bad debts Local Counter Fraud Service in Risk to UH Bristol of fraudulent 1623 Medium - place. Pro active counter fraud work. PM Medium - activity. Reports to Audit Committee. Long term financial model and in Delivery of Trust's Financial year monitoring of financial 962 Strategy in changing national Medium - PM Medium - performance by Finance Committee economic climate. and Trust Board. Private patient income @ 0.65% of patient Breach of Private Patient Income Monitoring and reporting to Finance 1418 Low - PM Low - related income remains well within the Cap Committee. Trust's Cap of 1.1%. Non receipt of pledges of Monitoring of capital expenditure. 1858 charitable moneys to partly Low - Maintain dialogue with respective PM Low - finance capital expenditure trustees. 172 Finance Committee 22nd March 2012 Agenda Item 5.1 – Appendix 6 Financial Risk Ratings – February 2012 Performance 1. Financial Risk Rating The following graphs will show performance against the 5 Financial Risk Rating metrics. The 2011/12 Annual Plan is shown as the black line against which actual performance will be plotted in red. The metric ratings are shown for FRR 5 (blue line); FRR 4 (green line) and FRR 3 (yellow line). A comment for the February performance is given alongside each graph. An EBITDA of £32.720m was achieved. This is 7.4% better than the proportion of the Annual Plan for the period value of £30.472m. EBITDA Achievement of 107.4% of Plan earns a metric score of 5. The EBITDA Margin of 7.13% for February achieves a metric score of 3. This is better than the Annual Plan forecast of 6.75% to date. The Return on Capital Employed for the eleven months to February is 5.47%. The result earns a metric score of 4. Annual Plan = 4.77% to date. 173 2011/12 Annual Plan Income & Expenditure surplus margin is 1.19% for the eleven months to 29th February. The Income and Expenditure surplus margin for the period is 1.69%, a metric score of 3. 2011/12 Annual Plan liquidity ratio is 31.9 days at 29th February. The actual liquidity ratio for February is 28.6 days and remains above the band 4 minimum of 25 days. The Trust’s Financial Risk Rating is calculated by using a weighted average score to determine the overall rating. The weighted average score is 3.65. The Trust has therefore achieved a Financial Risk Rating of 4 for the eleven months to 29th February 2012. 2. Prudential Borrowing Limit A summary of the Trust’s performance for February 2012 is given in the table below. Monitor Ratio Prudential Borrowing Limit Performance 29th February 2012 Tier 1 Minimum Dividend Cover >1x 4.0x Minimum Interest Cover >3x 88x Minimum Debt Service Cover >2x 62x Maximum Debt Service to Revenue <2.5% 0.1% It can be seen that Trust performance against all of these ratios is good. 174 Cover Sheet for a Report for a Public Trust Board Meeting, to be held on 27 March 2012 at 10:30 in the Conference Room, Trust Headquarters, Marlborough Street, Bristol, BS1 3NU Item 11 – Resources Book including Capital Programme Purpose To report to the Board on Financial Resources for 2012/13. Abstract The 2012/13 Resources Book has been prepared for consideration and approval by the Trust Board. The Resources Book follows on from the Board Seminar held on 6th March with some minor revisions made for technical accounting changes. The headlines for the 2012/13 Resources position include:- A surplus on the Income and Expenditure Account which represents an EBITDA rate 7%; A planned surplus of £5.7m; A planned cash balance at year end of £34.3m; A savings programme of £27.6m; A capital programme of £76.9m; A Financial Risk Rating weighted score of 3.45 leading to an overall rating of 3. Recommendations The Board is recommended to approve the Resources Book 2012/13, including the Capital Programme for that year. Executive Report Sponsor or Other Author • Sponsor – Director of Finance, Paul Mapson • Author – Paul Mapson and Paul Tanner Appendices The 23 appendices are listed separately in the Resources Book. Previous Meetings Trust Quality and Executive Finance Audit Management Outcomes Other Team Committee Committee Executive Committee 22/03/12 175 Report for a Public Trust Board Meeting, to be held on 27 March 2012 at 10:30 in the Conference Room, Trust Headquarters, Marlborough Street, Bristol, BS1 3NU Item 12 – Monitor Quality Governance Framework Self-Assessment Summary Report Purpose To report the results of the structured assessment of the Trust’s arrangements for governing quality, using the Monitor Quality Governance Framework as a guide to good practice. Abstract Monitor developed the Quality Governance Framework in response to the findings of their internal audit report into the lessons learned from the well documented failings at Mid Staffordshire NHS Foundation Trust. The framework sets out a series of questions to which ‘aspirant’ NHS Trusts are required to respond during the Foundation Trust authorisation process in order that Monitor may assess their quality governance arrangements. The framework of questions also underpins Foundation Trust Boards’ quarterly self-certification for Quality Governance as set out in the Compliance Framework for 2011/2012. The Quality and Outcomes Committee, in conjunction with the Trust Executive, has undertaken a structured assessment of the Trust’s arrangements for governing quality in the Trust, using the Monitor Quality Governance Framework as a guide to good practice. The schematic report at Appendix A sets out the top level findings which are indicated by a detailed analysis of over a hundred indicators. The headline results of the assessment are that of the 103 measures assessed, the Trust is considered to score ‘Green’ on 98, with 5 indicators classified as ‘Amber-green’. The scoring criteria adopted by the Committee are set out at Appendix B. Recommendations The Trust Board of Directors is recommended to note the results of the Quality Governance Framework Self-Assessment, and to receive an update report from the Executive once the remaining indicators are progressed to ‘Green’ status. Report Sponsor & Other Author • Sponsor – Chairman • Author – Trust Secretary Appendices • Appendix A – Schematic Report • Appendix B – Scoring Criteria 176 Appendix A – Schematic Report 177 Appendix B – Scoring Criteria Risk Rating Definition Evidence Green Meets or exceeds expectations. All major elements of good practice evident, no significant omissions in detail. Amber-Green Partially meets expectations but Most major elements of good practice evident, confident in management's capacity no significant omissions in detail and robust to achieve green compliance within action plans to address shortfalls - a reasonable timeframe. management has proven track record of achievement. Amber-Red Partially meets expectations but with Some elements of good practice evident. some concerns on capacity to achieve compliance within a Some omissions in detail. reasonable timeframe. Action plans to address omissions are in early development. No concerns as to the capacity of management to achieve compliance. Red Does not meet expectations. Not started or a majority of good practice elements not evidenced. Significant volume of actions required. Major concerns as to management capacity to achieve compliance. 178 Cover Sheet for a Report for a Public Trust Board Meeting, to be held on 27 March 2012 at 10:30 in the Conference Room, Trust Headquarters, Marlborough Street, Bristol, BS1 3NU Item 13 – Results of Q3 Compliance Framework Monitoring Exercise Purpose To brief the Board on the results of Monitor’s Q3 2011/12 monitoring of NHS foundation trusts. Abstract Monitor has confirmed that based on their analysis, the Trust’s current ratings are: Financial risk rating – 4 Governance risk rating – GREEN The executive summary at Appendix A provides Monitor’s assessment of the risks affecting compliance. Recommendations The Board is recommended to note the report. Executive Report Sponsor or Other Author • Sponsor – Chief Executive • Author – Trust Secretary Appendices • Appendix A – Monitor’s Executive Summary of the Q3 results 179 University Hospitals Bristol NHS FT Q3 2011-12 reporting executive summary Risk ratings Financial summary Financial Risk Rating: £m This Quarter Year to date 11/12 Plan: YTD FY YTD Actual: Q3 Plan Actual Variance Plan Actual Variance Op. Rev (adj donations) 122.3 125.3 3.0 368.0 374.6 6.6 3 3 4 Pay (76.7) (76.9) (0.2) (230.0) (233.0) (3.0) Governance Risk Rating: PFI Op. expense 0.0 0.0 0.0 0.0 0.0 0.0 11/12 Plan: AMBER-RED YTD Actual: GREEN All other Op. costs (37.7) (39.8) (2.0) (113.5) (115.9) (2.5) EBITDA 7.9 8.6 0.7 24.5 25.7 1.2 Declared • C. Difficile Breaches: • None Risks: • A&E 4 hour 95% target Operating Surplus 3.4 4.1 0.7 11.1 11.8 0.7 Surplus after tax 1.1 2.0 0.9 4.1 5.2 1.1 2011/12 Authorisation limits EBITDA % 6.4 % 6.9 % 0.4 % 6.7 % 6.9 % 0.2 % CapEx (9.7) (11.9) (2.2) (27.7) (26.5) 1.2 Long term £102.5m Working £37.5m Private 1.1 % borrowing Capital Patient Net cash flow (3.3) (3.1) 0.3 (11.4) (10.8) 0.7 Facility Income Cash & Equiv 41.5 42.2 0.7 41.5 42.2 0.7 FRR Liquidity days 32.0 31.9 (0.0) 32.0 31.9 (0.0) CIP% Op. Ex less PFI 3.7 % 5.4 % 1.6 % 3.4 % 4.0 % 0.6 % Net current assets 10.1 18.5 8.4 10.1 18.5 8.4 Borrowing (6.2) (6.2) 0.0 (6.2) (6.2) 0.0 • FRR 4 delivered at Q3 which is above the planned FRR of 3. • Trust is forecasting a full year FRR 4 and pre-exceptional surplus of £7.0m, which is £1.0m ahead of original plan. Key risks Action taken / committed Gaps and residual concerns • Corporate and clinical governance. • The Trust has reported that it continues to implement its action plan to address the • Trust should continue to report to Monitor by Review into Histopathology services at the Inquiry’s recommendations and related governance matters. exception where it experiences difficulty or Trust identified various governance material delays in implementing concerns. recommendations following the Histopathology Inquiry, which was published in December 2010. • Financial risks. 1 Financial Risk Indicator • Appropriate provisions have been made for potential bad debts. • This FRI has been triggered for seven triggered: • Trust has made some progress resolving longstanding debtor issues and further consecutive quarters. • >5% debtors >90 days. work is being done to enhance cash collection. • Trust continues to reduce the aged debtors (Q3 now stands at £3.2m net of CRU). • Major investment. Delivery of ‘significant’ • This investment has been risk assessed by Monitor as it met the ‘significant’ • No material concerns at this stage. capital scheme (Bristol Royal Infirmary and reporting threshold. Risk ratings of Amber-Green/FRR 3 provided. • Trust should update Monitor if the business case centralising specialist paediatrics). fundamentals adversely change. Next steps • Continue quarterly monitoring. 180 • Trust to update by exception if material issues arise in addressing Histopathology Inquiry recommendations. 1 Cover Sheet for a Report for a Public Trust Board Meeting, to be held on 27 March 2012 at 10:30 in the Conference Room, Trust Headquarters, Marlborough Street, Bristol, BS1 3NU Item 14 –Review of Board Risk Management Strategy Purpose To present the revised Risk Management Strategy. Abstract The Risk Management Strategy sets out the strategic direction of the Trust Board of Directors on the management of risk, including the Board’s risk appetite statement. It is not intended to define the detail or process of risk management. This is to be achieved using the ‘associated documentation’ as described under that heading in the Strategy. The strategy takes into account the revised corporate governance arrangements established by the Trust Board of Directors during the 2011-2012 Financial Year. Revisions have also been made to reflect the requirements of NHS risk management strategies as recommended by the NHS Litigation Authority (NHSLA). The document is presented in the new format and layout for strategy documents in accordance with the Trust’s Procedural Document Framework (which has also been updated to take into account the recommendations of the NHSLA with respect to Clinical Negligence Scheme for Trusts (CNST) accreditation). The Strategy was approved by the Risk Management Group in February 2012 and is presented for ratification by the Trust Board of Directors. Recommendations The Board is recommended ratify the decision of the Risk Management Group to approve the Risk Management Strategy. Executive Report Sponsor or Other Author • Sponsor – The Chief Executive, Robert Woolley • Author – Trust Secretary Appendices List your appendices, including your Report in the following format: • Appendix A – Risk Management Strategy 181 Risk Management Strategy Document Data Subject: Risk Management Document Type: Strategy Document Status: Draft Executive Lead: Chief Executive Document Owner: Assistant Director of Governance and Risk Management Approval Authority: Risk Management Group Document Reference: 0004 Review Cycle: 36 Months Estimated Reading Time: 13 Minutes Document Abstract The Trust Board of Directors is responsible for determining the nature and extent of the significant risks it is willing to take in achieving its strategic objectives The strategic direction set by the Trust Board of Directors is documented in the Strategic and Corporate Objectives approved by the Board annually. The Board’s tolerance of risk to the achievement of these Objectives is defined in the Board’s approved Risk Appetite as set out in this Strategy document. The measures established by the Trust Executive to achieve these Objectives are discharged through the System of Internal Control, including the Trust’s risk management arrangements, and the provisions set out in this Risk Management Strategy and associated procedural documentation. The Trust Board of Directors monitors the achievement of its Objectives, and associated risks through the annual cycle of Board Reporting set out in the Board Forward Planner, including the Board Assurance Framework and Risk Register. 182 Risk Management Strategy – Reference Number 0004 Document Change Control Date of Version Version Lead for Type of Description of Revision Number Revisions Revision Unspecified 1999 Unspecified Director of Nursing Minor Planned review and update. Unspecified 2000 Unspecified Director of Nursing Minor Planned review and update. Unspecified 2002 Unspecified Director of Nursing Minor Planned review and update. Unspecified 2004 Unspecified Director of Nursing Minor Planned review and update. Unspecified 2007 Unspecified Director of Nursing Minor Planned review and update. 20 August 2009 1.0 Assistant Director Major Supersedes United Bristol Healthcare of Governance Trust Risk Management Strategy. Planned review and update. 12 August 2010 2.0 Assistant Director Major Updated following NHLSA Level 1 of Governance assessment September 2009, Internal Audit of Risk Management 2009, review of Trust risk management arrangements March 2010, and updated linked polices and guidance. 09 February 2012 3.0 Chief Executive Major Rewrite to reflect NHS NHSLA Level 2 assessment and revised Procedural Document Framework. Status: Draft Page 2 of 13 183 Risk Management Strategy – Reference Number 0004 Table of Contents 1. Introduction 4 2. Purpose and Scope 4 3. Definitions 5 3.2 Objective 5 3.3 Risk 5 3.4 Risk Appetite 5 3.5 Risk Treatment 5 4. Duties, Roles and Responsibilities 5 4.1 Trust Board of Directors 5 4.2 Chief Executive 6 4.3 Executive Directors 6 4.4 Risk Management Group 6 4.5 Trust Secretary 6 4.6 Risk Manager 6 4.7 Board Committee Chairs 7 (a) Audit Committee 7 (b) Quality and Outcomes Committee 7 4.8 Divisional Management Boards 7 4.9 All Staff 7 4.10 Responsibility for Monitoring Compliance 7 5. Board Statement of Risk Appetite 8 6. References 9 7. Associated Documentation 9 8. Appendix A – Monitoring Table for this Strategy 10 9. Appendix B – Dissemination, Implementation and Training Plan 11 10. Appendix C – Document Checklist 12 Status: Draft Page 3 of 13 184 Risk Management Strategy – Reference Number 0004 1. Introduction 1.1 The strategic direction of the Trust Board of Directors is the key driver for addressing the risks associated with achieving its stated strategic and corporate objectives. A range of external influences also have an impact on the Trust’s approach to risk management. These include: the Monitor Compliance Framework, the National Patient Safety Agency, the NHS Litigation Authority, the Care Quality Commission, contractual arrangements with commissioners, and local accountability arrangements with Foundation Trust Governors and members. 1.2 It is widely recognised that an effectively planned, organised and controlled approach to risk management is a cornerstone of sound management practice. A comprehensive management approach to risk reduces adverse outcomes, and can result in benefit from what is often referred to as the ‘upside of risk’1. 1.3 A pervasive culture of risk-awareness and good practice throughout the Trust are key factors in ensuring the achievement of strategic aims and performance targets. 1.4 The strategic direction set by the Trust Board of Directors is documented in the Strategic and Corporate Objectives approved by the Board annually. The Board’s tolerance of risk to the achievement of these Objectives is defined in the Board’s approved Risk Appetite as set out in this Strategy document. 1.5 The measures established by the Trust Executive to achieve these Objectives are discharged and safeguarded through the System of Internal Control, including the Trust’s risk and performance management arrangements, and the provisions set out in this Risk Management Strategy and associated procedural documentation. 1.6 The Trust Board of Directors monitors the achievement of its Objectives, and the associated risks through the annual cycle of Board Reporting set out in the Board Forward Planner, including the Board Assurance Framework and Risk Register. 2. Purpose and Scope 2.1 The purpose of this Risk Management Strategy is to set out the Risk Appetite defined by the Trust Board of Directors and to describe the Trust’s headline framework for Risk Management and monitoring. 2.2 This Risk Management Strategy applies to organisational risk in the following forms: (a) Strategic risk (b) Employment risk (c) Clinical risk (d) Environmental risk (e) Financial risk 1 A structured approach to Enterprise Risk Management (ERM) and the requirements of ISO 31000 Status: Draft Page 4 of 13 185 Risk Management Strategy – Reference Number 0004 (f) Operational risk (g) Information risk (h) Compliance risk 3. Definitions 3.1 The following terms are used in this document: 3.2 Objective (a) The objectives set by the Trust Board of Directors in the annual planning process specify the standards, outcomes, achievements and targets for various areas of the Trust’s operations. 3.3 Risk (a) Risk is defined as “the effect of uncertainty on objectives2”. An ‘effect’ may be positive, negative or a deviation from the expected position. (b) Risk is measured as a combination of the likelihood and the consequence of an event occurring. 3.4 Risk Appetite (a) Risk Appetite is defined as “the amount of risk exposure an organisation is willing to accept in connection with delivering a set of objectives3”. 3.5 Risk Treatment (a) Risks can be treated in various ways, including: acceptance, mitigation, rejection and transfer. 4. Duties, Roles and Responsibilities 4.1 Trust Board of Directors (a) The UK Corporate Governance Code that states that “the board is responsible for determining the nature and extent of the significant risks it is willing to take in achieving its strategic objectives”. (b) The Foundation Trust Code of Governance states that the Board of Directors is collectively responsible for the exercise of the powers and the performance of the NHS foundation trust. (c) To discharge the duties set out for Boards in the codes of governance, the Trust Board of Directors shall: 2 ISO Guide 73 to ISO 31000. This definition links risks to objectives. Therefore, this definition of risk can most easily be applied when the organisational objectives are comprehensive and fully stated. The objectives themselves need to be challenged and the assumptions on which they are based should be tested, as part of the risk management process. 3 ISO Guide 73 to ISO 31000. Status: Draft Page 5 of 13 186 Risk Management Strategy – Reference Number 0004 (i) Set the Strategic and Corporate Objectives for each Financial Year, (ii) Specify the Board’s tolerance of risks to the achievement of the Strategic and Corporate Objectives in a statement of its ‘Risk Appetite’, (iii) Delegate responsibility for the management of risk to the Chief Executive, (iv) Ensure that relevant metrics, measures, milestones and accountabilities are developed and agreed so as to understand and assess progress in achieving the objectives, (v) Monitor and respond to variances from plan through the annual cycle of Board Reporting as set out in the Board Forward Planner, (vi) Ensure the maintenance of a sound System of Internal Control to safeguard public and private investment, the NHS Foundation Trust’s assets, patient safety and service quality, (vii) Conduct, at least annually, a review of the effectiveness of the NHS Foundation Trust’s System of Internal Control and report to members4 that they have done so. The review should cover all material controls, including financial, clinical, operational and compliance controls and risk management systems. 4.2 Chief Executive (a) In accordance with the decision of the Trust Board of Directors in January 2011, the Chief Executive is responsible for the management of risk on behalf of the Board. 4.3 Executive Directors (a) Executive Directors are responsible for managing risk as delegated by the Chief Executive and set out in the Risk Management Policy and the Terms of Reference of the Risk Management Group. 4.4 Risk Management Group (a) As a Management Group established by the Chief Executive, the Risk Management Group is responsible for discharging the responsibility of the Trust Management Executive for the management of organisational risk. 4.5 Trust Secretary (a) The Trust Secretary is responsible for ensuring that the Trust Board of Directors is cognisant of its duties as set out in this Strategy and for coordinating the annual cycle of Board business to ensure these duties are incorporated on the Board’s agenda. 4.6 Risk Manager (a) The Risk Manager shall: 4 In the Annual Report Status: Draft Page 6 of 13 187 Risk Management Strategy – Reference Number 0004 (i) Develop, maintain and implement the Risk Management Policy and associated procedural documentation, (ii) Maintain the structure for risk management, (iii) Oversee the building of a risk aware culture within the Trust, (iv) Identify and report changed circumstances and risk profiles, (v) Keep up to date with and advise the Trust Management Executive on developments in risk practice, (vi) Compile risk information and prepare reports for the Trust Management Executive, Risk Management Group and Trust Board of Directors. 4.7 Board Committee Chairs (a) Audit Committee (i) As set out in the Terms of Reference, the Audit Committee shall review the establishment and maintenance of an effective system of governance, risk management and internal control across the whole of the organisation’s activities. (b) Quality and Outcomes Committee (i) As set out in the Terms of Reference, the Quality and Outcomes Committee shall receive the Corporate Risk Register and review the suitability and implementation of risk mitigation plans with regard to their potential impact on patient outcomes. 4.8 Divisional Management Boards (a) Divisional Management Boards shall adopt a standardised approach to the management of risk in accordance with the duties defined in the Risk Management Policy and the Terms of Reference of the Risk Management Group. 4.9 All Staff (a) All staff are responsible for identifying and managing risk(s). This is addressed in more detail in the Risk Management Policy. 4.10 Responsibility for Monitoring Compliance (a) The Risk Manager is responsible for monitoring operational compliance with this Strategy. Status: Draft Page 7 of 13 188 Risk Management Strategy – Reference Number 0004 5. Board Statement of Risk Appetite 5.1 In determining its risk appetite, the Board’s overarching objective is to achieve maximum sustainable value from all the activities of the Trust. The Trust Board of Directors defines its Risk Appetite as: (a) The Trust Board of Directors has zero tolerance for harm to patients and staff through the actions or omissions of the Trust5, (b) The Trust will consider strategic and operational decisions in the context of risk- assessed strategies, business cases and projects to allow for these decisions to be taken with due regard to the quality, safety and sustainability of services to patients, (c) The Trust Board of Directors requires the reporting of risk exceptions of high and extreme risks to the Board by quarterly presentation of the Corporate Risk Register and the Board Assurance Framework. 5 Where clinical risks are known to be associated with treatment, these risks will be professionally assessed, understood, and discussed in full with patients and/or carers prior to commencement of any such treatment or procedure. Status: Draft Page 8 of 13 189 Risk Management Strategy – Reference Number 0004 6. References 6.1 The following sources were referenced in the drafting of this Strategy: (a) An Organisation-wide Document for the Development and Management of Procedural Documents. (NHS Litigation Authority; March 2011) (b) A structured approach to Enterprise Risk Management (ERM) and the requirements of ISO 31000 (The Association of Insurance and Risk Managers, The Public Risk Management Association, The Institute of Risk Management; 2010) (c) ISO 31000:2009 Risk management – Principles and guidelines (d) Reinventing your Board: a step-by-step guide to implementing policy governance. John and Miriam Carver (John Wiley & Sons; 2006) (e) The Policy Governance Model: An Introduction by John and Miriam Carver, (Jossey Bass; Revised and Updated edition, 16 April 2009) (f) Getting Started with Policy Governance: Bringing Purpose, Integrity, and Efficiency to Your Board. Caroline Oliver (Jossey Bass; 2009) (g) The power of principles: How to get back to business through sensible integration of governance, risk, and compliance. PricewaterhouseCoopers LLP (PricewaterhouseCoopers LLP; 2007) 7. Associated Documentation 7.1 The following Procedural Documents are associated with this Strategy: (a) Risk Management Policy (b) Risk Assessment Standard Operating Procedure (c) Risk Register Standard Operating Procedure (d) Policy for the Management of Incidents (e) Serious Incident Policy Status: Draft Page 9 of 13 190 Risk Management Strategy – Reference Number 0004 8. Appendix A – Monitoring Table for this Strategy Strategy Requirement Evidence Trust Board of Directors Trust Board of Directors quarterly reports and The Trust Board of Directors requires the reporting Minutes demonstrating receipt of the Corporate Risk of risk exceptions of high and extreme risks to the Register and the Board Assurance Framework. Board by quarterly presentation of the Corporate Risk Register and the Board Assurance Framework. Audit Committee Audit Committee reports and Minutes As set out in the Terms of Reference, the Audit demonstrating receipt of the Board Assurance Committee shall review the establishment and Framework. maintenance of an effective system of governance, risk management and internal control across the whole of the organisation’s activities (both clinical and non-clinical), that supports the achievement of the organisation’s objectives. Quality and Outcomes Committee Quality and Outcomes Committee reports and As set out in the Terms of Reference, the Quality and Minutes demonstrating receipt of the Corporate Risk Outcomes Committee shall receive the Corporate Register. Risk Register and review the suitability and implementation of risk mitigation plans with regard to their potential impact on patient outcomes. Status: Draft Page 10 of 13 191 Risk Management Strategy – Reference Number 0004 9. Appendix B – Dissemination, Implementation and Training Plan 9.1 The following table sets out the dissemination, implementation and training provisions associated with this Strategy. Plan Elements Plan Details The Dissemination Lead is: Assistant Director of Governance and Risk Management This document replaces existing documentation: Yes Existing documentation will be replace by: Withdrawal from circulation of superseded documents. This document is to be disseminated to: Trust Management Executive, Trust-wide Policy leads, Heads of Division, Divisional Managers Training is required: No The Training Lead is: Not Applicable Additional Comments None Status: Draft Page 11 of 13 192 Risk Management Strategy – Reference Number 0004 10. Appendix C – Document Checklist 10.1 The checklist set out in the following table confirms the status of ‘diligence actions’ required of the ‘Document Owner’ to meet the standards required of University Hospitals Bristol NHS Foundation Trust Procedural Documents. The ‘Approval Authority’ will refer to this checklist, and the Equality Impact Assessment, when considering the draft Procedural Document for approval. All criteria must be met. Checklist Subject Checklist Requirement Document Owner’s Confirmation Title The title is clear and unambiguous: Yes The document type is correct (i.e. Strategy, Policy, Yes Protocol, Procedure, etc.): Content The document uses the approved template: Yes The document contains data protected by any Not Applicable legislation (e.g. ‘Personal Data’ as defined in the Data Protection Act 2000): All terms used are explained in the ‘Definitions’ section: Yes Acronyms are kept to the minimum possible: Yes The ‘target group’ is clear and unambiguous: Yes The ‘purpose and scope’ of the document is clear: Yes Document Owner The ‘Document Owner’ is identified: Yes Consultation Consultation with stakeholders (including Staff-side) Yes can be evidenced where appropriate: The following were consulted: Trust Board of Directors, Risk Management Group Suitable ‘expert advice’ has been sought where Yes necessary: Evidence Base References are cited: Yes Trust Objectives The document relates to the following Strategic or All Corporate Objectives: Equality The appropriate ‘Equality Impact Assessment’ or Yes ‘Equality Impact Screen’ has been conducted for this document: Monitoring Monitoring provisions are defined: Yes There is an audit plan to assess compliance with the Yes provisions set out in this procedural document: The frequency of reviews, and the next review date are Yes Status: Draft Page 12 of 13 193 Risk Management Strategy – Reference Number 0004 Checklist Subject Checklist Requirement Document Owner’s Confirmation appropriate for this procedural: Approval The correct ‘Approval Authority’ has been selected for Yes this Procedural Document: Additional Comments None Status: Draft Page 13 of 13 194 Cover Sheet for a Report for a Public Trust Board Meeting, to be held on 27 March 2012 at 10:30 in the Conference Room, Trust Headquarters, Marlborough Street, Bristol, BS1 3NU Item 15 – Policy Review – Capital Investment Policy Purpose To seek ratification of the Capital Investment Policy following its annual review and subsequent revision. Abstract This policy sets out the governance arrangements for capital investments undertaken by the Trust. It is subject to annual review and as such has been reviewed and revised by the Capital Programme Steering Group and subsequently endorsed by the Trust Management Executive. The policy will be reviewed by the Trust’s Finance Committee at its March meeting. Revisions to the Policy There are two proposed revisions to the policy: 1) Section 7.1 Financial Criteria - to extend the stated circumstances in which the Board may choose to waive the requirement to deliver the specified rate of return on assets. New paragraph in this section to read (with additional text shown in bold) as follows: ‘The Board of Directors may choose to waive the requirement to deliver the specified rate of return on assets, where it deems that exceptional circumstances apply. Such circumstances may include mitigation against serious strategic, statutory, regulatory, operational or reputation risks or a desired investment in a quality improvement.’ Rationale: to update the Policy to reflect a circumstance which has been applied and may be a factor in business cases that may be considered by the Trust Board. 2) References to other groups within the Trust have been updated to reflect their current names. Previous Group Name Revised Group Name Trust Executive Group Trust Management Executive Capital Prioritisation and Review Group Capital Programme Steering Group It is normal practice for Monitor to consult on amendments to the Compliance Framework. At the time of writing no announcement has been made on possible changes for 2012/13. Recommendations The Board is asked to ratify the revised Capital Investment Policy. Executive Report Sponsor or Other Author • Sponsor –Deborah Lee, Director of Strategic Development • Author – Paul Tanner, Deputy Director of Finance Appendices • Appendix A – Capital Investment Policy 195 Page 2 of 2 of a Cover Sheet for a Report for a Public Trust Board Meeting, to be held on 27 March 2012 at 10:30 in the Conference Room, Trust Headquarters, Bristol, BS1 3NU Previous Meetings Trust Other Finance Finance Executive Outcomes Committee Committee Qualityand Management Executive Team Audit Committee 15 February 22 March Capital 2012 2012 Programme Steering Group - 15 February 2012 196 Finance Committee 22nd March 2012 Agenda Item 3.2c Appendix 1 CAPITAL INVESTMENT POLICY 197 Owner Deborah Lee, Director of Strategic Development Version 6 03 February Submitted to and considered by the Trust Management Executive meeting on 2012 15th February. Submitted to and considered by the Finance Committee meeting on 22nd March. To Trust Board for ratification 27 March. Version 5 04 February To be submitted to Trust Executive Group 16 February 2011. 2011 To be submitted to Finance Committee to be approved for ratification by Trust Board 23 February 2011. To Trust Board for ratification 28 February 2011. Version 4 15 October 2010 Submitted to Capital Prioritisation Group 19 October 2010. Submitted to Trust Executive Group 15 December 2010 for consideration. Version 3 7 December Submitted to Trust Board for approval 22 December 2009 2009 Version 2 18 July 2008 Submitted to Capital Prioritisation Group 16 July to note. Submitted to Trust Executive Group 23 July 2008 to support. Submitted to Trust Board for approval 29 July 2008 Version 1 24 June 2008 Draft considered at Trust Board 1 July 2008 198 1. PURPOSE This policy sets out the governance arrangements for capital investments undertaken by the University Hospitals Bristol NHS Foundation Trust. The policy takes into account the best practice guidance issued by Monitor, particularly that contained in Risk Evaluation for Investment Decisions by NHS Foundation Trusts (“REID”) [Monitor, February 2006]. This policy will be subject to annual review by the Board of Directors. It should be read in conjunction with the standing orders and standing financial instructions of the Trust. 2. SCOPE The policy applies to capital investments by the University Hospitals Bristol NHS Foundation Trust. It does not apply to investment of in-year surplus operating cash, pension funds, funds of associated charities or funds managed on behalf of other organisations. The provisions of this policy apply to UH Bristol investments, regardless of the source of funding. Charitably funded projects must be prepared and managed therefore in accordance with the policy. Particular consideration is given to capital investments classed as major or high-risk. The Trust’s definition of a major investment is given in section 4. The Trust follows the Monitor definition of high risk investments as below: Reportable transactions: all investments that are reportable to Monitor under the thresholds for reporting investments in the Compliance Framework. The applicable thresholds are shown at Annex 1. Other transactions: all investments that have any one or more of the following characteristics: An equity component, which is defined as any participation involving shares and securities, debt instruments convertible into equity, options conferring the right to acquire equity in the future, royalties, participation in the profits of the enterprise, and all types of mezzanine finance where the returns exceed normal secured debt returns; Significant reputation risk; The potential to destabilise the core business; or The creation of material contingent liabilities. Monitor also provides the following examples of the types of transactions that may be considered high risk: significant capital expenditure, acquisitions, joint ventures, equity stakes, major property transactions, mergers and alliances (e.g. formal or informal agreements to work with other institutions), irrespective of how they are financed. These definitions will be applied to risk assessment of capital investment proposals in the Trust. 3. INVESTMENT PHILOSOPHY AND OBJECTIVES The Trust will invest in opportunities that are consistent with its purpose, mission and aims. The statutory and principal purpose of the Trust is the provision of goods and services for the health service in England. 199 In fulfilling its core purpose, the Trust’s mission is to provide patient care, education and research of the highest quality. When appropriate, the Trust will make investments in line with the following key strategic aims, set out in the Integrated Business Plan: To be the major specialist service provider for the population of Bristol and the South West region; To provide additional services for the local population; To develop the Trust's research portfolio in line with its service strategy; To develop research activities in partnership with academic and healthcare organisations; To pursue teaching and learning partnerships with education providers and others; To achieve a sustainable financial surplus; To improve the environment for patients and staff, to improve ease of access for patients and visitors and to develop the Trust’s estate to give the optimal configuration of services. The investment philosophy conditions the criteria which will be used by the Trust to evaluate potential major or high-risk capital investments (defined in section 7). The Trust will take into account the financial and non-financial risk and return when evaluating potential investments. The Trust will not enter into any project that would result in a breach of the terms of its authorisation as an NHS Foundation Trust. 4. CAPITAL BUDGET-SETTING 4.1 ANNUAL CAPITAL INVESTMENT PROGRAMME The Board of Directors will approve both the size of the annual capital investment programme, taking account of the approved long term financial plan, and the budget allocation between classes of investment in the programme, which will include at a minimum: Strategic projects Information technology Operational capital Vehicles Medical equipment Residences and accommodation Other equipment Land A capital planning process will be integrated into the annual business planning round, which will determine the approval route for each class of investment. The Trust will move towards establishing rolling replacement programmes for key asset classes. Guidance will be made available about the process to be followed for each class of capital investment. The guidance will also make specific reference to the process for rapid preparation and approval of spend-to-save schemes. 4.2 IDENTIFICATION OF MAJOR OR HIGH RISK INVESTMENTS All capital investment proposals will be subject to a risk assessment to determine if they fall into the category of major or high-risk investment. 200 A proposal will be classed as a major investment if its estimated capital cost exceeds 1% of Trust turnover. A proposal will be classed as high-risk if it reflects any of the characteristics identified in Section 2. 4.3 BUSINESS CASE REQUIREMENTS All proposals will be supported by Business Case documentation as shown in Table 1. Table 1: Thresholds for business case production. Projected scheme cost as % of Documentation required Trust turnover Up to 0.25% Short-form business case Between 0.25% and 2% Comprehensive business case Outline business case and (subject to OBC approval) full business case (following More than 2% NHS Capital Investment Manual guidelines). Any project requiring financial support for production of the appropriate business case prior to scheme approval must have an approved Project Initiation Document. Detailed templates and guidance for each form of business case is available from the Director of Strategic Development. 4.4 PROJECT SPONSOR Each proposed capital investment will be supported by an Executive Director, who will be the Project Sponsor. The Project Sponsor is responsible for ensuring that the terms of the Capital Investment Policy and other Trust policies are respected and that business cases follow the appropriate decision route (see section 6). 5. FINANCE COMMITTEE The Finance Committee will take the role of capital investment committee for the purposes of this policy. It will have delegated authority from the Trust Board for: Approving the investment and borrowing strategy and associated policies; Setting performance benchmarks and monitoring investment performance; Reviewing and revising the Capital Investment Policy on an annual basis for Board approval; Obtaining assurance that there is compliance throughout the Trust with the Capital Investment Policy; Approving capital investments above the de minimis amount defined below, including ensuring that the Trust has the legal power to enter into a particular investment; Approving Project Initiation Documents for all schemes above the de minimis amount defined below. 201 6. DECISION RIGHTS 6.1 BOARD OF DIRECTORS The Board will provide oversight of the Finance Committee. It will have the final decision over all major (i.e. greater than 1% of Trust turnover) and high risk investments as defined in this policy. The Board will approve the Capital Investment Policy on an annual basis. 6.2 FINANCE COMMITTEE The Finance Committee will have delegated authority to approve business cases with a value between 0.25% and 1% of Trust turnover. It will report its approvals to the Trust Board, including an account of the cumulative value of schemes approved in-year. It will also consider all business cases classed as major or high risk and make recommendations for approval or rejection to the Board. 6.3 TRUST MANAGEMENT EXECUTIVE The Trust Management Executive will have delegated authority to approve investments below the level of 0.25% of turnover, which do not qualify as high risk investments. It will report its approvals to the Finance Committee, including an account of the cumulative value of schemes approved in-year. It will also consider schemes which have costs between 0.25% and 1.0% of Trust turnover and which do not qualify as high risk investments. It will make recommendations about these proposals to the Finance Committee. The Trust Management Executive may choose to delegate approval of capital investments below a certain value to the Capital Programme Steering Group. 6.4 CAPITAL PROGRAMME STEERING GROUP The Capital Programme Steering Group will report to the Trust Management Executive. The Group will be responsible for co-ordinating the capital planning process and issuing internal guidance, ensuring that the appropriate initiation and risk assessment documentation is in place for proposed schemes. It will make recommendations about proposals to the Trust Management Executive and the Finance Committee in line with their respective decision rights. These recommendations will cover both approval or projects and the programming of related expenditure. The Group will approve capital investments which fall below a delegated limit defined by the Trust Management Executive. The Capital Programme Steering Group will report performance against the capital programme both to the Finance Committee and the Trust Management Executive. 202 6.5 SUMMARY Table 2 summarises the business case requirements and decision rights for the various categories of investment described in this policy. Table 2: Investment categorisation and decision Business Case Requirements Decision rights Category % of turnover % of turnover Business case Trust Finance Board of as a monetary requirements Management Committee Directors Value Executive £m >2% 10 OBC + FBC High risk 0.25%-2% 1.25 to 10 Comprehensive <0.25% 1.25 Short-form Major >2% 10 OBC + FBC (> 1% 5 to 10 turnover) 1% – 2% Comprehensive 0.25%-1% 1.25 to 5 Comprehensive Other <0.25% 1.25 Short-form NB: The % of turnover as a monetary value is based on turnover for the Trust being £500m 7. EVALUATION Business cases will be evaluated against explicit financial and non-financial criteria. 7.1 FINANCIAL CRITERIA Proposals which are not classed as major will be assessed for scheme affordability. Business cases for major capital investment (over 1% of turnover) will be expected to demonstrate a sustainable positive return on assets as follows: 3.5% if internally funded or financed through Public Dividend Capital at the opportunity cost to the Trust of interest, if financed through prudential borrowing (currently assumed to be 5.0%). The return from an individual capital project will be calculated as the return on all assets invested in the project. The Board of Directors may choose to waive the requirement to deliver the specified rate of return on assets, where it deems that exceptional circumstances apply. Such circumstances may include mitigation against serious strategic, statutory, regulatory, operational or reputation risks or a desired investment in a quality improvement. In this case, the Board will make the final investment decision itself, including explicit approval of the cross-subsidy arrangements which should apply to the investment in question. 7.2 NON-FINANCIAL CRITERIA The following non-financial criteria will be used to evaluate all capital investment proposals. Strategic Fit – the extent to which the proposed investment is consistent with the corporate strategic objectives highlighted in the investment philosophy above (or other agreed corporate strategic objectives) and will contribute to delivery of those objectives. 203 Magnitude / Scope of Benefit – the breadth of the proposed investment Improving Quality – the extent to which the proposed investment delivers UH Bristol’s Quality Objectives and improves patient care Risk Mitigation - the extent to which the proposed investment addresses existing or anticipated strategic, financial, operational, regulatory, political or reputation risks. Weightings will be applied to the scoring of investments against these criteria. The weightings will be formally agreed by the Board of Directors as part of the annual review of the Investment Policy. The current applicable weightings are shown in Table 3. Table 3: Weighting Criterion Weighting Strategic fit 20% Magnitude / Scope of Benefit 10% Improving Quality 35% Risk mitigation 35% A scoring template for non-financial appraisal of an investment is attached at Annex 2. 8. RISK MANAGEMENT The non-financial evaluation criteria include risk mitigation. They therefore take into account the risk of not entering into a proposed investment. The Trust will also take into account the risk and return (both financial and non-financial) of making a proposed capital investment. The risks will be fully identified and assessed according to the Trust’s standard risk assessment tool. A sample due diligence checklist from Monitor is attached at Annex 3. The Trust will seek to quantify the risks of a proposed investment in financial terms wherever possible. Business cases for major investment will include a quantified risk assessment and full sensitivity analysis. The Trust will actively monitor the performance of its investments and ensure that adequate risk mitigation is in place. 9. APPENDICES Annex 1 – Thresholds for reporting investments to Monitor. Annex 2 – Scoring Matrix for non-financial evaluation for an investment. Annex 3 – Simple due diligence checklist to inform risk assessment. 204 ANNEX 1 THRESHOLDS FOR REPORTING INVESTMENTS OR DIVESTMENTS TO MONITOR Source: Compliance Framework, Monitor, September 2011 MAJOR INVESTMENTS: IF A TRANSACTION MEETS ANY ONE OF THESE CRITERIA, THEN THE NHS FOUNDATION TRUST SHOULD REPORT THIS TRANSACTION TO MONITOR Reporting requirements Ratio Description Non healthcare/ international UK healthcare Assets The gross assets* subject to the transaction divided > 5 % > 10 % by the gross assets of the foundation trust Income The income attributable to: > 5 % > 10 % the assets; or the contract associated with the transaction divided by the income of the foundation trust Consideration to total The gross capital** of the company or business > 5 % > 10 % NHS FT capital being acquired /divested divided by the total capital of the foundation trust following completion * Gross assets is the total of fixed assets and current assets **Gross capital equals the market value of the target’s shares and debt securities, plus the excess of current liabilities over current assets CATERGORIES FOR MAJOR INVESTMENTS/DIVESTMENTS IF A TRANSACTION MEETS ANY ONE OF THESE CRITERIA, THEN THE NHS FOUNDATION TRUST SHOULD REPORT THIS TRANSACTION TO MONITOR Categories* Ratio Description Material Significant Assets The gross assets** subject to the transaction divided > 10 % > 25 % by the gross assets of the foundation trust Income The income attributable to: > 10 % > 25 % the assets; or the contract associated with the transaction divided by the income of the foundation trust Consideration to total The gross capital*** of the company or business > 10 % > 25 % NHS FT capital being acquired /divested divided by the total capital of the foundation trust following completion * For non-healthcare/international transactions the thresholds will be reduced by 50% ** Gross assets is the total of fixed assets and current assets ***Gross capital equals the market value of the target’s shares and debt securities, plus the excess of current liabilities over current assets 205 ANNEX 2 SCORING MATRIX FOR NON-FINANCIAL EVALUATION OF AN INVESTMENT SCORE STRATEGY FIT IMPROVING QUALITY RISK MITIGATION Delivery of UH Bristol’s Strategic Fit Magnitude / Scope of Benefit Quality Objectives * and Patient Care Clear evidence that the case delivers a Clear evidence that the case delivers a Very high risk score (> 20) as per Trust’s specific & tangible element of the Trust’s Trust-wide specific & tangible improvement to 5 Risk Assessment Matrix Strategy delivery of one or more Objectives Clear evidence that the case directly Clear evidence that the case directly drives a drives a specific & tangible High risk score (15 to 19) as per Trust’s specific & tangible element of the Trust’s Division-specific 4 improvement to delivery of one or more Risk Assessment Matrix Strategy Objectives Clear evidence that the case influences Clear evidence that the case directly drives Medium risk score (9 to 14) as per Specialty-specific improvements in delivery of one or more 3 the delivery of the Trust’s Strategy & Mission Trust’s Risk Assessment Matrix of the Objectives Evidence that the case influences a specific Clear evidence the case directly Moderate risk score (4 to 8) as per part of supports the wider delivery of the Service-specific delivers a specific and tangible 2 Trust’s Risk Assessment Matrix Trust’s Strategy & Mission improvement to patient care Clear evidence that the case directly Evidence that the case influences the delivery Low risk score (1 to 3) as per Trust’s Element within a service drives the Strategy on improving patient 1 of the Trust’s Strategy & Mission Risk Assessment Matrix care No impact on delivering the Trust’s Strategy & No impact No impact on patient care improvements No risk, score 0 0 Mission Scores Weighting x 20 X 10 x 35 x 35 Weighted scores Total score *Quality Objectives: 1. To reduce further the incidence of healthcare-acquired infections; 2. To improve antibiotic prescribing compliance; 3. To reduce the number of high risk medication errors which cause actual harm to patients; 4. To reduce Hospital Acquired Thrombosis; 5. To increase the level of patient and public involvement in service improvement; 6. To meet the requirements of the proposed NICE Quality Standard for Dementia. IT SHOULD BE NOTED THAT SOME INVESTMENTS WILL BE FUNDED WITHOUT RECOURSE TO THIS MATRIX. THESE WILL BE UNAVOIDABLE INVESTMENTS EXCEPTIONAL IN THEIR NATURE 206 ANNEX 3 DUE DILIGENCE CHECKLIST TO INFORM RISK ASSESSMENT Typical due diligence items Type of process Area Example Items . Strategy . Rationale for how proposed investment will deliver value . Strategic and business plans . Business strengths and weaknesses . Competitive dynamics . Finance . Historical normalised earnings . Most recent 5-year projection Financial and . Key assumptions and sensitivity analysis commercial due . Working capital strategy diligence . Operations and manufacturing . Business economics . Customer and supplier relationships/contracts . Management capabilities . Organisation and Management . Organisation structure . Systems integration . Corporate culture and style . Key research efforts . Research and development . Research relationships and contracts . Security and contingency plans . Information technology . Types of systems . Outsourced services . Financial reporting systems . Accounting . Contribution margin Tax and accounting . Depreciation schedules due diligence . Capital structure . Finance . Covenants triggered by deal . Tax liabilities from non-paid taxes . Tax . Tax reserve . Claims history and policy status . Insurance . Contingent liabilities . Shares outstanding and shareholder interests (if . Corporate structure relevant) . Legal entities . Indemnification provisions . Legal . Outstanding and pending limitation . Licences, patents and trademarks Legal due diligence . Employment contracts and agreements . Labour . Pension provisions and funding levels . Non-paid benefits . Potential anti-trust liabilities . Anti-competitive . Potential remedies/outcomes . Existing and future liabilities . Environment . Successor liability . Remediation plans This is not an exhaustive list of areas to be covered within due diligence. The scope of due diligence will vary depending on the proposed transaction and should be discussed and agreed with the NHS foundation trust’s professional advisers. Source: Risk Evaluation for Investment Decisions by NHS Foundation Trusts Monitor, February 2006. 207